26th December, 2023

What Shame Made Me Do

With Dr Sandy Miles

Photo of Dr Sandy Miles

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On this episode

If you have a high-stakes job like medicine, shame can show up in unexpected and unwelcome places. Doctors have incredibly high societal expectations, with constant pressure to be invulnerable. It’s time to challenge these unrealistic expectations and foster an environment that supports doctors in their vulnerability.

This week, we’re featuring one of our most popular and impactful episodes from 2023 to help you identify and combat shame. In this episode, Dr Sandy Miles discusses the impact of shame on doctors and how we can address it by changing the toxic stories we tell ourselves.

We all make mistakes, but shame keeps us from being objective and fair, leading us feeling like we’re inherently bad or wrong. Finding ways to be kinder and more supportive to ourselves will help not only our wellbeing, but will brighten the lives of those closest to us.

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About the guests

Dr Sandy Miles photo

Reasons to listen

  • To discover the powerful impact shame has on us, and how our wellbeing and professional identity can be affected
  • To explore the different ways we respond to shame
  • To learn how to create a healthier and more supportive environment

Episode highlights


What is shame?


How identities are tied to shame


How people respond to shame


How to respond to shame


Shame and perfectionism in healthcare


How to overcome maladaptive perfectionism


Fostering a growth mindset


How to combat shame


Where to find help


Sandy’s top tips for deadling with shame

Episode transcript

[00:00:00] Rachel: Every year on the podcast, I find that a new theme emerges and really strikes a chord. This year, I would never have predicted that an episode about burnout and shame would become our most popular episode ever. However, once you’ve heard the message contained in this conversation. It’s very difficult to unhear it.

[00:00:18] In fact, this interview with GP, Dr. Sandy Miles led me on my own personal voyage of discovery and formed the basis of my keynote talk, How to Say No, Set Boundaries and Deal With Pushback.

[00:00:30] You see, the thing I’ve got wrong all my life is thinking that I needed to learn yet more skills, yet more techniques, and yet more models that would allow me to take control of my own life and have difficult, but honest conversations with people and set boundaries so this I could meet my own needs. I never realized that the one thing that was stopping me was the shame associated with upsetting people. So believing I’ve done something wrong or I am wrong, or not getting things right all the time, which leads to a deep shame spiral of I’ve done it again, I really should know better, and I am not good enough, I am not enough.

[00:01:08] As I’ve carried on thinking about this and investigating these toxic shame stories, I’ve come to realize that shame is often embedded deeply in people like doctors who are in high stress roles from whom a lot is expected. And it’s this very thing, the sense of responsibility, which makes it impossible for us to say no or let people down. So much so that we push on relentlessly towards burnout. Even though we know that there’s an alternative path.

[00:01:34] In 2024, I intend to double down on how to change these toxic shame stories that we tell ourselves and which keeps us trapped in unfulfilling work within toxic cultures, and explore just how we can think differently so that we can choose to live our one wild and precious life free from shame, guilt, and fear.

[00:01:54] But until then, I hope that this replay episode helps to uncover for you some of the unhelpful stories and beliefs which are keeping you stuck. And in the new year, I sincerely hope that you’ll make the resolution to be kinder to yourself so that you’ll also be able to be kinder to everyone else around you. And believe me, your nearest and dearest will thank you for it.

[00:02:14] If you’re in a high stress, high stakes, job like medicine, and you’re feeling stressed or overwhelmed, burning out or getting out are not your only options. I’m Dr. Rachel Morris, and welcome to You Are Not a Frog.

[00:02:33] It is fantastic to welcome onto 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.

[00:03:00] Sandy: Thanks for having me.

[00:03:01] Rachel: So Sandy, first of all, I’d love to know how did you get involved with shame? Tell me how it all started.

[00:03:07] Sandy: Yeah, so it all started with me being ill. Um, so I was ill probably about 10 years ago now, and that involved taking a prolonged period of time out of medicine. Um, 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. Uh, and I started looking around to see how I could regain that interest.

