Shame in Surgery Part 3 - Internalized Shame and Burnout ===

Hello everyone. I'm Steven Thornton, a surgery resident at Duke and one of the behind the Night Surgical Education research fellows. Today I'm really excited to be bringing you a special series on shame and surgery with a particular focus on shame and surgical training. First things first. What is shame? Well, scholars conceptualize shame in a variety of ways. One way to understand it is that it is the feeling of being globally flawed, inadequate, or unworthy in BTK language. It's when you feel like you're not the kind of person who dominates the day. Does that sound relatable? I wonder how many of you listening may have felt this way about yourself. While training in surgery or working as a surgeon,

so why talk about shame surgeons forever change their patient's lives? As we work to address the impact of illness, injury, and disability on the human body, we are changed to training and working in surgery has a profound impact on lives of the people. Learning and doing this craft. There is a richly documented, but in completely understood while being crisis in surgery. Rates of depression, anxiety, PTSD, suicidality and substance use disorder are all elevated. And recent evidence would suggest that the rates of each of these are higher in the period of time following a surgical complication. This problem became personal for me early in my training when one of my first mentors in surgery died by suicide.

And since then, I've viewed understanding the effects of the surgical learning and working environment as among the most pressing challenges in surgical education. Now, this problem is complex. Emotions and in particular, self-conscious emotions are one way to understand how surgeons are feeling and more specifically how they're feeling about themselves. So it's with that in mind that we're gonna dive into a multi-part series on Shame in Surgery. This is the third episode in that series. If you missed them, I recommend pausing here to check out our first two episodes in those. We set the stage for the series and discuss another important paper on shame and surgery. We'll wait for you here for those who are tuning back

in, let's get into it. Today I'm joined by Dr. Tej Ham from Cedar-Sinai, and Dr. Shana Theodore from Boston University. Could you tell our listeners a little bit about your backgrounds? Hi everybody. I'm Tegel Braham Butt. I'm an associate professor of surgery serving as an attending trauma and acute care surgeon and surgical intensivist at Cedars Sign Medical Center here in Los Angeles, California. I have a particular academic focus on surgical education and the discipline of surgery as a whole, and the psychological impact it can have on trainees and surgeons. And thank you very much for the opportunity to be here. Hi everyone. I'm Shayna Theodore. I'm an assistant professor of surgery and attending acute care surgeon at Boston Medical Center in Boston, Massachusetts. I have specific interests in surgical education. I'm very excited to be joining you all today. BTK is my all-time favorite surgery podcast, so this is a great honor for me. It's especially fitting to join on such an important topic that's near and dear to my heart. Well, it's

really wonderful to have you both on the show. Thanks for taking the time to talk about your recent work on shame and surgical education. Maybe we can start off by just reflecting on how you both became interested in this topic. My interest in shame stems from experiencing it myself throughout medical school and training, and watching my fellow classmates and co-residents go through it as well, thinking that it was something normal, like a rite of passage in an odd way. It was later in my training that I began to realize that this was more common than I thought, and it doesn't have to be this way. Both external and internal. Shame break you down. It can lead to loss of confidence, burnout, and even suicide. I think it's important to recognize that we cannot lose the future of surgery to old doctrines that are rooted in shame-based learning. That's really powerful. Dr. Theodore. What about you, Dr. Braham? I've been interested in the, uh, mental and emotional wellbeing of surgical residents as a surgical educator for a while. Over the years, I've

seen how things like shame can really affect not only how residents feel, but also how they perform. And this study gave me a chance to dig deeper into those ideas and actually measure their impact. As a trainee. I'm really so thankful that there are faculty thinking about these topics. Shame is one of those terms that I feel like gets thrown around a lot, but in the setting of rigorous scholarship, it's important that we're all on the same page about what we're referring to. Can we just define shame in the context of your study? Shame can either be external or internal, external shame. Think of it as shaming behavior. It causes a self-conscious emotion from an external source and the individual perceives that they have fallen short. And in contrast, external shame, internal shame reflects the psychological state of the individual, including feeling responsible for poor outcomes, knowledge gaps, perceived errors, or any other component of surgical training.

