Goat women

Have you ever noticed that women that keep goats stay young and independent well into their 90's? No? Just me?

Shame, vulnerability and the Impostor Syndrome

Take a look at this TED talk. 

Brené did a mixed methods study on connection and shame and unexpectedly found that at the base of our connections was our comfort with vulnerability.

 “Connection is why we’re here. It gives purpose and meaning to our lives”. Connections are the basis for all social interactions. It is impossible as a physician to ignore connections in our daily lives. I think of the usual connections when I say this, the relationships we have with our patients and their families, our colleagues, our community, our own families and friends, and ourselves. Brené suggests that shame unravels connection. Shame makes us feel unworthy of connection. Underpinning the shame was excruciating (not comfortable) vulnerability. Impostor syndrome strikes again!! I’m not smart, thin, fit, happy, well enough to be a doctor. The sense so many of us feel that there was a mistake including us in the Hippocratic Oath. 

In this study Brené describes a subset of her population as having a sense of worthiness, a strong sense of love and belonging, and who also believe they are worthy of love and belonging. Brené calls these “whole hearted” people. She found they had a sense of courage, originally defined as telling the story of who you are with your whole heart. They had the courage to be imperfect. They had the compassion to treat themselves well first, then someone else, because we can’t be kind to others unless we are kind to ourselves. Lastly, they had connections in their lives because they were brave enough to let go of who they are. They fully embraced vulnerability, believing that what made them vulnerable made them beautiful, a necessary (if occasionally difficult) willingness to invest themselves in something that might not work out. To me, all docs must at some level be these whole hearted type folks. To apply for medical school, to write the MCAT, to apply for residency and finally join a practice requires an acceptance of our vulnerability, even if we, like everyone else we struggle with it.

“We numb vulnerability” with substances, poor behaviour, food, work, etc., but Brené suggests that this numbs all of our emotions as well. Essentially, if we are unable to allow ourselves to feel vulnerable, that we won’t feel joy, sadness, etc. There are lots of reasons for docs to feel vulnerable as we constantly flirt with the unknown, perform tasks others wouldn’t dare, etc. We also know lots of ways to feel numb.

 Certainty for us comes in the form of, well, forms and checklists and Evidence Based Medicine. If we can point to a study that allows us to stop/start/increase/decrease a statin, we can make a choice that we don’t have to worry about. I’m not advocating for a return to paternalistic medicine, but that we continue to treat the patient, not the numbers. Even writing that makes me feel uncomfortable. What if my patient has a stroke that is debilitating and decides to sue me because I didn’t push hard enough to keep her on a statin? Making choices with our patients in a patient centred way requires us to feel vulnerable in several ways. We are allowing our patients to know that we don’t know all the answers. This flies in the face of many of my preceptors who advocated that I pretend I know what I’m doing and talk about my proposed treatment plan as though it was unquestionable  to make the patient feel comfortable. As I’ve talked about before, there are thousands of new journal articles published every week making it impossible for us to keep up on everything, especially if we are generalists. I think it takes courage to prescribe ANYTHING given that there may be a time in a few weeks or a few years that this med is considered as useless as blood letting (or is that back in fashion again). Nutritional advice is a perfect example of how information flip flops. Again though, we are encouraged in our training to stand by our published guidelines of our various groups. These are helpful to be sure, but are still just guides to helping patients make decisions. 

Being taught explicitly and implicitly through paternalistic modelling, I rarely had a chance to feel comfortable in my uncertainty as a learner. Thinking about answers when I was being pimped, trying to consider more than one organ system in treatment plans, offering more than one treatment for an illness was discouraged. I was to be confident at all times, and if I didn’t feel it, I was to fake it. I was punished with poor grades if I acknowledged uncertainty in my assessments and plans. It makes allowing myself to feel vulnerable in my practice difficult. 