[00:03:37] And I found this Masters in Medical Humanities, um, in London and signed up for that. Through the course of that, I had to write obviously a dissertation with that masters. And I, um, 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, um, when I was unwell.

[00:04:08] 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, um, affects doctors and how it’s involved with something called the medical identity.

[00:04:26] Rachel: So 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?

[00:04:37] Sandy: So I think shame is, is always a feeling that you are, that you are 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. And 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 wellbeing and not on your own. So when I became unable to help other people, clearly that caused me to experience shame.

[00:05:16] Rachel: Is that how that’s defined in sort of all the literature about shame?

[00:05:19] 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 our, to ourselves. But um, guilt is about when we’ve done something wrong. So it’s about behavior 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, of recovering from guilt. You can say you are sorry is the most common way people experience guilt.

[00:05:53] Um, shame on the other hand is about feeling that you are, you are wrong. It’s not that you’ve done something wrong, but that’s something fundamentally wrong about you. And I think I illustrate this with a story about, um, a physician in the states called Danielle Offy. And she talked about an occasion in the A and E department of this New York hospital as a junior rector when she’d forgotten to give a patient some, uh, long-acting insulin when they came in in DKA. And what that meant was that her consultant screamed at her in the middle of the A and E department surrounded by patients and staff.

[00:06:30] And what she, when she reflected on it, she said the guilt of having made that medical error, actually she got over pretty quickly. She could rationalize that to herself. She’d done something wrong, she apologized, put it right. What stuck with her was the shame of realizing 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.

[00:06:53] And a lot of people will have read Adam K’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.

[00:07:08] Rachel: Do you think that doctors get more shame than other people just because they hold themselves perhaps a really, really high standard when it comes to treating patients? ie, I must never make a mistake?

[00:07:22] Sandy: I think, uh, I mean to experience shame is to be human. Everybody experiences it. You can’t abolish it. Um, 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 and you, you quite rightly point out making a mistake or the fear of making a mistake is probably the main driver for most people, um, and why, why doc? Most doctors experience shame.

[00:07:51] I think more broadly being ill is a source of shame as I experienced, uh, as a doctor, feeling that you are different in some way. So shame is a social emotion. It’s about trying to, um, make sure that you fit in, ’cause if you, if you step outside of the kind of group rules, if you like, you are gonna 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.

[00:08:24] And then 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, um. As a human to human interaction, you are seeing people as a doctor at their most vulnerable, and so those people are themselves experiencing shame. And our witnessing that as a GP every 10 minutes has a, has significant impact on us as doctors. So seeing that we will in some way be experiencing some of their shame.

[00:09:11] Rachel: That is very interesting. So literally seeing someone else’s shame means that we experience some of it ourselves. Is that through empathy or how does that work?

[00:09:21] Sandy: Yeah, so I think that is, my understanding is that is through empathy and you know that you’re experiencing it. And I dunno if you can take yourself back to when you’re watching somebody in a hospital bed, for example, being sick or, 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, you would witness their shame if you looked at them and it’s too uncomfortable, so you look away.

[00:09:45] And, and that’s an extreme example, but seeing a patient who’s their most vulnerable, you, yourself, will be experiencing some of their feelings of shame and it makes it uncomfortable and, and often doctors will tend to push those patients away because it is so uncomfortable.

[00:10:04] Rachel: I’ve never really thought of that. I guess I can sort of see how, yeah, if, if a close relative is sort of embarrassing themselves in some way, you just feel dreadful. You try and stop it, don’t you? So, yes, that, that does make a, make a lot of sense. So with probably unconsciously, I guess then absorbing.

[00:10:21] Sandy: Yeah.

[00:10:21] Rachel: The shame of, of, of other people that, that we are seeing. What effect does that have on people?

[00:10:26] Sandy: Then 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.

