Doctors make mistakes and shame makes them rude?

Posted in: 

I don't know how I'd missed this, but Dr. Brian Goldman of CBC's White Coat Black Art did a TEDx talk last year, and it's wonderful. It's called: "Doctors make mistakes, can we talk about that?" (The video is at the bottom of this post if you'd like to watch it in its entirety.)

On my health pilgrimage, and as part of working on my zine, I've been tracing back through my medical history, trying to connect dots between all the possible factors that got me into this state of less-than-ideal health. I've been researching root causes of various symptoms and ailments, and how they're all intertwined. I've been thinking back to all the various extremely traumatizing interactions I've had with healthcare practitioners over the years.

One thing is crystal clear: doctors make mistakes. And some of the really good ones are starting to admit it.

Mistakes in their evaluations and prescriptions. Mistakes in the way they treat their patients. Mistakes in the ways they distrust and condemn peoples' own experiences of what's going on in their bodies. Mistakes in believing they know best. Mistakes in not being able to admit that they don't.

Coincidentally, I recently started reading Daring Greatly, Brené Brown's book about shame and vulnerability, and I am currently on Chapter 3: Understanding and Combating Shame.

Just like Brené explains,

The majority of shame researchers and clinicians agree that the difference between shame and guilt is best understood as the difference between "I am bad" and "I did something bad.
Guilt = I did something bad.
Shame = I am bad.
 
(Daring Greatly, p. 71)

In his talk, Dr. Goldman speaks to this in the context of medical mistakes:

Over the next few weeks [after making my first big medical mistake], I beat myself up. And I experienced for the first time the unhealthy shame that exists in our culture of medicine, where I felt alone, isolated. Not feeling that "healthy" kind of shame that you feel, cause you can't talk about it with your colleagues. You know that healthy kind, where you betray a secret that a best friend made you promise never to reveal, and you get busted, and your best friend confronts you, and you have terrible discussions. And at the end of it all, that sick feeling guides you, and you say, "I'll never make that mistake again." And you make amends, and you never make that mistake again. That's the kind of shame that is a teacher.

The unhealthy shame I'm talking about is the one that makes you so sick inside. It's the one that said, not that what you did was bad, but that you are bad. And it was what I was feeling...

And I kept asking myself these questions: "Why didn't I ask my attending?" "Why did I send her home?" And at my worst moments, "Why did I make such a stupid mistake?" And, "Why did I go into medicine?"

Slowly, but surely, it lifted. I began to feel a bit better. And on a cloudy day, there was a crack in the clouds, and the sun started to come out, and I wondered if maybe I could feel better again. And I made myself a bargain: that if only I redoubled my efforts to be perfect, I never make another mistake again, please make the voices stop. And they did. And I went back to work.

And then it happened again...

And I went through the same period of shame and recriminations, and felt cleansed, and went back to work.

Until it happened again, and again, and again, and again...

Alone, ashamed, and unsupported.

Here's the problem: If I can't come clean and talk about my mistakes, if I can't find the still, small voice that tells me what really happened, how can I share it with my colleagues? How can I teach them about what I did, so that they don't do the same thing?...

When was the last time you heard somebody talk about failure, after failure, after failure? …You're not going to hear somebody talk about their own mistakes... And that's the system that we have. It's a complete denial of mistakes. It's a system in which there are two kinds of physicians: those who make mistakes, and those who don't…

This is the thing, it's a lie. All physicians make mistakes, but only some talk about it.

As Brené says,

When we apologize for something we've done, make amends, or change a behavior that doesn't align with our values, guilt--not shame--is most often the driving force. We feel guilty when we hold up something we've done or failed to do against our values and find they don't match up... Guilt is just as powerful as shame, but its influence is positive, while shame's is destructive. In fact... shame corrodes the very part of us that believes we can change and do better. (Daring Greatly, p. 72)

The ones who talk about it surely feel/felt guilt about their mistakes, but they learned from them. The ones who don't, keep their mistakes, and their shame, burried inside where it eats away at them.

The experiences I've had with doctors who are rushed, dismissive, and legitimately seem to feel shameful for not immediately knowing the right answer, and/or not having the time to figure out what the right answer is, are the ones who I have personally been hurt by. 

I always wondered why some would go so far as becoming angry or dismissive when I would come in for help with my chronic illnesses, and have heard doctors label patients just like me "difficult patients" when the appropriate label would actually be "patients with complex health problems". I always do my best to be very nice, very organized, and very patient, even when they seem less than prepared to deal with me. So when their behaviour and attitude turn blatantly hostile, it's hard not to take it personally.

But this new connection I've made between shame and behaviour may well be the missing link that I was always looking for. Not that it excuses the behaviour by any means, but it might at least allow me to understand why I am often treated so poorly by physicians.

My knight in shining armour of late has appeared in the form of a lovely nurse practitioner at a women's health outreach center. This might sound backwards, and it doesn't speak at all to her competence or knowledge (which are both very high), but one of her biggest strengths in caring for me--a patient with complex health problems--is her willingness to say, "I don't know."

She appears to have no shame in admitting her limitations or saying directly to me that she needs to research some element of my care before making a recommendation. She trusts my own evaluation of what is going on in my body rather than needing to know, or should I say assume, everything inately. She does not hesitate to refer me to someone more specialized when my problems are beyond her realm. And that is why I trust her more than any other practitioner or physician I've seen: she seems to have overcome that shame mechanism, and what it allows her to be is honest.

Back to the conclusion of Dr. Goldman's talk:

What I've learned is that errors are absolutely ubiquitous… we work in  a system where errors happen every day. Where one in ten medications are either the wrong medication given in hospital, or the wrong dosage. Where hospital acquired infections are getting more and more numerous, causing havoc and death... Mistakes are inevitable. 

So, if you take the system as I was taught, and weed out all the "error prone" health professionals, well... there won't be anybody left.

And you know that business about people not wanting to talk about their worst cases? [When I'd] point the microphone towards them[…]their pupils would dilate and they would recoil. Then they would look down and swallow hard, and start to tell me their stories. They want to tell their stories, they want to share their stories, they want to be able to say, "Look, don't make the same mistake I did." 

What they need is an environment to be able to do that. What they need is a re-defined medical culture. And it starts with one physician at a time. 

The redefined physician is human, knows she's human, accepts it. Isn't proud of making mistakes but strives to learn one thing from what happened, that she can teach to somebody else. She shares her experience with others. She's supportive when other people talk about their mistakes. And she points out other people's mistakes, not in a "gotcha" way, but in a loving, supportive way so that everybody can benefit. And she works in a culture of medicine that acknowledges that human beings run the system, and when human beings run the system, they will make mistakes from time to time. So the system is evolving to create backups that make it easier to detect those mistakes that humans inevitably make, and also fosters in a loving, supportive way, places where everybody who is observing in the health care system can actually point out things that could be potential mistakes, and [are] rewarded for doing so. And especially people like me, when we do make mistakes, we're rewarded for coming clean.

My name is Brian Goldman. I am a redefined physician. I'm human. I make mistakes. I'm sorry about that, but I strive to learn one thing that I can pass on to other people. I still don't know what you think of me, but I can live with that...
From the patient's side of the gurney, that sounds a lot like a healthcare practitioner who is willing to be human, vulnerable, and honest. And to me, that's a darned good start.