In this episode of the Voices of Duke Health podcast, we hear from a School of Medicine faculty member and two medical students who work with him to understand how health care workers find strength through sharing their vulnerability.
Will Bynum, MD, is assistant professor in community and family medicine. He serves as associate program director of the Duke Family Medicine Residency, and researches self-conscious emotion (shame, guilt, & pride) in medical learners. Prior to coming to Duke, Dr. Bynum served seven years on active duty in the U.S. Air Force.
Medical students Claire Edelman and Ashley Adams work with Dr. Bynum on that research.
Hear their voices in the full episode starting Thursday, November 29, 2018.
This is Voices of Duke Health. I’m your host, Karishma Sriram.
Let’s talk about the dirty R word. According to Dr. Will Bynum, that’s what resiliency is becoming to the medical community. He’s worried that there’s this growing idea that you put on your resilience cape and should blast through anything in your way. So that’s not resiliency, right, but what is?
Will Bynum, MD: So let me explain what I mean when I say that resilience can become a dirty word in our community. I realize that’s a bit of a provocative statement and no way mean to say that resilience is a dirty word. In fact, it’s incredibly important. Really what I’m saying is we need to be careful not to oversimplify resilience or to contain it to something that can be packaged into a set of curricular resources or lectures, and that you either have or you don’t. It has to be something deeper and more complex than that, and we need to think about it more broadly. And be especially careful not to develop resources or tools that do create a burden and actually have the unintended effect of undermining resilience.
And so for me, resilience is a is a personal journey, within sort of a community of people that are supporting that. When you can take those experiences, of finding what makes you resilient, or what helps you develop resilience, and then share those with other people. And not just the great things you figure out, but also the really crappy things that you have to slog through to get to the other side. There’s a bond there.
Ashley Adams: I think that definitely to echo what you were saying, talking with other people who want to talk about it.
Karishma: That’s Ashley Adams, one of the two med students who works with Dr. Bynum. Claire Edelman is the second student, and you’ll hear from her in a minute.
Ashley: It’s really just, sort of groundbreaking when you realize that someone else has been going through the same thing and sort of having the same thoughts. So even if you can’t solve it together, or figure it out together right at that moment, it’s just very cathartic to know that you’re not going through that alone.
Claire Edelman: And I feel like for me, finding my resilience has come from friendships and being able to talk and be vulnerable with people. And Ashley and I are at different stages of our medical careers than Dr. Bynum, we are learners still. But for some reason coming to Duke, day one, it felt like it was more than that. I don’t know, that medicine was just a huge responsibility and that I was always comparing myself to others. I was like, everyone else is perfect and they know everything and I’m so dumb compared to everyone else. And all I needed was someone to be like, no this is really hard for me, too.
Dr. Bynum: One of the things we’re finding is we begin to understand how people in medicine, medical learners, compare themselves, is that they very often seem to do so sort of inaccurately. Where the standards against which they’re comparing themselves are either completely unreasonable, completely unattainable, they’re not accurate. So if you’re looking up—we were talking about this earlier—if you’re looking at an attending being like, wow, how did attending it so perfect? The attending is sitting there being like, man I’m like- all these learners know more than me, and I’m the really flawed one, I’m supposed to be perfect. So everyone- or many people in our environment I think are comparing, we’re striving to become something. And I think it’s very healthy to try to become something better. But when we’re trying to become the best, that gap is often so far and distant, that that makes us get down ourselves when when we inevitably recognize that we aren’t or can’t get there. What do y’all think, at your level?
Ashley: Yeah, I think just the fact that it is so difficult to get into medical school and you have to, at least it seems, be so near perfect to get into med school. I mean it’s just a tough road to get here. So, and then it feels often that you have to keep that up when you are here.
Claire: Not to mention that med school is full of transitions. You know this Karishma from second year, you’re going through all your clerkships and as soon as you think you’ve mastered PEDs you’re onto the next thing and you immediately don’t know anything again. And it’s just- for us type-A perfectionists, it’s really hard to be a beginner. To let ourselves be a learner, because we want to be perfect.
Bynum: I’m going to suggest that our resilience is potentially strongly influenced by what it is that we’re trying to become. So one of the ways that I’ve found resilience is thinking about, you know, my expectations of myself as a doctor. And for me, I’m totally okay not being the best doctor in the room. I’m defined by a lot of things that have nothing to do with my job as a doctor and recognizing that those things help me to become a better doctor. And so that acknowledgement and knowing of myself is what allows me to be resilient.
Ashley: I would echo that really strongly. There are some values in this field that I just don’t agree with. There are more that I do agree with, and I’m so happy to be in this profession. But there are many that I felt like are detrimental to people’s mental health, wellbeing, enjoyment in this profession. I sort of realized that I don’t need to adopt all of the values and this profession. And I can sort of be a little bit rebellious and say, okay, I’m going to set my own values. And that might mean that I’m not the smartest person in my class, or doing the best on board exams. But, you know, I have values that I am able to live up to and I strive to, that allow me to focus on the real meaning of what I’m doing every day.
Bynum: That’s cool, because what you’re talking about is just being yourself. And so it’s really, how well can you retain a core sense of self and values as you navigate these really challenging experiences in becoming a doctor? I think that’s where- that gets to a pretty core part of resilience.
Ashley: And I think it’s sort of a self-fulfilling prophecy too, that sort of just promotes continued wellness and resilience. So once I started paying attention to the values that I really wanted to pay attention to, and fostering them, I found myself surrounding myself by other people who had the same values and the same interests. And in that process I feel like I’ve enjoyed my medical experience way more than when I was trying to sort of jam myself into the values of the overall profession.