[00:10:38] So if you imagine, if you remember, I’m sure you remember, um, being humiliated in some way at medical school, and there’s difference between being humiliated yourself and watching other people being humiliated. So when you, when you witness other people’s shame, you also feel very uncomfortable. So witnessing somebody else’s shame is really uncomfortable. So you either, you put a barrier to prevent yourself from engaging fully with that person. ’cause you know it’s gonna make you feel uncomfortable, um. or you, or you open yourself up to their own vulnerability, and that may have an emotional cost to you as as a doctor as well.

[00:11:19] 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.

[00:11:33] 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 with there some other stuff going on as well?

[00:11:51] Sandy: So I think what I’ve come to understand is this, this concept of identity is quite complicated.

[00:11:56] So identity means the same. So you, 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 their identity they have at home. And my understanding is that the medical identity is such a powerfully integrated identity in our social network that you are always a doctor, whether you’re at home, whether you are watching your children playing sport, whether you are in the supermarket, you carry that identity in all settings, and people expect you to always behave as a doctor regardless of the setting.

[00:12:48] 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 become, they 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. Are you, uh, 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.

[00:13:26] And I’ve also understood that shame is a gendered thing. So men experience shame when they, 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, mom, wife, all those other identities I carry, I suddenly couldn’t do any of them anymore. And so I therefore experienced shame, I think.

[00:14:12] Rachel: Gosh, I was just thinking about the whole gender thing as well. And of course, you know, we can’t completely generalize and there’ll be people that, that, that,

[00:14:19] Sandy: yeah, of course.

[00:14:20] Rachel: Different genders who identifies everything that can do both. But I think for women as well, this whole, I’ve gotta do Beverly, no effort. Um. I must never get angry.

[00:14:29] Sandy: Mm-Hmm.

[00:14:29] Rachel: Or cross or be assertive. And I, I know that I’m quite an emotive person when I have got a bit cross and, you know, said some things or been a bit impulsive, a lot of shame afterwards that that’s not the way a woman should behave. And then you just feel terrible, don’t you?

[00:14:43] Sandy: Mm-Hmm. 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, and I talk a lot to, to people about shame in 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.

[00:15:08] Rachel: Mm-Hmm.

[00:15:08] Sandy: Everybody can understand and recognize what that feeling is like.

[00:15:12] Rachel: How do people react to those feelings of shame then?

[00:15:16] 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 recognize 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 will might be shown as sometimes people physically shrink their posture changes. Sometimes it mean 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.

[00:15:55] The other way that people respond is they can move into appeasement. So that they, um, in order to protect themselves from further shame, if you like, they, um, get close to the, to the person or the 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, the other response is something that. People will recognize, and that is the anger, the rage, the narcissism, the bullying. Those are all responses to people’s shame.

[00:16:31] Rachel: That’s interesting. Can you expand on that? How is bullying a response to your, to one’s own shame? Or is it response to somebody else’s shame?

[00:16:39] Sandy: No. So it’s a response to your own shame, because if you bully other people, I guess you are protecting yourself from being threatened in any way. So you, you, by bullying other people, you prevent other people shaming you. ’cause you are kind of getting in there first if you like.

[00:16:57] Rachel: Okay, that, that makes sense. What about narcissism? Just, that’s just like, I have to do everything I can to look utterly amazing and brilliant. ’cause then that won’t cause me any shame? Is that right?

[00:17:09] Sandy: Yeah. And I tell everybody how wonderful I am all the time, and I,

[00:17:12] Rachel: Mm-Hmm.

[00:17:12] Sandy: Yeah.

[00:17:13] Rachel: Gosh. I, I was just saying this. I’m just having various different people springing to mind here and going, 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 shame? Because those are all really unhealthy, right?

[00:17:30] Sandy: They’re really unhealthy and I think, um, shame has got lots of different names and, and one of them is it’s a guardian of your values. So I think there is a real,

[00:17:37] Rachel: Yeah.

[00:17:38] Sandy: Educational aspect to shame.

