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.
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