It sounds like external shame can lead to internal shame, but shaming behavior isn't necessary for someone to experience an internal shame state. Is that right, Dr. Theodore? Exactly. So there's different ways to study shame and how we operationalize it has an important impact on what we learn. Can you tell us a little bit about that in the context of your study? What exactly were you interested in learning and how did you go about investigating it? Our study aimed to explore the intersection of internalized shame and burnout among general surgery residents. A topic that before our study had not been studied, uh, we recognized that while burnout in surgical residency is well documented, the role of internalized shame as a contributing factor. Has been largely overlooked in the literature. To investigate this, we conducted a cross-sectional survey involving 122 general surgery residents across the United

States. We utilized two validated tools, the Malac Burnout Inventory, or MBI to measure burnout. And it encompasses emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. And then we use the experience of shame scale, the ESS to quantify levels of internalized shame. Our objective was to quantify the prevalence of internalized shame and assess its association with burnout rates. We hypothesized that if you had higher levels of internalized shame, that this would correlate with increased odds of experiencing burnout. Thereby highlighting an important psychological aspect that could be targeted for interventions to improve overall resident wellbeing. So this study provides the first. Quantitative analysis of internalized shame states and surgical residents offering new insights into psychological dimensions of burnout and surgical training. And by

understanding these dynamics, we hope to inform the development of targeted interventions to mitigate burnout and enhance the overall mental health and professional development of our future surgeons. I think one of the real strengths of this study is that you used survey instruments with validity evidence for measuring the constructs you were interested in. It occurs to me that with complex phenomena like shame, there's varied approaches to how we seek to understand them. Uh, your study is an excellent example of the quantitative approach. I'm curious your reflections on its relationship to qualitative inquiry in this space. So when we're talking about something as personal and emotionally complex as shame, you know, qualitative research is incredibly powerful. Quantitative studies are great at showing patterns like how often shame shows up, who's most affected, how it correlates with.

Things like burnout or attrition, but numbers can only take us so far and they tell us that something is happening, not why or how. You know, and that's where the qualitative research will come in. But we needed to create that foundation, especially in this kind of unique domain. So like, you know, in qualitative research, you know, interviews, focus groups, narrative analysis, you know, we get to hear the real stories, what actually shame feels like. Where it shows up in our culture and kind of how it shapes learning and our professional identity, and it captures the nuances that emotions and impressions, it captures those things that the data points can't. You know what's interesting though is that the relationship goes both ways. So quantitative data can inform qualitative work by helping us identify trends and outliers worth exploring more deeply. You know, for example, if survey data shows that

certain groups of residents report higher levels of shame, you know, a qualitative study can help unpack why that's happening and what it looks like in practice. So it's really a dynamic kind of cycle. You know, quantitative research gives us breath. And it shows the scope of the problem while qualitative research gives us depth, and we had neither in this particular conversation when it comes to shame and burnout and internalized shame. So it helps us understand the meaning and mechanism better and together. They will create a fuller kind of more actionable picture, and it's when we use these both approaches, that's when science really starts to drive ch cultural change in surgery. So we've embarked on that first step of informing future qualitative research, but providing that quantitative data to inform how we would conduct a qualitative study.

Got it. So burnout has been studied pretty extensively, but shame is a more novel lens for understanding surgeon wellbeing. What exactly did we already know about burnout and shame separately prior to this study? Before our study, the literature on burnout among surgical residents is pretty robust with numerous studies highlighting high burnout rates due to factors like emotional exhaustion, degradation, and reduced personal accomplishment. All other things that I mentioned before. These studies often emphasize external factors like workload, lack of autonomy, administrative burdens as a key contributor to burnout. However, despite this extensive focus on burnout. There was no focus on the role of internal psychological factors, specifically internalized shame, and it was not thoroughly explored in this context, especially looking at surgical residents.

