How Perfectionism and Shame Lead to Stress and Burnout

Dr Rachel Morris: It’s not often that an idea comes along, which feels as if quite literally, a light bulb has appeared above my head. Now this is how I felt recording this episode about perfectionism and shame. You see, I’ve been obsessed recently with why doctors work and work and work until they make themselves sick, burnout or in crisis, and why they find it so hard to say no, not to go above and beyond the call of duty all the time to drop stuff or even admit that they need help.

The answer lies, I think, in not giving them yet more training on well-being or assertiveness, but to address the very real and very toxic problem of shame. Specifically, the shame, which comes from perfectionism, this deeply internalised belief that we always need to meet an impossibly high standard in a system which demands more than we can ever give. And then when we can’t, who do we blame? Ourselves, thinking that we should be able to cope, and that we are not enough.

So in this podcast, Dr Sandy Miles, a GP and trainer with an interest in shame in medicine, explores with me, what causes shame, and what it looks like in doctors, as well as the very real problems it causes us. Now, I think that every doctor experiences significant shame on a regular basis. And it’s one of the root causes of stress and burnout. So what if the key to resilience was not changing the system — although system change is definitely needed — but tackling our own internal mindset and self talk, the shoulds and the oughts, which lead to shame.

So listen to this episode, if you want to know how shame shows up in our daily lives, and the problems it causes. What exactly shame is and the difference between healthy guilt and unhealthy shame? And how shame can be linked to perfectionism and how to overcome this and live a life in which we can believe that we are valued as a human being, not a human doing.

Welcome to You Are Not a Frog, the podcast for doctors and other busy professionals in high stress, high stakes jobs. I’m Dr Rachel Morris, a former GP now working as a coach, trainer and speaker. Like frogs in a pan of slowly boiling water. Many of us don’t notice how bad the stress and exhaustion have become until it’s too late. But you are not a frog. Burning out or getting out are not your only options. In this podcast, I’ll be talking to friends, colleagues and experts and inviting you to make a deliberate choice about how you live and work so that you can beat stress and work happier.

Could you do with some time away from the day to day to take stock of your life and career? Our off-air, off-grid You Are Not a Frog retreat with myself and coaching trainer Henry Stephenson is happening this May in Devon. And you can get a special early bird price when you book before the 10th of February. We had some incredible feedback after our sold out pilot retreat in September and Henry and I would love you to join us and take in some much needed timeouts connecting with nature and other like-minded people to help you discover what you really want and what do you need to get there. Spaces are limited. So check out the link in our show notes now if you’re interested.

It’s fantastic. So welcome on to the podcast today Dr Sandy Miles. Now Sandy is a GP. She’s been involved in medical education for over 20 years, both in undergraduate and postgraduate education. And she has a special interest in medical humanities. In particular, around shame and how that manifests and how that affects people in medicine. This is a really fascinating topic. So Sandy, thank you so much for coming on the podcast.

Dr Sandy Miles: Thanks for having me.

Rachel: This Sunday. First of all, I’d love to know, how did you get involved with shame? Tell me how it all started.

Sandy: Yeah, so it all started with me being ill. So I was ill about 10 years ago now. And that involved taking prolonged period of time out of medicine. And when I came back to medicine, I kind of had this itch, feeling that actually I’d missed out on doing the kind of literature and art and history and all those things I’d really loved as a teenager that I’d had to give up when I went to medical school. And I started looking around to see how I could regain that interest.

And I found this master’s in medical humanities in London, and signed up for that. Through the course of that, had to write obviously a dissertation with that master’s and I started reflecting on my own experience. And I became aware that the thing that I’d really felt when I was ill was the shame of moving from being a doctor to being a patient. And that sense that doctors really shouldn’t be ill or couldn’t be ill even — I think that’s been smashed a bit by COVID — but certainly a lot of people said that to me, when I was unwell.

I did have excellent support from my medical colleagues when I was ill. But all the same, I was left with this lingering feeling that I kind of wasn’t enough. And that led me off onto a pathway to sort of think a bit more about shame and in particular, how it affects doctors and how it’s involved with something called the medical identity.

Rachel: There’s a lot in that, Sandy. How would you define shame? I mean, what were the emotions that you experience that you would identify as shame?

Sandy: So I think shame is always a feeling that you’re that you’re not enough, that you’re falling short in some way. And I think my investigation led me to understand that shame is really based around your values. So you experience shame when you fall short of your values.

I think as a doctor, one of your values that you’ve imbibed without really being aware of is that you are well, that you stay well, that your focus is on other people’s well being and not on your own. So when I became unable to help other people, clearly, that caused me to experience shame.

Rachel: Is that how that’s defined in sort of all the literature about shame?

Sandy: So the key thing really is to understand the difference between shame and guilt. So they’re both what are called self-conscious emotions. So they’re both things that we experience in relation to ourselves. But guilt is about when we’ve done something wrong. So it’s about behaviour. And it’s about breaking a rule. And you can be punished for that. So you may have to pay a fine, you may have to go to prison, whatever. But there’s a way of recovering from guilt, you can say you’re sorry, is the most common way people experience guilt.

