Shame has a toxic impact on individuals and teams. But there are practical steps we can take to minimise it and create safer, more open spaces.

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Over the last couple of years, I've become obsessed with how shame shows

up for doctors and other senior professionals in health and social care.

And I've come to believe that a sense of shame or feeling

like we're not good enough.

It's the one thing which drives this into overwork, stops the

saying no, or setting boundaries, and paradoxically prevents us from

practicing that necessary self-care that we need to, to perform at our best.

Shame can be like a toxic fungus.

And if it's allowed to spread within organizations, It can create unsafe

working environments, which prevent us speaking up when things are going wrong.

As Brene Brown teaches shame can't survive in the light.

When we speak out loud, even just to a friend or a colleague, we

expose it, take the power out of it, and stop it from spreading.

My first interview with Dr Sandy Miles a few years ago, really

brought to light for me, how much shame motivates us into behaviors

that really aren't very helpful.

And so I'm delighted to welcome her back onto the podcast.

discuss what else she's discovered about shaman medicine over the last few years.

So, whether you're a senior leader or someone just starting out in a

team, this conversation will help you identify what shame looks like

in yourself, and how to recognize when shame might be a reason for the

difficult or challenging behavior in those around you, as well as how to

create safer environments where we can all learn and perform at our best.

If you're in a high stress, high stakes, still blank 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

Hi.

I'm, um, Dr.

Sandy Miles.

I'm a GP, uh, have been for, oh gosh, over 20 years now.

and I've been working for the last six or seven years on

Shame in medicine, specifically following a master's that I did.

and I'm particularly passionate as well about communication skills and

supporting, uh, international doctors with their communication skills.

I am so excited to have you back on the podcast, Sandy, because the

podcast that we recorded together, I can't even remember how long

it was a year, 18 months ago.

It was the podcast that had the biggest impact on me because that was

the time that I realized that the, the one issue that stops doctors and

other professionals in these high stress jobs who are, who feel very

over responsible for everything, the one thing that stops us looking after

ourselves, creating time for ourselves, setting boundaries, being able to just

be resilient is shame, is the way we feel about ourselves when we have to do

that, when we have to set boundaries.

I just thought there was something going on.

I knew we felt a bit guilty when we couldn't serve people, but I

think guilt you can overcome, but shame is really, really difficult.

So yeah.

When you, when you talked about that, when you talked about the

fact that we feel shame when our actions hit on our inner deeply held

values and that when they contradict them, that's when we feel shame.

I thought, bang, that's, that is the key.

That is the key.

And someone in a workshop once said to me, well, why would you ever do

something that's against your sort of deeply internal, internally held values?

And I thought, gosh, we have to all the time, don't we?

When we don't have the time to spend with people that we want to, or we,

you know, can't give them the immediate treatment that they need to because

we are finite and because we're human.

So yeah, obviously we're not going, we're not going against like the values

of like, don't lie and don't steal and don't cheat, that sort of thing.

But it, it's the thing of I must always be there.

I must be the superhuman.

I must help help people out.

Now is, is that a quite, is that an accurate sort of summary of what we

talked about, like all those years ago?

those years ago?

Yeah, I think that's exactly right.

And I think, what I, what I am aware of.

'cause I, I teach now a lot about, uh, shame to lots of different

groups of doctors is people experience it very differently.

So some people are very aware of when they experience shame.

So they may feel it very physically.

So classically, I guess in your gut you might feel it,

that kind of sinking feeling.

Um, you may find yourself blushing, you may find yourself just feeling deeply

uncomfortable and people sometimes struggle to describe what it's like,

but they know what that feeling is.

Whereas I think because a lot of people don't have access to that word,

which sounds silly 'cause it is a, you know, it's a word that we're all aware

of, but people don't really use it.

People use it in newspapers, but they don't really use it in, in,

um, day-to-day conversations.

So I think, uh, my experience of talking with lots of doctors now is that they

are starting to recognize that some of the feelings that they've been holding

often for many, many years, is shame.

And when they can name it, there's something quite kind of,

transformational that happens because once you know what it is,

you can then start to think about how can you can resolve it or make

it less, uh, impactful on your life.

It's interesting, I have had people say, well, I've never felt that before.

So it's definitely possible that some people don't experience it.

And that the sort of psychology jargon is whether you are shame prone or not.

So who would be the sort of person that would be more shame prone?

I think, people who are, what I would call vulnerable, so that covers a

wide range of, of possibilities.

So it might be a hierarchical thing, it might be a gender thing.

So there may be some sense that you are less worthy.

If you have a sense of being less worthy than other people And there

be multiple reasons why that might be the case, you are gonna be much

more prone to experiencing shame.

And when it comes to medicine do you think doctors are particularly

shame prone, or do you think they're the same as the same

distribution as normal society?

Or do you think because so much is expected of doctors, they're

slightly more vulnerable to it?

I think there is a particular, it, it's interesting, isn't it?

'Cause, 'cause doctors in many, in many senses are actually in a very

powerful position within society.

So in many ways they're not vulnerable or less vulnerable

maybe than a lot of their patients.