Karishma: I think it’s really neat that we’ve been talking about how your journey to resilience has been a very personal journey, but then you guys are talking about how you want to make resilience a part of the curriculum. How does that work?
Bynum: The most optimal way is to change the culture, and maybe the easiest and lowest hanging fruit is if we just start talking about what it means to be a person going through this. And not just doctors, or students, but I’m talking about everyone in this building, including the patients. If we can all talk about that and develop some shared community around that, that’s how we’ll start to move the needle.
We did a two hour workshop in which we introduced these emotions that you can feel when you evaluate yourself. So shame, guilt, pride. And we talked about ways in which shame, or feeling, you know, flawed or unworthy, can manifest in the process of learning medicine. And we did we did so by sharing a number of personal stories, we all shared a story, and somewhat painful stories. But what can y’all talk a little bit about what happened after that? You know, and the way that people started talking and communicating, because that was what was really kind of exciting.
Ashley: It was cool. I think it was- it was funny to me that when I went to my seat and checked my phone afterwards I already had had like five different text messages from different people saying, “thank you so much for sharing. That was super powerful. You did an awesome job. How can we keep this going?” And I think it is very telling that there’s a need and a desire to have more conversations like this.
Claire: And I want to acknowledge that what we did was terrifying. Like I am generally an open book and like very happy and free to speak, and I’m generally comfortable in a large group setting. But it was very scary to be vulnerable and share things that I hadn’t even shared with close friends, in front of a group of strangers. But strangers that I know are going through the same thing that I went through, and just hoping that I could be the one person to normalize the experience for someone else.
Bynum: This seminar was not earth-shattering. It was not sexy. It was really not innovative. All we did was we created a safe space in which we normalized these emotions and then created a forum to talk about them. And what you especially did was just sort of open up and and dig deep, in a courageous way, talk about things that we all have felt or will feel or are feeling, but are very very hesitant to talk about.
Karishma: I think it’s kind of amazing, Claire—actually all of you guys—have brought up this point that once we’re vulnerable, conversation can open up. And it’s amazing and beautiful. But I think it’s crazy that our profession, as physicians, we expect our patients to be so vulnerable and so open with us. And it’s kind of a double standard to, you know, expect our patients to tell us everything and then we just bottle up all of our emotions, all of our worries and fears, and never share them. Where do you think that paradoxical setting comes from?
Bynum: There’s a term for for this phenomenon. Brené Brown is where I came across it. She talks about the vulnerability gap. It exists when, between two people, one person is forced or willing to be more vulnerable than the other person. There is an inherent gap in the vulnerability between people who come to us with all variety of medical challenges, many of which are very sensitive and very difficult to talk about. And they tell them to us as we sit, sort of buttoned up, white coat, behind a computer, receiving this information and not having to give any sort of vulnerability back. And I think that we miss an opportunity to connect with people when we sit on the high side of the vulnerability gap. And what it comes down to is showing our patients about something about ourselves. You know, and this is this idea of letting them see us, our emotions, our weaknesses. It’s often labeled as oversharing. And there is definitely a point at which you can share too much with your patients. But what do y’all think about this notion of the vulnerability gap with patients?
Claire: I think I would want to go to a doctor who is a human and who can connect with me. And I would want to get know a little bit about them, that’s just the type of person I would want to provide my care. So that’s the type of doctor I want to be as well.
Karishma: Yeah. I just I wanted to share a quick story about physicians being vulnerable with their patients. I think this is back when I was shadowing a doctor, before we walked in, he was like “what is the wife’s name?” or like, “where is their daughter in school right now?” I was like, I have no idea who this patient is. Anyway, we walk in, he magically remembered the wife’s name and the daughter’s name and they had a great conversation about the patient’s family. And then he had to step out for a second and I just stayed in the room. And at that same moment, the patient was like, “wait, what was his daughter’s name? Didn’t she get married?” And it was so amazing to see that both of them were so invested in each other’s lives, just like, as people and like when the physician returned she was like, “you know, I heard that she got married recently,” and just had this whole conversation about it. And I think that was the moment that I realized that a doctor patient relationship doesn’t have to be a one way street.
Bynum: And I would say that those moments now, in modern day medicine, those moments matter more now than ever because those moments are less common. Those opportunities are less common. We spend so much time on a computer, that we do spend with patients, that is the opportunity for connection with them, connection with another human. And we need to take those opportunities, and I think doing so can serve as a real buffer from the burnout and disconnection and all the challenging emotions that come from all the other crap we gotta deal with. Maybe vulnerability is sort of the key to unlocking those opportunities. And if we can find that connection there, that could potentially be a driver of resilience as well.
Maybe one of the last things I’ll say is one of the best articles I’ve read in a while was a New York Times editorial that made the argument that maybe it’s not self-confidence that really matters, but self-compassion. So rather than projecting this high degree of capability that hides the vulnerability, rather, have enough self-compassion to promote that vulnerability, even at times when what’s needed more is just a dose of sort of self-compassion and vulnerability. I’ve started to operationalize that and I love it.
Karishma: Thank you guys, Claire, Ashley, and Dr. Bynum, for joining us. This was an amazing conversation and I’m so glad that you guys could come.
Claire: Thank you.
Ashley: Thank you.
Bynum: Thanks for doing this cool project and it’s awesome to have the forum to share.