Shame, on the other hand, is about feeling that you are wrong. It’s not that you’ve done something wrong, but there’s something fundamentally wrong about you. And I think I illustrate this with a story about a physician in the States called Danielle Ofri. And she talked about an occasion in the A&E Department of this New York Hospital as a junior doctor, when she’d forgotten to give a patient some long acting insulin when they came in and DKA.

What that meant was that her consultant screamed at her in the middle of the A&E department surrounded by patients and staff. When she reflected on it, she said the guilt of having made that medical error actually she got over pretty quickly. She could rationalise that to herself. She’d done something wrong, she apologised, put it right. What stuck with her was the shame of realising she wasn’t the competent doctor she thought she was. And that was what ate away at her for 20 years, actually, until she wrote about it in her book.

A lot of people will have read Adam Kay’s work. And the fact that he didn’t talk about the incident that made him leave medicine until he wrote about it in his book, also, to me speaks of shame, as the overriding emotion,

Rachel: Do you think that doctors get more shame than other people just because they hold themselves perhaps to a really, really high standard when it comes to treating patients — I must never make a mistake.

Sandy: I think, to experience shame is to be human. Everybody experiences it, you can’t abolish it. I certainly feel that there are lots of occasions when doctors are much more vulnerable to shame than maybe other people. And I’ve kind of looked at some of those issues. You quite rightly point out making a mistake, or the fear of making a mistake is probably the main driver for most people and why most doctors experience shame.

I think more broadly, being ill is a source of shame, as I experienced as a doctor, feeling that you’re different in some way. So shame is a social emotion, it’s about trying to make sure that you fit in. Because if you step outside of the kind of group rules, if you like, you’re going to feel shame. So feeling different in any way, whether that’s around class, whether that’s around gender, whether it’s around ethnicity, whatever it happens to be, makes doctors experience shame.

I think a really important area that I don’t remember anybody ever talking to me about was that witnessing patient shame. So when patients come to see doctors, they are at their most vulnerable. Whatever the illness is, and there are particular illnesses where they may feel even more vulnerable. But as a human-to-human interaction, you’re seeing people as a doctor at their most vulnerable. And so those people are themselves experiencing shame and witnessing that as a GP every ten minutes has significant impact on us as doctors. So seeing that we will, in some way, be experiencing some of their shame.

Rachel: That is very interesting. So literally seeing someone else’s shame means that we experience some of it ourselves. Is that through empathy? How does that work?

Sandy: Yeah. So I think, my understanding is that is through empathy, and you know that you’re experiencing it. And if you can take yourself back to when you’re watching somebody in a hospital bed, for example, being sick or looking really unwell, you kind of can’t look at them. And you can’t look at them, you can’t meet their eye, because actually, you would witness their shame, if you looked at them, and it’s too uncomfortable. So you look away.

That’s an extreme example, but seeing a patient who is their most vulnerable, you yourself will be experiencing some of their feelings of shame, and it makes it uncomfortable. And often doctors will tend to push those patients away, because it is so uncomfortable.

Rachel: I’d never really thought of that. I guess I can sort of see how, yeah, if a close relative is sort of embarrassing themselves in some way, you just feel dreadful, you’re trying to stop it, don’t you? So yes, that does make a lot of sense. So with probably unconsciously, I guess, then absorbing the shame of other people that we’re seeing, what effect does that have on people, then?

Sandy: You find ways of dealing with it, everybody finds their own way. And I guess for some people, they’ll put up a barrier to try and stop that sensitivity to the other person’s emotion. So if you imagine, if you remember, I’m sure you remember being humiliated in some way at medical school. And there’s a difference between being humiliated yourself, and watching other people being humiliated. So when you witness other people’s shame, you also feel very uncomfortable.

So witnessing somebody else’s shame is really uncomfortable. So you either put up a barrier to prevent yourself from engaging fully with that person, because you know, it’s gonna make you feel uncomfortable. Or you open yourself up to their own vulnerability, and that may have an emotional cost to you, as a doctor as well. So there are different ways I think of people dealing with it. And it probably depends on the day and on the patient. But it’s not a cost neutral thing. It has an emotional cost. And it affects how patients and doctors interact with each other.

Rachel: I know you said earlier that when you were ill, you felt a lot of shame. And that was tied into some of your medical identity. Is that all just because doctors shouldn’t get ill or is there some other stuff going on as well?

Sandy: So I think what I’ve come to understand is this concept of identity is quite complicated. So identity means the same. So you have an identity, where you are the same as other people in your group, and in our, in my situation, other doctors. And the other way you have an identity is the thing that makes you unique. So your own special identity, your personal identity. And for most people, their identity they have at work is kind of somewhat different from the identity they have at home.

My understanding is that the medical identity is such a powerfully integrated identity in our social network, that you’re always a doctor, whether you’re at home, whether you’re watching your children playing sport, whether you’re in the supermarket, you carry that identity in all settings, and people expect you to always behave as a doctor, regardless of the setting.