I think the vulnerability to shame for in medicine comes from this,

this link with your identity, the sense that you have to be, uh, you

know, let's say the word perfect, perfect in your job, in order to

maintain that professional identity.

And for so many doctors, their professional identity is completely

linked to their personal identity.

So the two.

Uh, if that professional identity is threatened, they feel threatened

as an individual, as a person.

And I think that does make them particularly vulnerable.

And they are held to high standards by the rest of society.

So there's a lot to kind of live up to.

So you kind of get the benefits of the kind of power, if you like,

but that, that comes with huge responsibility and expectations from

other people, which I think is what makes p uh, medics vulnerable to shame.

And I think working in the system that we're currently working

in here in the UK, shaming is becoming a institutional fact.

There's a couple of reasons isn't there for that, that firstly, you

know, it's interesting, this, this high, high standard that, that

doctors and, and other healthcare professionals, or I think any, any

professionals really are, are held to much higher than anything else.

So, you know, someone would, would judge a doctor for, you know,

standing outside surgery, having a fag much more than judge anybody

else, for example, for example.

That's just a, a, a silly thing.

But, you know, they're supposed to be the, the truth hairs,

this, that and the other.

And then they've got the, the organization that they work

in, which is just, you know, a lot of the organizational

cultures really difficult.

It's funny, I was at the hairdresser yesterday and, uh, well, he would

talk about GPs or something and, and the fact that, you know, you only

need one difficult interaction with a patient before it's splashed all

over Facebook, all over the ne you know, all over the news or whatever.

So a lot of people think that doctors are fair game to, to try

and shame them, and that is the.

Is the common response to error.

But we hold ourselves to these impossibly high standards and

then feel immense amounts of shame when we cannot meet them.

'cause nobody could meet them.

But we still have this idea in medicine that we still can, and

then that myth is perpetuated.

And then when you do make a mistake or fail in some way, you get

reported, you get disciplinaries, you get taken to the GMC, you have

to phone your medical defense union.

Everything has gone over the fine tooth comb.

So it's not just us is it?

It's it's a system as well that's perpetuating this, I think.

I mean, it's deeply embedded.

And not just in the medical culture, obviously it's in, in lots of

institutions and organizations, but, medicine's kind of my world.

So that's what I'm interested in looking at.

Um, you know, I've talked and thought a lot about shame as an individual

doctor, and shame, particularly in teaching environments and learning

environments, because that, again, is, is fertile ground for, for shaming.

And I'm starting now to think.

about shame, uh, from an organizational perspective and what, what systems

or what factors play a role in a, in organizations perpetuating

shame in their employees and their, and their associates really.

And what have you discovered?

Well, going back to that idea about, and, and this is very much based

on the work that, um, Professor Luna Dolezal has been doing at the

University of Exter, part of the Shame in medicine, um, project, thinking

firstly about this idea of hierarchy.

So within, within, I guess, medical organizations, you've

got, you've got the staff, but also you've got the patients.

So you've got a hierarchy within the staffing.

I would say.

So in my world, in general practice, we've got partners, we've got salary

doctors, we've got other healthcare professionals, we've got, administrative

staff, and there is a very definite but often unspoken hierarchy that

occurs within that organization.

You've also got a hierarchy with patients.

So as, as medics, we have, you know, we have a lot of power, whether

we, we might not feel very powerful much of the time, but anybody who's

coming into contact with us is in a position where they are vulnerable.

So they're vulnerable in one case because they're presumably

unwell, um, and need help.

But they also have to wait a long time to see us.

There's a kind of a gatekeeping role, both by the administrative

team and by our appointment systems.

People can't get answers, they can't get an appointment, they may be forced to

sit and wait in an outside waiting room.

And these are not what I would call intentional shaming activities.

But the result is that people do feel shamed or can feel

very shamed, um, because of it.

For many people, just going to the doctor by itself

is a shaming experience.

They don't want to have to do that.

Um, and they see it as a weakness on their part.

So there are lots of kind of issues around the medical encounter, which, um,

potentially cause shame for the patient.

And what that does is it drives behaviors that we then

find difficult to deal with.

So it might mean they avoid seeking help altogether

because it's so uncomfortable.

They might not turn up to appointments, they might not disclose things to us,

or they might be frankly, dishonest to us because they're protecting

themselves against that shame.

And they might just not trust you as an individual clinician

or you as an organization.

And that can make people defensive.

It can make them aggressive, you know, the very worst.

It can make them violent.

So when we're thinking about how patients are behaving, we, it's very

easy to kind of label them as a problem or, or label their behavior as a

problem, I guess, for the organization.

But I think what I'd like to do is start to look at, well, what

can the organization more broadly do to, to minimize that risk?

You can't ever eliminate it, but I think how can we, um, desham

or Unha, um, our, our medical environments for, for, for patients?

And then I, then we need to think about staff and how, how

does an organization shame?

Its, shame Its staff.

Yeah.

It seems to me that the whole of the NHS, though, this is a broad

sweeping generalization, is just based on, on a culture of shame.