[00:17:40] So when you experience shame, if you can kind of sit with it long enough to to, to get with it, you kind of will know. That, that means one of your values is being challenged. ‘Cause 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, uh, definite that one of your values has been challenged. And so therefore you can. It can build your own self-awareness.

[00:18:08] And obviously the, the main, you know, use of shame if you like, or main purpose of shame, if you like, is, is to make us social animals. It, it brings 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 realizes that’s not a good way to be.

[00:18:32] Rachel: That makes a lot of sense because when you were talking earlier about, you know, we, we group. We are group animals, aren’t we? We are 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, this triggering response, which is so uncomfortable to us, our stress responses into our, our fight, flight or freeze response. And, and we, we go. We go miles away from anything that causes that response and we go miles 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.

[00:19:14] So I’d never really thought about that before, actually, that shame is I direct directly related to that group threat that we experienced through the amygdala. It’s interesting, isn’t it?

[00:19:26] 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’ve been left behind to die, if you like, in the, 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.

[00:19:59] Rachel: Yeah. So, 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, 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, and say what they wanted to say. And I felt, I felt absolutely dreadful. I mean, I, I felt. Really upset. And the person that gave me that feedback, I think was quite shocked by my response. I was, I was utterly devastated and I felt really ashamed, I guess.

[00:20:37] Sandy: Hmm.

[00:20:37] Rachel: And, and then ev it’s every time I’ve been out since, I’ve been trying to think, okay, am I letting people finish? Am I, am I busting in? Am I overexerting my opinions and stuff like that? ’cause 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, and I had done that, I had knocked my own value perhaps.

[00:21:02] Sandy: Yeah. You’ve come up, you’ve, you know, come up short, I guess is how most people

[00:21:06] Rachel: mm-hmm.

[00:21:06] Sandy: Think of it, you fall short of your values when you experience shame.

[00:21:10] Rachel: Okay, so it’s like your personal alarm bell of you falling short of your own values. So it can be helpful sometimes.

[00:21:17] Sandy: Yeah. Yeah.

[00:21:18] Rachel: So how, how can I tell whether it’s helpful shame or or unhelpful shame here?

[00:21:23] Sandy: Well, I guess as I said earlier, I think one of the hallmarks of shame, shame is silence. So it’s when there are things that we don’t want to tell other people about. Now 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 gonna talk to Sandy or other people about it. And in some way that will dispel that shame if it’s met with empathy.

[00:21:54] So if you’re, 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 gonna 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.

[00:22:15] So talking about shame, there’s um, Brene Brown, who’s the professor of social work in the states who I’m sure many, many people have heard, speak and seen her TED talks, et cetera. She has a great expression about this and she says, talking about shame, basically cuts it off at the knees. And that’s it.

[00:22:34] 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.

[00:22:51] Rachel: And that’s interesting. So we did a podcast, uh, quite a while ago actually, about the second victim, you know? Yeah. When, when you make a mistake as a doctor, you are, you are often, or, or, or a patient comes to harm, whether it’s your fault or not, you are often the second victim.

[00:23:04] And, uh, the people in podcast saying that one of their patients had died by suicide and they felt incredibly responsible even though, you know, looking back that there wasn’t really anything that could have been done.

[00:23:15] Sandy: Mm-Hmm.

[00:23:15] Rachel: And they felt absolutely awful until they told somebody about it and discussed it. And it wasn’t just telling anybody about it. He goes, 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, in different circumstances or had made a mistake themselves. So they really got it. They had experienced that and, and so it wasn’t, you are on your own, you are the only person that’s done that thing or experienced that thing. No, we have as well. And that’s just takes, like you said, it takes a sting out of it.

[00:23:52] Sandy: Yeah. And, and that’s, that’s the basis of all group therapy really. So if you think about a therapy for, say, addiction, you know, 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 gonna get it, they’re gonna 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, um, solutions to, to how you feel. But that is the, that is the background concept really behind all therapy groups.

[00:24:33] Rachel: Now that makes a lot of sense, an absolute lot of sense. And 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, of illness as well. And like you said, as doctors, we’re constantly coming up against patients who get ill and who die 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 a 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 are 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 get it open or 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?