And the danger there, what happens is, is that your personal identity and your medical identity as I’m calling it, become conflated. They kind of merge together. And so when something happens at work that threatens your medical identity, if you like, so threatens your status as a doctor, it also threatens the status of who you are — do you have enough worth not just as a doctor, but as a human being as a person? And that sense of shame, not being able to do enough is, I think, partly what happened to me.

I’ve also understood that shame is a gendered thing. So men experience shame when they show weakness, and I’m talking about in a kind of Western culture here. So if men show weakness in any setting, they may well experience shame. For women, you’re expected to do everything, do it all perfectly, and pretend it was no effort at all. And if you can’t achieve those things, then you can experience shame. So I think for me having been an extremely busy doctor, mum, wife, all those other identities I carried. I suddenly couldn’t do any of them anymore. And so I therefore experience shame. I think.

Rachel: I was just thinking about the whole gender thing as well. And of course, you know, we can’t completely generalise and there’ll be people that, of course, different genders who identify with everything that can see both. But I think for women as well, this whole, I’ve got super no efforts. And I mustn’t ever get angry, or cross or be assertive. And I know that I’m quite an emotive person when I have got a bit cross. And, you know, said some things have been a bit impulsive, have had a lot of shame afterwards, that that’s not the way women should behave, and then you just feel terrible. They

Sandy: Yeah, it’s a really painful emotion, it’s probably the most painful emotion. Because it’s so painful, we work really hard to avoid it. And when we experience it, and I talk a lot to people about shame and medicine now, and I ask them, What does it feel like? And they go, Oh, it’s that thing, that sinking feeling in the pit of your stomach — it’s that feeling, you want the floor to swallow up? Everybody can understand and recognise what that feeling is like,

Rachel: How do people react to those feelings of shame, then?

Sandy: So broadly, I think there are three different ways that people respond to shame, or to the fear of shame. And one of them, the first one that probably most people recognise is they withdraw. So the concept of shame is to be covered, cover yourself, to make yourself small and insignificant, kind of hide away. So that might be shown as sometimes people physically shrink, their posture changes. Sometimes that means, they don’t turn up to things anymore, or they turn up late, or they become depressed, or they develop an addiction. All of those things can result from shame.

The other way that people respond is they can move into appeasement. So they, in order to protect themselves from further shame, if you like they get close to the person or this situation that’s causing them the shame to try and make sure they’re always perfect. They never do anything wrong. They never answer back. They never argue, and they never challenge. And that’s a reaction to that shame. Finally, the other response is something that people will recognise, and that is the anger, the rage, the narcissism, the bullying. Those are all responses to people’s shame.

Rachel: That’s interesting. Can you expand on that? How is bullying a response to someone’s own shame? Or is it a response to somebody else’s shame?

Sandy: No. So it’s a response to your own shame, because if you bully other people, I guess you’re protecting yourself from being threatened in any way. So you you by bullying other people, you prevent other people shaming you, because you’re kind of getting in there first, if you’re like,

Rachel: Okay, that makes sense. What about narcissism just, that’s just like, I have to do everything I can to look utterly amazing and brilliant, because then that won’t cause me any shame.

Sandy: Right. And I tell everybody how wonderful I am all the time. And I- yeah,

Rachel: Gosh, I just say this, I’m just having various different people’s being, oh, my gosh, maybe they’re like that, because they’re, yeah, well, they’re trying to avoid shame. Yeah, what’s a healthy response to these are all really unhealthy, right?

Sandy: They are really unhealthy. And I think shame has got lots of different names. And one of them is it’s a guardian of your values. So I think there is an educational aspect of shame. So when you experience shame, if you can kind of sit with it long enough to get with it, you kind of will know that that means one of your values is being challenged, because I think it’s quite difficult to know what your values are, until they’re really challenged.

But if you experience shame, that is an absolute definite that one of your values has been challenged. And so therefore you can- it can build your own self awareness. And obviously, that the main, you know, use of shame, if you like, or main purpose of shame, if you like, is to make us social animals, it bring social control, it means we behave ourselves. And you kind of know that when you come across people who are shameless. So if you talk about somebody who’s shameless. Everybody realises that’s not a good way to be.

Rachel: That makes a lot of sense, because when you were talking earlier about, you know, we’re group, we’re group animals, aren’t we? We’re pack animals, and we want to belong to the group. And I guess the shame that we feel is our amygdala response going, “Yeah, you’ve done something here that’s not going to be acceptable to the group that other people won’t like.” And that is this triggering response, which is so uncomfortable to us as our stress responses into our fight, flight or freeze response.

And as we go, we go miles away from anything that causes that response and we go moves towards things that make us belong, that make us feel that people like us, that they accept us, that we’re not we’re not different and all those sorts of things. So I’ve never really thought about that before actually, that shame is directly related to that group threat that we experience through the amygdala. It’s interesting, isn’t it?