Previous research and related fields suggested that shame could infect. Impact mental health and professional performance. There was a clear gap in the literature in understanding how internalized shame a personal, often hit emotional experience, interacts with the high pressure environment of surgical training, while external shame and shaming behaviors had been discussed In some studies, the unique impact of internalized shame on burnout. Had not been examined, so the literature had not really addressed what is the potential exacerbating stressors related to internalized shame and how these can be identified in surgical residency, and how these can be contributing to burnout in a way that external factors alone could not explain. Our study was. Hoping to fill this critical gap and

provide a quantitative analysis to show the relationship between these two things, internalized shame and burnout among surgical residency. Okay, that totally makes sense. So there's lots of other psychological constructs that could be explored here. Can you tell us a little bit more about why you decided to pair shame and burnout together for this study? So, as Dr. Theore mentioned, you know, our study looks at how burnout and shame are connected, especially internalized shame, which happens when people turn feelings of failure or inadequacy inward and blame themselves. This is different from external shame, or someone feels shamed by others, or attendings or peers through things like criticism or public reprimand. You know, the connection between burnout and internalized shame is important because. That inward shame can make residents feel even more inadequate and isolated. These are two key parts of burnout. Once those feelings take hold, they can create a cycle where shame fuels stress and emotional

exhaustion, which in turn deepens burnout. External shame, you know, while still it's harmful is more about how others treat you. And that can sometimes be improved through institutional culture changes or policy adjustments. But internalized shame, it's a little trickier. Uh, it's deeply personal and often invisible, but it can have a serious impact on mental health and job performance. Our findings will suggest, and we'll talk about it here, that, uh, to really tackle burnout, we need to focus not just on external pressures of the workplace behavior, but also kind of on helping residents recognize and manage their own internalized shame in doing so, could really make a real difference in their mental wellbeing, their resilience, and their overall growth during training. I really like that emphasis on the difference between the external factors that we need to manage and the internal factors that we have to manage as well. Can you tell us a little bit more about what you learned in this study?

What did your findings show? So our study uncovered a strong association between internalized shame and burnout among general surgery residents. This was not something unexpected, but now the numbers were showing what we sort of all thought to be true. There was a high median ESS score, which indicated. Prevalent internalized shame, and this significantly correlated with an increased odds of burnout as measured by the MBI. So with just under 70% of residents meeting burnout criteria, the findings highlight the critical role internalized shame plays alongside external stressors in contributing to burnout. Importantly, the higher ESS scores were linked to greater burnout risk. Independent of demographic factors like age and sex, and on adjusted analysis, individuals with children had lower odds of burnout, which is

consistent with prior literature. That's really interesting and parts of it definitely map onto my experience. There's interesting literature that shows that while rates of burnout in surgery are similar to other fields like internal medicine, the attrition in surgery is much higher. I'm curious, what do you make of that? Is there something unique about burnout in surgery? Could it be related to shame? How does this tie in with the population based norm calculations that you performed in your study? That's a really great question, and although our study doesn't give any data to help me answer that question, I know from my own experience and experience of other colleagues that there's something unique about surgery. Right? There is the concept of the procedural complication nature of surgery, and how both external and internal shame ties into this. Concept of not being built to be a surgeon. And I think that definitely ties into the attrition rate. Let me

explain. Surgery is a field of a small margin of error. What I mean by this is that it's hard to bounce back from a bad week or a bad month, like you have a bad month and now you feel like you're labeled by a group of attending or peers, or you perform poorly on the app site and now things start to snowball. So sometimes these things are not even clear to yourself or those around you, the your co-residents and attendings. And by the time help comes, it feels like it's too late. I'm really struck by the concept of whether or not someone is quote unquote, built to be a surgeon. It feels like that question to me has to be related to shame's definition of a self-assessment of being globally flawed or deficient. Maybe that's the wrong question for us to be asking. The link between internalized shame and burnout and surgery is pretty striking. Our study showed that residents are dealing with higher levels

of shame and burnout compared to other fields. This makes sense when you think about the intense pressure in surgical training where every decision can have major consequences. Now, looking at population norms, surgical residents seem more vulnerable to these feelings, probably because the culture of surgery is so focused on perfection and resilience. The mistakes can feel incredibly personal and shameful, especially in a high stakes environment. And what makes this unique to surgery is the culture and hierarchy that we have now. The constant evaluations can sometimes feel more punitive and supportive, which can make shame and burnout even worse. It's like a cycle where the pressure to be perfect just keeps feeding these feelings. So, so understanding these dynamics is crucial in our opinion. You know, if we can address internalized shame, we might be able to reduce burnout and create a more supportive training environment for surgical residents.