[00:25:33] 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 and it’s in some way Mm-Hmm.

[00:25:41] Um. I talk a lot with, um, colleagues in secondary care ’cause they don’t have the same setup in psychiatry they do, but not in other specialties, and I think it’s a big gap. Um, and I think it, that can leave people definitely isolated feeling they’re the only one who’s experiencing this. Um, and that can end really badly, sadly, in lots of situations.

[00:26:04] So, um, yeah, I’m a massive fan of those sort of peer support groups, places where people can talk without judgment, uh, 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. Um.

[00:26:23] Rachel: Hmm. Sandy, I know that you’ve already talked about the fact that, um, 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, and so if we get ill or can’t be the doctor that we think we should be, we feel quite a lot of shame.

[00:26:43] One of the, the issues I’ve seen in lots of doctors is this issue of perfectionism as well. How does that link into shame? Because I’m thinking that probably. Really, really influences the amount of shame you feel, right?

[00:26:55] 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, who treat doctors and their cleon tell, if you like, has shifted in the 10, 12 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.

[00:27:18] Um, so, the root really behind perfectionism is shame. There are two types of perfectionism, so I’m just gonna kind of quickly, uh

[00:27:27] Rachel: oh, great.

[00:27:27] Sandy: Cover those. So the first is what they call a psychologist call adaptive perfectionism. And that’s where you’ve set a goal and you’re gonna go, I’m gonna be the best at something, or I’m gonna get an excellent mark 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 gonna be setbacks. You know, there’ll be something doesn’t go right and that’s okay. So 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. And that’s a very adaptive perfectionism. So it’s hard work, but you get to a goal.

[00:28:11] Now, the other form of perfection is 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, is you, you are very careful. You are constantly focusing on past mistakes and things that haven’t gone well. Um, you, you have this all, always this sense of someone’s looking over your shoulder and you’re ready to be, you know, knocked down at any point. So you end up just working harder and harder and harder and really going nowhere.

[00:28:51] 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.

[00:29:02] 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. And that’s, to me. Is the perfect recipe for incredible amounts of stress and burnout, right?

[00:29:21] Sandy: Totally. And that’s why people are ending up, you know, uh, 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, if you make a mistake, someone is gonna get seriously harmed. And that is the recipe I think that really generates this, this perfectionism. So your fear and shame are really at the root of it all.

[00:29:49] Rachel: Mm-Hmm. And 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 are doing, you are making it impossible for them to use their coping mechanism, the shame, and, and, and, and you’re just gonna get into this massive vicious cycle and it’s gonna get worse and worse, right?

[00:30:24] Sandy: Yeah. And I think, you know what you, that that’s kind of what you often see is people, so when I’ve worked in training obviously, and seeing lots of, um, people working their way through the various hoops you have to jump through now. Um, you know, when you get hit, setback, and, and often that setback is nothing to do with anything that they have done, it’s just something happened. And then we’re gonna 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 around while I’m, I’m one step away from failure all the time, then you don’t have that resilience because it’s just too hard. And, uh, if your organization that you are working for doesn’t support you in that, then yeah, that’s when things go badly wrong.

[00:31:10] Rachel: How many doctors do you think suffer from this maladaptive perfectionism?

[00:31:15] Sandy: The vast majority, I would say in my experience, talking to them. Yeah. A lot.

[00:31:21] Rachel: Yeah.

[00:31:21] Sandy: It’s a big driver.

[00:31:23] Rachel: It really is. But how, how on earth then do we move out of maladaptive perfectionism and into the adaptive one, right?

[00:31:31] Sandy: Okay. So one of the answers is CBT, surprisingly.

[00:31:35] Rachel: Mm-Hmm.

[00:31:36] Sandy: Um, so what I mean by that is asking people to take small risks. Small, safe risks, if you like. And, and the one that the, that 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.