Sandy: Yeah. So shame is all about fear of disconnection. So we want to be connected to other people. And evolutionarily, I guess, you know, if we broke the rules of the social group, we would have been left behind to die if you like in the desert, or wherever we were. So it was a genuine threat to your survival. And so shame drives disconnection. So trying to remain connected is kind of the opposite to that, obviously. And that’s what we’re all often unconsciously striving for.

Rachel: So shame, if I can get this right is this warning bell to you that one of your values, one of the things that you think is really important has been knocked, has been sort of bashed against or something like that. I mean, I do remember quite recently, we went out for a meal with some friends. And on the way home, I was told, I talked too much. And I hadn’t let someone else finish and say what they wanted to say. And I felt absolutely dreadful. I mean, I felt really upset. And the person that gave me that feedback, I think, was quite shocked by my response. I was, I was absolutely devastated. I felt really ashamed, I guess.

And then it’s every time I’ve been out since I’ve been trying to think okay, am I letting people finish? Am I butting in, am I over exerting my opinions and stuff like that, because I can talk a lot as my family will tell you.

So that was an example of the shame response showing me that my value of valuing other people and listening to other people had been knocked, and I had done that I had knocked my own value.

Sandy: Yeah, you’ve come up, you’ve come up short, I guess is how most people think of it, you fall short of your values when you experience shame.

Rachel: Okay, so it’s like your personal umbrella view falling short of your own family. So it can be helpful. Sometimes, yeah. So how can I tell whether it’s helpful shame or, or unhelpful shame here?

Sandy: Well, I guess, as I said earlier, I think one of the hallmarks of shame is silence. So it’s when there are things that we don’t want to tell other people about, then you’ve just told me that story, which is a really healthy response. So it’s saying, actually, I felt really uncomfortable, I felt the shame. But now I’m going to talk to Sandy or other people about it. In some way, that will dispel that shame, if it’s met with empathy.

So if you have an experience of shame, and you choose to go and tell somebody about it, who actually responds in a very negative way, that’s not going to help. Whereas if you talk to a friend or somebody close to you, that you respect and you feel will meet, meet that with empathy, that’s a good place to go with it.

So talking about shame, there’s Brene Brown, who’s the Professor of Social Work in the States who I’m sure many, many people have heard her speak and sing her TED talks, etc. She has a great expression about this. And she says, talking about shame, basically cuts it off at the knees. That’s it. So the only way to really resolve shame is to connect back with another human being, it’s not really about writing about it. It’s not thinking about it, it’s about speaking it out loud, is the way to stop it having that powerful hold over you.

Rachel: And that’s interesting. So we did a podcast quite a while ago, actually, about the second victim, you know, when you make a mistake, as a doctor, you’re often or a patient comes to harm, whether it’s your fault or not, you’re often the second victim. The people in podcasts were saying that’s one of their patients had died by suicide, and they felt incredibly responsible, even though you know, looking back, but there wasn’t really anything that could have been done.

They felt absolutely awful until they told somebody about it, and discussed it. It wasn’t just telling anybody about it, because oh, don’t worry, it wasn’t your fault. It was actually telling someone that also had had a patient maybe died by suicide in different circumstances, or had made a mistake themselves. So they really got it. They had experienced that. And so it wasn’t you’re on your own. You’re the only person that’s done that thing or experience, I think no, we have as well. And that’s just takes, like you said it takes the sting out of it.

Sandy: Yeah. And that’s the basis of all group therapy, really. So if you think about therapy for say addiction, you have a group of people who’ve all experienced addiction in its various forms, and they’re able in that group safely to talk about what’s happened to them, and what they’ve experienced, because they know that the other people in that group are going to get it, they’re going to understand. And that is, the first step is to try and dispel that shame, in order to then move forward and come up with some, you know, therapeutic solutions to how you feel. But that is the background concept really behind all therapy groups.

Rachel: And that makes a lot of sense, an absolute lot of sense. It leads me to wonder why we don’t promote sort of peer groups for doctors much more, because we know that it helps with addictions, we know that it helps with other forms of illness as well. Like you said, as doctors, we’re constantly coming up against patients who get ill, and who died through no fault of our own, or things that we’ve done wrong, or even not being able to help people in the way that we’d want to because of COVID, or lack of resources, or even the fact we might have made a mistake or not known something.

So there’s constantly things that are quite likely to make us feel shame. And if you’re saying that just getting together in a group of people who pretty much are experiencing the same thing will make that go away, or just gonna open up out in the open or as Brene Brown says, cutting it off at the knees. I love that, then why aren’t we talking about the importance of getting together and talking about it more?

Sandy: Well, I’m a massive fan of that kind of group. You know, I think anybody who’s trained as a GP was part of a small group in some way. I talk a lot with colleagues in secondary care, because they don’t have the same setup in psychiatry. They do but not in other specialties. And I think it’s a big gap. And I think that can leave people definitely isolated, feeling they’re the only one who’s experiencing this. And that can end really badly, sadly, in lots of situations.

So yeah, I’m a massive fan of those sort of peer support groups, places where people can talk without judgement, and get some understanding and empathy back from their peers is hugely powerful. And I think, almost essential, really, to have a healthy experience as a doctor.