I want to explore some of the demographics of your study in a little bit more detail. Looking at the participants in the study, I noted that female residents made up 60% of the sample, which is an overrepresentation compared to their share of the general surgery cohort nationally. This is something I've seen in other research on shame too, where males are often underrepresented. What do you make of this? You know, in our study, we noticed more women residents, which is important because everyone experiences unique pressures in surgery. The fields, high expectations can lead anyone regardless of gender to feel like they need to continually prove themselves. Both men and women might internalize feedback differently. And that can lead to feelings of shame and burnout. It is crucial to encourage an environment where all residents feel comfortable seeking support and discussing challenges. Ultimately though, fostering open dialogue and providing

mentorship can help everyone manage the stress better, reducing shame and preventing burnout. To that end, what thoughts do you have about how other demographic identities might shape the experience of shame during surgical training? When we look at different identities like race, ethnicity, sexual orientation. Being an immigrant or first generation in academics, it's clear that these can really shape how residents experience shame. For example, facing biases or feeling like you have to represent your community can add extra pressure. Those residents that are within groups that are underrepresented in medicine worry about fitting in. First generation residents often feel like they have to succeed to honor their families or communities' efforts. It's crucial to create a supportive environment where everyone's unique background is respected and valued. Encouraging diversity and offering mentorship can go a very long way, and helping residents feel included

and less burdened by internalized shame. This is really complex stuff and it sounds like to continue studying it. Well, as you guys have started doing here, we're gonna have to recruit a lot of multidisciplinary expertise. I know we talked about this briefly before, but I noticed that it comes up again in the discussion of your paper. Can you elaborate on some of the differences between external shaming behavior? Internalized, let's call it state shame. Shame. You know, when we talk about external shame, we're really looking at those moments when someone else makes you feel inadequate, like through criticism or public embarrassment. It it's that outside pressure where others might be pointing out your mistakes or your shortcomings on rounds or in the operating room, and it can be tough to handle because it's right there out in the open. Internalized shame is a little bit different and it's, it's more about how you feel inside. It's when you start believing you're not good

enough, even without anyone saying anything. This kind of shame is more about your own inner dialogue and can be triggered by high expectations you set for yourself, or perceived failures that are in front of you. It can be deeply personal and harder to shake off because it comes from within. Both types of shame can weigh you down, obviously, but internalized shame is particularly tricky because it's often invisible to everybody else, and tackling it means working on self-compassion and changing how you perceive your own worth, which can be a powerful step in reducing burnout and improving wellbeing. You know, it reminds me of what you were saying earlier with how so many of the efforts to address wellness and surgery are about removing external stressors. Addressing the burdens of work hours and difficult working conditions, but with internal shame, it sounds like it's something from within, and it doesn't sound like simply removing external

forces can solve this problem. So what I'm hearing is that internal and external shame are both super important to the wellbeing of surgical residents. They're just different lenses for understanding the phenomenon of their wellbeing. Is that right? It's definitely appropriate to think of these as different lenses, but in our opinion, one can be removed, which is the external and the other will need to be reprogrammed, which is the internal in a sense. So even if we get rid of all of the shaming behavior that exists in surgical culture, it sounds like you're saying people are still going to experience shame. It's a human emotion, it's unavoidable. We need healthy ways to engage with it. Is that correct? Exactly. I totally agree. So in your paper, another topic that you explore is the difference or the relationship between the emotions of shame and guilt. Can we explore that a little bit? Yes. Uh, shame and guilt are closely related,

self-conscious emotions. Uh, they're kind of like cousins. Related, but distinct guilt is typically about feeling bad for something specific you've done like making a mistake or hurting someone. It's tied to actions and can actually be constructive because it might motivate you to make amends or change. Shame though goes deeper. It's more about feeling like there's something wrong with you as a person, instead of thinking, I did something bad. Shame makes you feel. I am bad. It's less about the action and more about your overall self-worth. That can be really heavy because it affects your whole sense of identity in the context of surgical training, feeling guilty might push you to improve or learn from an era, whereas internalized shame can make you withdraw. And feel isolated. That's why understanding and