[00:32:09] And I think the. A concept that comes in here is something about a growth mindset, and that comes from the, some work by a lady called Carol Dweck who worked with primary school children. And 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, saw it as a great challenge, just tried it, had a go. If it didn’t go right, they tried a different way. And then there were other children who just looked at it and went, oh, I, I just can’t do it. I can’t do it. I dunno where to start. And she labeled those children who just kind of had a go, if you like, as having a growth mindset. And the key term that came outta 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.

[00:33:10] 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 gonna be able to do it, it’s they just can’t do it yet. And that might mean they need a bit more time, they might need a bit more, uh, training, they might need a bit more support, but they probably can do it eventually.

[00:33:33] And we, I think often as doctors, people feel they should be dealt to do everything straight away because our background at school and so on. Probably for most people was that they could just do stuff.

[00:33:44] Rachel: I think having taught a lot of medical students when I was on faculty running professionalism course and teaching general practice, I think, yeah, we had a lot of medical students coming through with very fixed mindsets, not very growth mindsets, being taught by lots of people who also have very fixed mindsets, it has to be said.

[00:34:00] Sandy: Yeah.

[00:34:00] Rachel: And I, and I, and I get, I get the thing about saying to the people, you know, 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 forties, early fifties, just before a time, and how on earth do you start to foster a growth mindset in yourself if you are being a perfectionist all your life?

[00:34:22] Sandy: Well, I guess often people come to this kind of thing when, when they’ve had a crisis, don’t they? When when they’ve reached a point where they want to make some sort of change because what they’ve, what they’ve used up till now is not working anymore. So if you are 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.

[00:34:41] I don’t think any of this you can foist on people. You can’t just tell them to do something and it’s not gonna work. But I think if people coming to you and asking, well, what, and 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.

[00:34:58] Um, 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 are really not very good at celebrating who people are. So we label people, we say, oh, you are an ST1 or you’re a consultant, or you’re a GP, and that’s their whole identity.

[00:35:24] 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.

[00:35:43] So valuing them, being interested in them as a person, um, and helping them to develop their own self-awareness is probably the route to go.

[00:35:54] Rachel: Sandy, I’m interested, so you’ve already mentioned CBT can help me with perfectionism, but can the, the CBT methods, all 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 pushback. And one of the, 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.

[00:36:29] So a lot of it, the shame is due to these untrue stories that we already have in our heads.

[00:36:36] Sandy: Yeah.

[00:36:37] Rachel: 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?

[00:36:44] 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 I had moral injury, or I’ve got imposter syndrome. And we use all sorts of terms when actually we mean shame. And I think if you are labeling it as something that sounds comfortable, then you can’t really address it.

[00:37:08] So, um, when I tell people I was writing a dissertation about shame, I wouldn’t say people cross the street. But, uh, you know, it wasn’t like universally warm welcome to that idea, because the word itself is so uncomfortable for people. And. 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, that you know you’ve missed the first step really.

[00:37:49] So I think for a lot of people it’s, it’s helping them to understand themselves better, to recognize 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.

[00:38:18] Rachel: And what would you say the hallmark toxic self-talk that goes on in shame that helps you identify that, oh, this is shame?

[00:38:27] Sandy: I think the shoulds are really important in there.

[00:38:30] Rachel: Should.

[00:38:30] Sandy: So shoulds are about

[00:38:31] Rachel: Mm-Hmm.

[00:38:31] Sandy: And they might be about meeting your values, but they quite often are about meeting other people’s expectations.

[00:38:37] Rachel: Mm-Hmm.

[00:38:37] Sandy: So the should is a, is a, is a bit of a, um, say red flag, but it’s a bit of an indicator.

[00:38:42] Rachel: Mm-Hmm.

[00:38:43] Sandy: I think when you hear people say, I’m a terrible doctor, or I even, I’m a terrible person.

[00:38:49] Rachel: Yeah.

[00:38:49] Sandy: That is a, 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.