Rachel: So, Sandy, I know that you’ve already talked about the fact that the medical identity may maybe makes doctors particularly prone to shame because we feel we should always be working as a doctor, we should be doing more, we should be helping people. So if we get ill or can’t be the doctor that we think we should be, we feel quite a lot of shame. One of the issues I’ve seen a lot of doctors is this issue of perfectionism as well. How does that link into shame is that I’m thinking that probably really, really influences the amount of shame you feel right?

Sandy: Yeah, and it’s a massive issue with doctors. So part of the research that I did was talking with people at practitioner health, who treat doctors and their clientele, if you like, has shifted in the ten, twelve years that they’ve been around. And from sort of depressed, older doctors to now much younger, and often very anxious doctors, and perfectionism is a huge part of that.

The root really behind perfectionism is shame. There are two types of perfectionism. So I’m just gonna kind of quickly cover those. So the first is what they call, what psychologists call adaptive perfectionism. And that’s where you’ve set a goal, and you’re going to go, I’m going to be the best at something, or I’m going to get an excellent mark in an exam or whatever, and you set a goal and you work towards it. And when before you even start off, you know, there’s going to be setbacks, you know there’ll be something doesn’t go right. And that’s okay. When you hit a setback, you’re okay, you’re prepared for that. You work through it, you keep climbing up, and I call it the upward looking perfectionism because you’re always looking up at your goal. And when you reach your goal, you celebrate, and you might celebrate very publicly. That’s a very adaptive perfectionism. So it’s hard work. But you get to a goal.

Now, the other form of perfectionism, unsurprisingly, called maladaptive perfectionism, and it and it’s all about looking down. It’s all about working incredibly hard to avoid falling into the pool of shame. So what happens in that situation is you avoid risk, you’re very careful. You’re constantly focusing on past mistakes and things that haven’t gone well. And you have this always: the sense of someone’s looking over your shoulder and you’re ready to be knocked down at any point. So you end up just working harder and harder and harder, and really going nowhere.

So those are the two types of perfectionism — one of them really, shame doesn’t come into it. But the maladaptive perfectionism is fundamentally rooted in shame.

Rachel: And I’m looking at that list of things that you’ve just told me. You do working harder to avoid falling into that pool avoiding risk, being really careful dwelling on your past mistakes and just working harder and harder and harder. That, to me, is the perfect recipe for incredible amounts of stress and burnout, right?

Sandy: Totally. And that’s why people are ending up needing help, because that’s what’s happening. You’re taking very high achieving medical students or school students, you’re putting them into a job that says, if you make a mistake, someone is going to get seriously harmed. And that is the recipe, I think that really generates this, this perfectionism, of fear and shame are really at the root of it all.

Rachel: Also, I’m just thinking, if you’ve got someone that is really prone to this maladaptive type of perfectionism, you stick them in a job, where they just try and work harder and harder to make it better. Yet you give them a completely unachievable workload, then what you’re doing you are making it impossible for them to use their coping mechanisms, the shame, and you’re just gonna get into this massive, vicious cycle, and it’s gonna get worse and worse, right?

Sandy: Yeah, and I think you know, what you see that that’s kind of what you often see is people. So when I’ve worked in training, I was then seeing lots of people working their way through the various hoops, you have to jump through now.

You know, when you get hit by a setback, and often that setback has nothing to do with anything that they have done. It’s just, something happened. And then we’re going to come back to the resilient word, right? So people would then expect you to be resilient in the face of that setback. But if you’ve set up your whole belief system is all about, well I’m one step away from failure all the time, then you don’t have that resilience, because it’s just too hard. And if your organisation that you’re working for doesn’t support you in that, then yeah, that’s when things go badly wrong.

Rachel: How many doctors do you think suffer from this maladaptive perfectionism?

Sandy: The vast majority, I would say, in my experience, talking to them, yeah, a lot. It’s a big driver.

Rachel: It really is. But how on earth then do we move out of maladaptive perfectionism and into the adaptive one, right?

Sandy: Okay. So one of the answers is CBT, surprisingly. So, what I mean by that is asking people to take small risks, small, safe risks, if you like. And the one that the practitioner health talk about their first step is they get people to send an email to a colleague with a deliberate spelling mistake in it. So on many people’s scale, that’s a really tiny thing. But actually, for a lot of people, even that feels unmanageable. So taking small risks, and then being supported to take slightly bigger risks, so graded approach.

I think the other concept that comes in here is something about a growth mindset. And that comes from some work by a lady called Carol Dweck, who worked with primary school children. She gave them a task, and then asked them how they felt about it. And some children just kind of just pressed on with the task. So it was a great challenge just tried it had a go, if it didn’t go right, try a different way. And then there were other children who just looked at it when I just can’t do it, I can’t do it, I don’t know where to start.