addressing shame is so important. It can have a big impact on mental health and professional growth, for example. I made a bad decision, but I will learn from this or correct this behavior. That's what guilt can do. But shame sounds more like I made a bad decision, therefore I am a bad surgeon. And even go as far as someone feeling like I should leave the field of surgery because of my bad decision, making me a bad surgeon. I think plainly stating the impacts of shame. On learners in surgery really underscores the importance of this work. I mean, you drew attention to how shame can cause people to withdraw, how it can cause them to become isolated and potentially even consider leaving the field all together. All of those things I think surgical educators would agree are worth rallying

around and preventing. So what's the big takeaway from this work? What can, and what should we be doing about internalized shame in surgery? You know, the big takeaway from our work is that internalized shame is a significant factor, one of many that contributes to burnout among surgical residents. It's not just about the long hours or the heavy workload, but it's also about her residents perceive themselves and their abilities. So, you know, what can we do about it? First, we need to create an environment where it's okay to talk about these feelings, and we'd encourage open conversations. Normalizing discussions around mental health can make a big difference. Uh, we should focus on building resilience and self-compassion among residents and helping them understand that mistakes are part of learning and don't define their worth. Now mentorship can play a huge role there too. You know, having mentors who can share their own

experiences and offer guidance can really help residents feel supported and less isolated. Now, ultimately, addressing internalized shame is about fostering a culture that values growth and wellbeing just as much as technical skills. I'm really excited to be working together on building that culture in the future of surgery. Can you share a little bit about what the next steps are in your research agenda? Looking ahead, it's important to focus on developing interventions that directly address internalized shame, like resilience training or mindfulness. We should also research how different identities impact these experiences to tailor support more effectively. Implementing these interventions in real surgical programs and assessing their impact can offer valuable insights. We need to encourage a culture shift towards open communication and mental health prioritization and surgical training, and how this

will help reduce stigma and support residents better. Ultimately, it's about creating a supportive environment where residents can grow and succeed, both professionally and personally. It's also important to note that there is no one size fits all approach and no one thing or group of things that will quote unquote cure shame and burnout. Instead, it's a constant flexible effort with frequent check-ins and understanding that approaches need to pivot. If they're not working. It needs to be more for the sake of improvement and less for the sake of checking a box. You touched on assessing the impact of any interventions that we use to address wellbeing in the learning environment, and it's probably worth acknowledging that this sort of research is nascent or still emerging in surgery. Those studies of human emotion and wellbeing are commonplace in social sciences. It's not exactly the kind of stuff that people have traditionally built their academic careers on in surgery. How

can we lean on the rich history that exists in the social sciences to ensure methodologic rigor in this space? You know, I, um, I think one of the biggest gaps in surgery right now is that we talk a lot about wellness and burnout, but we don't really always study it with the same level of rigor that we bring to, like everything else that we study in surgery. Uh, we're surgeons, we're trained to be data driven. To test hypotheses, to look at outcomes. But when it comes to things like shame and mental health or emotional experiences of training, we've often relied on stories or like gut feelings, you know, and that's where I think we, we think that the research really matters. You know, if we can make this work more scientific with good study design, validated tools, real data. It gives the conversation legitimacy and it moves from this is how people feel to like, this is what we can measure and improve. And

that, that is powerful because science is what drives change in our field. And once you quantify something, you can design interventions, you can track progress, you can hold systems accountable. It's how. We make training not just safer and and more effective, but also more humane. So I think for us, for me, you know, the science isn't about taking the emotion out of it. It's using evidence to honor those emotions and to kind of make them the starting point for real lasting change. That's been really wonderful to talk with you both about this topic. Thanks so much for coming on the show and we'll be excited to follow along with your future work in this area. To our listeners, thanks for tuning in to the series on Shame in Surgery. Check back later this year when we will share the results of an ongoing qualitative study that seeks to understand the lived experience of shame among surgical residents. Until next

time, dominate, dominate the day.