[00:39:08] Rachel: So it’s sort of an I am

[00:39:10] Sandy: mm-hmm

[00:39:10] Rachel: something. I am terrible. I am not enough. I am a dreadful person. I should have. Rather than. Actually that’s interesting. I guess the should have, could, could just be guilt, right?

[00:39:23] I should have remembered her birthday.

[00:39:24] Sandy: Yeah. No, that

[00:39:25] Rachel: I’m a terrible person.

[00:39:27] Sandy: Right.

[00:39:27] Rachel: Versus shame, right?

[00:39:28] Sandy: Guilt versus shame. And they can get, they can coexist. So you can have both. One incident can gender 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.

[00:39:43] 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. So 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 talk to someone, so try and connect with someone, try and get that in the open. What else can you do? What else practically can we do to start to resolve all of this?

[00:40:11] Sandy: So I think you can challenge yourself as to where’s the evidence. So if you, 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.

[00:40:37] 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? ‘Cause it becomes a pattern. Very quickly is, well, where’s the evidence for that?

[00:40:52] 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, oh, that’s completely untrue. Why would you think that type thing, you think, oh, I’ve just sort of sense checked so, so some triangulation can be helpful as well, right?

[00:41:06] Sandy: Yeah, definitely. And I think, you know, people who know you well will be really good at challenging you on that.

[00:41:12] Rachel: Mm-Hmm.

[00:41:12] Sandy: Yeah.

[00:41:13] Rachel: Mm-Hmm. So challenge the evidence. Notice what the self-talk is. Notice what’s going on. Anything else?

[00:41:21] Sandy: I think, recognizing that your, 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 wifi 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.

[00:41:55] 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. ’cause belonging is what this is all about we want to be able to belong.

[00:42:10] And so things that people can do both in work and out work is outside work is have that is generate that sense of belonging. And feeling that you are being valued for who you are, not just ’cause you’re there to do a job, or, or service provisions, that terrible phrase that we use, but actually that you have inherent value as a human being.

[00:42:32] This, my favorite song is that, um, one from the Proclaimers Sunshine on Leaf, and she goes, while I’m worth my room 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.

[00:42:51] Rachel: I love that. Oh, I really love that. That’s hard sometimes, isn’t it? When you feel your value is in how hard you’re working and getting things right all the time and being that doctor and always being the one that’s helping someone. And so you start to, you tell yourself these stories that you ought to always be there for everybody and you should never make mistakes and that you are a bad person if you can’t. And then 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, even though you had absolutely no choice in the matter.

[00:43:26] Sandy: Yeah, completely. And, and, and I think it’s recognizing, um, 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, 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, really, you can’t affect it. So, yeah, you can’t beat yourself up with that particular stick.

[00:43:57] Rachel: And this is part of our work we talk about all the time is, you know, are you in your zone of power? Outside your zone of power? If stuff happens outside your control, absolutely. 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 actually things always will go wrong because we’re human and we do make mistakes?

[00:44:30] I think 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 are we gonna start to accept ourselves when we have done something?

[00:44:46] 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? I was like, no, I really didn’t. But obviously I had, you know, I had done that wrong and I bit 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 mean, I don’t know if we’re gonna come to the answer now, but maybe it’s just the recognition of it. Is important, right?

[00:45:16] Sandy: Yeah. And I think it comes, it comes from training, it comes from our, our training system. And I think I. As now a, a, a more senior doctor, I guess, as somebody who’s, who’s educating, uh, younger doctors and students, I’m really clear to tell them that nothing is certain, that, that we are. 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. And, and 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. And so people are made to feel that, you know, you can’t be a doctor and be vulnerable at the same time. And I kind of challenge that idea, but certainly that concept of uncertainty is pretty key to understand so that it’s a safety thing.

[00:46:11] ‘Cause it means you’re allowed to be uncertain, therefore you’re allowed to ask somebody. But it also means that you are gonna have to get comfortable with it because it’s not gonna go away and you can’t make it go away. There’s no way to be a perfect doctor.