She labelled those children who just kind of had a go, if you like, as having a growth mindset. The key term that came out of that is I can’t do that — yet. So those children who could say yet, or those parents or those teachers, or those supporters or friends who say, well, you can’t do that at the moment, you can’t do it yet. leaves open always a room for possibility. It leaves open a room for growth and for development and improvement. And that, for me, is a really key concept for people to understand.

So if they’re struggling to do something, it’s not that they’re never going to be able to do it, is they just can’t do it yet. And that might mean they need a bit more time, they might need a bit more training, they might need a bit more support. But they probably can do it eventually. I think often as doctors, people feel they should be able to do everything straightaway. Because our background and school and so on, probably for most people was that they could just do stuff.

Rachel: I think having taught a lot of medical students when I was on faculty, running professionalism courses and teaching general practice, I think yeah, we had a lot of medical students coming through with a very fixed mindset, not a very growth mindset. It’s being taught by lots of people who also have very fixed mindsets.

It has to be said and I get the thing about saying to the people, you can’t do it yet. But what do you do? How else can you get someone to, particularly if, you know, we’re talking to doctors who are in their late 40s, early 50s, just before retirement, how on earth do you start to foster a growth mindset in yourself if you are being a perfectionist all your life?

Sandy: Well, I guess often people come to this kind of thing when they’ve had a crisis, don’t they? When they reach the point where they want to make some sort of change, because what they’ve used up to now is not working anymore. So if you’re in a position where you’re ready to make a change, where you’re keen to make a change, then those options are things you can talk about. I don’t think any of this you can foist on people, you can’t just tell them to do something that’s not going to work.

But I think if people coming to you and asking, an understanding some of these ideas around shame, and perfectionism can be quite powerful, I think in helping people to unpick it for themselves and figure it out. But I also think there’s a really important thing here about being valued, not just as a doctor. So we’re very good in medicine in celebrating what people know. And what people do, we’re really not very good at celebrating who people are.

So we label people, we say, oh, you’re an ST1, or you’re a consultant, or you’re a GP, and that’s their whole identity. Obviously, it isn’t, is it? You know, we’ve all got other parts to our personalities and our interests and experiences that we bring to bear as a doctor. But fundamentally, we’re a human being first and a doctor second, and reminding people of that can also help to just bring a bit of perspective to the whole thing. So valuing them being interested in them as a person, helping them to develop their own self awareness is probably the route to go.

Rachel: Sandy, I’m interested — so you’ve already mentioned CBT can help you with perfectionism. But can the CBT methods or the sort of mindset stuff, help you get over shame? Because the reason I’m asking is a lot of the work that I do is around how to say no to people, and then how to tolerate when you get pushed back. One of the main things about tolerating consequences and pushback is getting rid of those toxic stories we tell ourselves like, I should, I ought to, I must never upset people, I’m a bad person, if I have to go home for dinner on time.

So a lot of it, the shame is due to these untrue stories that we already have in our heads. What do you tell people to do about that? Or what do you think people can do for themselves? What sort of things can help this?

Sandy: So I think a large part of it is about language. So I hear people say, oh, I was a bit embarrassed, or I felt a bit guilty, or had moral injury, or I’ve got impostor syndrome. We use all sorts of terms, when actually we mean shame. I think if you’re labelling it as something that sounds comfortable, then you can’t really address it. So when I tell people, I was writing a dissertation about shame, I wouldn’t say people crossed the street. It wasn’t like a universally warm welcome to that idea, because the word itself is so uncomfortable for people.

I think if you can actually get people to really think about is what I’m feeling here is this shame that I’m feeling, okay? If it’s shame, then I know now how I need to deal with that. I need to go and talk to somebody about it, I need to find a way to resolve it in my mind. But if you can’t even label it, if you don’t even know that that’s what the emotion is that you’re experiencing, you’ve missed the first step, really.

So I think, for a lot of people, it’s helping them to understand themselves better to recognise what the emotion is, they’re actually feeling. And I’m on a bit of a mission to just say the word shame at all opportunities, because I just want to detoxify it as a word so that people are comfortable saying it. Because I think when you do name it for people, if they can’t do it themselves, there is a real, it really gives them good insight, and helps them to then resolve it.

Rachel: And what would you say is the hallmark toxic self talk that goes on in shame that helps you identify that, oh, this is shame.

Sandy: I think the shoulds are really important in there. So shoulds are about and they might be about meeting your values, but quite often are about meeting other people’s expectations. So the should is a bit of a red flag, but it’s a bit of an indicator. I think when you hear people say I’m a terrible doctor, or even I’m a terrible person. That is a blanket worldview that they’ve got. And that is embedded in shame because they’re not saying I did something wrong. They’re saying I am fundamentally wrong. And that if you hear that sort of talk, that, to me speaks of shame.

Rachel: So sort of an, I am something, I am terrible. I am not enough. I am a dreadful person I should have, rather than well, actually, that’s interesting, I guess the ‘should have’ could just be guilt, right? I should have remembered her birthday. I am a terrible person, right. Guilt versus shame, right?