One step I’ve taken to correct this is to find my own therapist, and as Brené suggested, I found one who is a therapist for therapists - “it’s necessary because their bullshit meter is higher”. You know it’s true. Anyone who has ever done time in the ER with psych patients knows how to say what needs to be said to ‘pass’ your suicidal ideation screen. She is not a therapist of other doctors though which has provided me with a refreshing insight into what I’ve learned to take as gospel. She will frequently say, what? does everyone think that is reasonable?? and help me to find my place in this community. 

We need to believe that we are enough. This rewards our courage to feel vulnerable in front  of our patients and colleagues and sets the stage for an ability to feel grateful and well in the future. It sounds that uncertainty and vulnerability is something we can practice until we are comfortable with. We should promote vulnerability in our learners. We need to talk about the shaming that occurs in our profession (these young docs, thinking they should only take on 1000 patients at a time; oh, vacation AGAIN?, etc.) and show its ridiculous nature. Shame has no place in a doctor’s professional and personal life if at the end of our day we have completed our job to the best of our abilities. It doesn’t need to be perfect or neat, but given the resources of the day, it will be enough. The connections we have with other people in our lives will be stronger, and, hopefully, quiet the shaming and impostor syndrome voices. 

I speak fluent poverty

It doesn't make me terribly popular with administration folks. I've recently been accused of being unprofessional. This stems from the way I talk about and to patients.

I treat my patients as thinking, feeling beings who can make their own choices about their health and their life in general. I call them out on their bullshit and try to find out why they're making the choices they do. There's no point in preaching at a patient about not eating fruits and veg if the food bank has been out for a month.

I don't use flowery language because unfortunately, most of my patients are illiterate. When I started practice, I assumed many would be health illiterate, but I certainly wasn't expecting this. My staff has stepped up (I love them so) and help my patients to fill out the millions of forms that we process every month. I've stopped playing along with "I left my glasses at home" and ask them straight out how their reading is. They've been so used to lying about it, it takes them back and puts them on the defensive for a minute or two until they realize there's no judgement, just me looking to do best by them. I've gotten into the practice of reading out my referral letters to my patients so that 1. I have to finish it while I'm in the room with them, 2. they know what I'm saying about them and 3. they can correct me as I go along. My patients frequently laugh at my "doctor words" that go into those letters. That lets me know that the way I'm speaking with them is different than how I speak with other docs. I like that.

From the stories I hear from my patients, they haven't had someone who will actually listen in a long time. They get painted with the same brush as their drug dealing brother, as their morbidly obese mother, and as their father who has been in and out of jail since they were born. These folks are rarely treated as an important individual.

The same approach works for those patients I have with money and more stable upbringing. I fancy up my language, but otherwise, I continue to treat them as individuals. I don't care that you were mayor for 20 years, we are just starting a relationship, I want to know WHO you are, not what other people see you as.

Part of my approach has to do with my appearance. I've written about this before and I think I've made it clear that I am an untraditional appearing doctor. Most patients ask to see the doctor after I've been in, even when I clearly introduced myself at the beginning. Their response is not one of disbelief but of relief. "oh! you're like a real person!". I'm a bit quirky, I'm overweight, I smile all the time, especially when I don't feel like it. When my patients die, or I need to give someone bad news, or someone has divulged some horrific part of their life, I cry with my patients. It's the only way I can think of to let them know that they matter to me.

I also have a strong feeling for what is and is not fair. This is something that comes through whenever I talk to a child living well below the poverty line. Their anger and emotional outbursts are almost always associated with a feeling that something that has happened is unjust. I grew up well below the poverty line and I still get surges of rage when things are unfair. I've learned to breath deeply, reconsider my stance, and decide whether or not I need to proceed. If I need to proceed, look out. It will feel like molten lava is being rained on your head, because on top of my previous poverty speak, I am now also fluent in affluence, biz speak, economics, and ethics.

This all sounds very Polly-Anna-y, and it might be. Putting my personality in with a hospital that has administration that could, easily, use walkers, doesn't always work. I'm optimistic though that I can persuade admin to my side even through continuing to be patient centred. It's in the mission statement of every hospital of Ontario, including ours.