[00:46:25] I kind of sometimes say to people, okay, so you wanna be a perfect doctor. Well 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.

[00:46:40] Rachel: No. So Sandy, we’re nearly out of time. I can imagine that also our listeners, like I have, 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?

[00:47:01] Sandy: So I think you, you, you commented on peer groups and I always really encourage people to join or set up a peer group, ’cause I think that goes a long way to offsetting this discomfort and is it’s therapeutic for everybody really. I also appreciate, not everybody feels, they don’t wanna go to a group. They feel uncomfortable with that, in which case you need to find somebody. It might be one individual that when you’ve had a bad day and we all have them, um, 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 I can I just talk about it? You’re just going to minimize the risk that you’re gonna end up carrying some heavy load that will trip you up at some point further down the line.

[00:47:51] Rachel: And then I guess there are other places that you can go to if you’re really struggling, like,

[00:47:54] Sandy: Yeah, of course.

[00:47:55] Rachel: Practitioner Health, coaches, therapists, all those sorts of things. I mean, there’s, and really encourage that people to do that.

[00:48:00] 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, aren’t you? Or 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. Um, but they all require you to. Pick up the phone or send an email, make that first step.

[00:48:26] Rachel: If people feel that sort of getting some therapy and accessing, you know, medical help or, or, or therapeutic help is too much, then they could always start with a bit of coaching, right? That could be helpful too.

[00:48:36] Sandy: Can’t Absolutely. Of course, just having somebody else’s perspective on it can be really helpful.

[00:48:40] Rachel: Yeah. Yeah. Great. So Sandy, what would your top three tips be really for identifying, recognizing, and dealing with, with shame? As a doctor or as a professional with a, a lot of responsibility?

[00:48:52] 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 ahead, 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.

[00:49:23] And then 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, to being guilt, and there’s, 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.

[00:49:50] 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. There’s um, TED talk from Brene Brown and, and things like that. If people wanna find out more about you and your work, where can they go to find out about that?

[00:50:04] 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, um, based on X to university. And they have a website, shameinmedicine.org. And I’m also recommending that people, if you, this is the. Subject that interests you, there’s been a fantastic new podcast by the Nocturnists. Um, there’s 10 episodes of Stories of Shame in Medicine. Those are all stories told by healthcare professionals of their experiences of shame.

[00:50:34] Rachel: And Sandy, I know you and a colleague also run retreats for doctors as well.

[00:50:38] Sandy: Yeah, so we’ve got one coming up later this year and, uh, we’d love people to come and join us. We’ve been running them for several years now. Um, and it’s a great opportunity to just. Get together with different colleagues, have a lot of downtime, eat some really good foods, 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.

[00:51:01] Rachel: Great. So we’ll put all those links in the share notes. Sandy, thank you so much for coming to talk to us and say, I think that’s been really mind blowing actually, I, I, I’ve got all these thoughts in my head now that I just really wanna go and really have a look at this thing about shame. Like you said, it seems to me to be the root of, of a lot of the stuff that we all struggle with and the stuff about perfectionism particularly fascinating as well.

[00:51:24] So thank you and probably gotta get you back another time to talk more about this.

[00:51:28] Sandy: Happy to help, yeah.

[00:51:29] Rachel: That’d be wonderful. And if anyone’s got any questions or comments or suggestions for topics, then please do drop us an email at youarenotafrog.com. Uh, love to hear your feedback at 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 thank you for listening, everyone, and we’ll see you soon. Thanks, Sandy.

[00:51:50] Sandy: Cheers.

[00:51:53] Rachel: Thanks for listening. Don’t forget, we provide a self-coaching CPD workbook for every episode. You can sign up for it via the link in the show notes, and if this episode was helpful, then please share it with a friend. I. Get in touch with any comments or suggestions at hello@unnotterfrog.com.

[00:52:12] I love to hear from you. And finally, if you are enjoying the podcast, please rate it and leave a review wherever you are listening. It really helps. Bye for now.