Sandy: Guilt versus shame. And they can coexist. So you can have both. One incident can engender guilt and shame, but separating them out and understanding, and just listening really carefully to what people say about themselves gives you a lot of information,

Rachel: I guess a lot of this stuff is inside your head as well. So other people can’t, other people can’t see it’s looking at yourself when you’ve got those stories, when you’ve got that I’m not enough. I’m a terrible person, I’m a bad this, I should have done that what’s wrong with me type thing. When you find yourself doing that, and I know you said, talking to someone, so try and connect with some try and get out in the open. What else can you do? What else practically can we do to start to resolve all of this?

Sandy: So I think you can challenge yourself as to where’s the evidence? So if you come across something and you say, well, I’m obviously a bad doctor, or I’m a bad person, whatever. where actually is the evidence for that? So these are stories, as you say, that we can end up telling ourselves really based on no concrete evidence at all. You can’t come up with any evidence for it, well, then it may well not be true. So work you can do yourself, is when you hear yourself saying these things, challenging it and thinking, actually, is this just something I’ve started telling myself? Because it becomes a pattern very quickly, as well. Where’s the evidence for that?

Rachel: And I guess getting out and talking to someone like phoning a friend is also very helpful as well, isn’t it? Because you say I felt like no, that’s completely untrue. Why would you think that type of thing? Oh, I just sort of sense check. So some triangulation can be helpful as well. Right?

Sandy: Yeah, definitely. And I think you know, people who know you, well, will be really good at challenging you on that. Yeah.

Rachel: So challenge the evidence, notice what the self talk is, notice what’s going on. Anything else?

Sandy: I think, recognising that your needs as a human come first. So we’re often thinking about what are our needs as a doctor, so what are my needs at work, but actually, you know, the whole kind of Maslow’s Hierarchy of Needs, is saying, you know, at the bottom of that, the bottom level is kind of, Well, nowadays, it’s Wi-Fi and battery, right, but, but fundamentally, it’s about warmth, and comfort, and stability, and security. Those all have to come first, before you start trying to, you know, challenge yourself to do a really hard job on top of that.

So making sure that you’ve got your people close to you, whether they’re physically close to you, or you can contact them but you have a sense of security and belonging. Because belonging is what this is all about. We want to be able to belong. And so things that people can do, both inward and outward is: outside work is generate that sense of belonging and feeling that you’re being valued for who you are. Not just because you’re there to do a job, or service provisions, that terrible phrase that we use, that actually that you have inherent value as a human being.

There’s my favourite song is that one from The Proclaimers — Sunshine on Leith: And she goes while I’m worth my rube on this earth. And that’s it. Really, you need to feel that you deserve and are valued enough to take up your place on the planet.

Rachel: I love that. Oh, I really love that. That’s hard sometimes, though, isn’t it when you feel your value is in how hard you’re working and getting things right all the time and being backed up to and always being the one that’s helping someone. So you start to tell yourself these stories that you ought to always be there for everybody. And you should never make mistakes and that you’re a bad person if you can’t.

If you take that to its extreme, you get ill, through no fault of your own, and you feel shame about it. Because you can’t do what you thought, even though you had absolutely no choice in the matter.

Sandy: Yeah, completely. And, and I think it’s recognising the difference between stuff that’s going on from externally that you really genuinely have no control over. And then and then feeling in control of the things that you can do something about, and making sure that you’re aware of the difference between those two, so that you’re not blaming yourself for stuff that is totally outside of your influence or that you can’t affect it. So yeah, you can’t beat yourself up with that particular stick.

Rachel: And this is part of our work we talk about all the time is are you in your zone of power, outside your zone of power if stuff happens outside your control? That stuff you just have to accept. Interesting though, if there is stuff within your zone of control that maybe was your fault, or you have done something wrong, I think for me, what I struggle with is the fact that we really blame ourselves when something has gone wrong. Why can’t we just accept that actually, things always will go wrong, because we’re human, and we do make mistakes?

For me with this whole complaints and mistakes and failure, I think doctors haven’t yet got a handle on not blaming themselves for stuff that’s outside their control. So how on earth can we start to accept ourselves, when we have done something? I remember- quite sort of slight side note, you know, luckily, the pharmacist picked it up. But they said, you know, ‘Rachel, did you really mean to prescribe 280? diazepam?’ No, I really didn’t! But obviously, I had, you know. I had done that wrong. And I beat myself up about it for ages. It’s like, really silly mistake. It got picked up, no harm happened. And it was fine. But we can’t resolve that.

So I’m gonna- I don’t know if we’re going to come to the answer now. But maybe it’s just the recognition of it is important. Right?

Sandy: Yeah. And I think it comes, it comes from training. It comes from our training system. And I think, as now a more senior doctor, I guess, as somebody who’s educating younger doctors and students, I’m really clear to tell them that nothing is certain. I live with uncertainty every day, I don’t know all the answers, I never will know all the answers, I will definitely always make some mistakes. Being able to be comfortable with that vulnerability is a really key attribute of being a doctor. And it’s something that’s not talked about enough.

So people are made to feel that, you know, you can’t be a doctor and be vulnerable at the same time when I kind of challenged that idea. But certainly, that concept of uncertainty is pretty key to understand. So that it’s a safety thing, because it means you’re allowed to be uncertain, therefore, you’re allowed to ask somebody, but it also means that you are going to have to get comfortable with it. Because it’s not going to go away and you can’t make it go away. There’s no way to be a perfect doctor.

I kind of sometimes say to people, okay, so you want to be a perfect doctor. Point out for me the perfect doctor that you’ve met in your life? And who’s that person that you want to be then? And obviously, there isn’t one is there doesn’t exist.

Rachel: So Sandy, we’re nearly out of time, I can imagine that lots of our listeners, like I have been listening to you talk going, oh, my goodness, that just makes so much sense. I can see now there’s shame here. And here. And here. And that’s why I’m responding like this, this and this. What help can people access if they feel they really need some help with this sort of stuff.

Sandy: So I think you commented on peer groups. And I always really encourage people to join or set up a peer group, because I think that goes a long way to offsetting this discomfort, and is therapeutic for everybody, really. I also appreciate not everybody feels they don’t want to go to a group, they feel uncomfortable with that, in which case, you need to find somebody — might be one individual, that when you’ve had a bad day, and we all have them is you can debrief it with them. So that you’ve got somebody there that you can call up and say, ‘Look, this just happened. I don’t think it’s anything really serious, but can I just talk about it?’ You’re just going to minimise the risk that you’re going to end up carrying some heavy load that will trip you up at some point further down the line.

Rachel: I guess there are other places that you can go to if you’re really struggling like practitioner health, coaches, therapists, all those sorts of things. I really encourage people to do that.

Sandy: Yeah, and I think in order to access that help, you have to make yourself a bit vulnerable. You know, you’re putting yourself in the shoes almost, of being a patient on you’re saying, I need help. And some people find that much harder than others. And we know that doctors as a group, generally find it quite difficult. But there are lots and lots of sources of help out there now. But they all require you to pick up the phone or send an email, make that first step.

Rachel: If people feel that sort of getting some therapy and accessing, you know, medical help or therapeutic help is too much, then they could always start with a bit of coaching, right, that can be helpful.

Sandy: Absolutely, of course. Just having somebody else’s perspective on it can be really helpful.

Rachel: Yeah. Great. So Sandy, what would your top three tips be really for identifying, recognising and dealing with shame, as a doctor or as a professional with a lot of responsibility?

Sandy: Okay, so I would say find yourself a workplace where you feel really valued as a human. You’re not just a pair of hands, you’re not just a head and that the people there celebrate your uniqueness in some way, so find that within your workplace. On the perfectionism front, I think keep looking up, not down, become aware of when you’re looking down all the time. And remember, if you can’t do something, that just means you can’t do it yet. And there’s always a possibility of growth.

I think finally, if something does leave you feeling like you’re a failure or not good enough, and you hear yourself saying that to yourself, try and talk to somebody, you’re trying to shift something from being shame, to being guilt. And there’s an opportunity there for recovery. You can say sorry, or you can do something differently next time. But being consciously aware of that feeling, I think is really important and helpful.

Rachel: That’s brilliant. Sandy, thank you so much. And I know you’ve given us a load of links and some quite useful stuff that people can look at this TED talk from Brene Brown, and things like that. If people want to find out more about you and your work, where can they go to find out about that?

Sandy: Yep. So I’m happy for people to email me at sandy.miles2@nhs.net. There is a huge shame in medicine research project going on that I’m involved in, based in Exeter University, and they have a website, shameinmedicine.org. And I’m also recommending that people, if this is a subject that interests you, there’s been a fantastic new podcast by The Nocturnists, which 10 episodes of stories of shaman medicine, those are all stories told by healthcare professionals of their experiences of shame.

Rachel: And so I know you and a colleague also run retreats for doctors as well.

Sandy: Yeah, so we’ve got one coming up later this year. And we’d love people to come and join us. We’ve been running them for several years now. And it’s a great opportunity to just get together with different colleagues, have a lot of downtime, eat some really good food, have an opportunity to chat and to try out some things that you might not have tried out before. So you’ll find us at acaciaretreats.org.

Rachel: Great. So I’ll put all those links in the show notes. Sandy, thank you so much for coming to talk to us and say I think that’s been really mind blowing. Actually, I’ve got all these thoughts in my head now that I just really want to go and really have a look at this thing about shame. Like you said, it seems to me to be the root of a lot of the stuff that we all struggle with. And the stuff about perfectionism — particularly fascinating as well. So, thank you, I’m probably gonna get you back another time to talk more about this.

Sandy: Happy to help. Yeah.

Rachel: That’d be wonderful. And if anyone has got any questions or comments or suggestions for topics, then please do drop us an email at youarenotafrog.com. I’d love to hear your feedback on the podcast. But if there’s anything in particular, people would like to ask Sandy about this or anything you’d like us to address, then please let us know. So thanks for listening, everyone, and we’ll see you soon. Thanks, Sandy!

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