Because when I talk to people, it's like, well, yeah, they

put in a Datix about me, or I'm gonna Datix them or whatever sort

of reporting system you have.

The freedom to speak up guardians sometimes used as a a shaming

technique rather than what I think they were supposed to be.

But it's just like, let's create a safe environment that we can raise

issues in a safe, nonjudgmental way.

All that sort of stuff.

It's something's gone wrong, let's find somebody to blame.

It's always got to be somebody's fault,

I just see it endemic amongst the people I work with on the courses.

And I know you do, um, a lot of work teaching human medical humanities,

but also teaching about shame and, and communication skills with a lot of

international medical graduates as well.

Absolutely.

I mean, I guess I've got that particular lens now, haven't I?

Where I'm, where I'm seeing it, but I, I think what I find now is whenever

I'm find experiencing a, a behavior of either a patient or a colleague

or, or a trainee or somebody I'm working with that doesn't quite fit,

there's some kind of discomfort, it sort of develops a discomfort

in me, I'm kind of thinking, well, I don't really understand why

somebody is behaving in this way.

I, I do now very early on, start to think about could

Shane be playing a part in this?

And that's not to say that I would immediately say that, but it certainly

forms now, I guess part of my, is it, is it a diagnostic possibility?

It's in by differential, if you like,

Differential diagnosis.

Yeah.

Is it fit, fear, guilt, shame?

Well, how?

How do you find out then?

Yeah.

It's interesting, isn't it?

So I think what I find myself doing is when people are talking in generali

in general terms about things, I start to ask them about specifics.

So I will ask them.

So it's interesting you're talking about that.

Do you have a specific example when that has happened to you

or when you have witnessed that?

And it comes back to that story thing.

Human beings communicate best with each other.

I think when they are telling and listening to stories, and we can get

so much from our, from our patients, but also from our colleagues if

we really listen to their stories.

And I don't think any, any story I've heard anybody said, oh yes, so this

happened and I experienced shame.

That's not how it is.

You have to listen to the story and see the shame experience within

it to really understand that.

But if somebody's gonna tell you their story, honestly, you have to

have built that trust beforehand.

So that's a, a very important step that you can't miss out.

And you have to build that trust that what people are telling

you is told in confidence, and they're not gonna feel judged.

That's the basis of psychological safety, isn't it?

Vulnerability based trust where, not, not just, I'm assuming that you've

got good intent, but I'm assuming that you believe that I have got

good intent, which is that funny, weird back and forth, back and forth.

But if I know that I can tell you something and I know that

you will always assume that I did that thing out of, out of

good, not out of maliciousness, you know, not out of being evil.

And actually, not many people are evil.

No, not many people go to it to be evil, do they?

Most people, but I think people do evil stuff or, or let's not

say evil stuff, stuff that's not helpful, or stuff that doesn't

work out of fear, shame, or guilt.

Yeah.

I think there's that.

But I think there's also stuff happens to people, and I guess bullying

is probably the, the best example.

You know, bullying is shaming, that's what bullying is, right?

So people are bullied and they internalize it and assume

they've done something wrong.

Or they put up a barrier, which means that nobody else can get

anywhere near them or, or they get very angry and they react.

So I think most of the stories I hear probably 'cause of the position I'm

in is, is hearing stories of things that have happened to people as

much as things that they have done.

Creating that space where people feel safe and comfortable to talk about those

things is, is a big priority, really.

so then if you, if we are feeling shame, there's someone that's, that

says something to us that's making us feel shame, then it's very easy to

feel bullied, even if that other person has the best intent in, in the world

and is not intending to bully you.

But on the flip side of that, there is some behavior that's absolutely

atrocious, that is absolutely bullying and is, and is done in order

to make somebody else feel shamed.

Or maybe as I'm thinking this through, you are not doing it in order to bully

that person, but you, you, you want to feel less shame yourself, so you're

putting that shame onto somebody else because that's, that's just a lot

easier and unconsciously, I think we do that all the time, don't we?

So it's a total minefield family.

How on earth do we navigate it?

Yeah, everything you've said is, is right.

I mean, I think, you know, what you, described earlier was kind of, I

guess what I would call feedback.

You know, if you're saying to somebody, right, this isn't, and I, I, my kind of

real, go-to description within feedback is that you need to think about talking

about somebody's behavior rather than addressing their themselves as a person.

So it's, it has to be objective.

As soon as you slide into subjective feedback, as in you are this or you

are that, rather than you did this or you said that, you're on sticky ground.

You can't know how it's gonna be received by people.

And people are shamed very much often unintentionally.

So it's not to do with the intention behind it, it's to do with are you

addressing their behavior or are you addressing their whole sense of self?

Because if you're attacking their sense of self, they

are gonna experience shame.

And how they respond to that is entirely unpredictable.

So I think historically, um, and, and currently, you know, shaming is

used as a, as a public health tool.

There was a good example in Covid.

So people who were overweight were deemed to be using up too much of

NHS resources and, and the adverts, you know, you look back on, on those

adverts, it was pretty shocking, really.

So there was a deliberate use of shame as a public health tool.

And that's, that's one example.

There are many, many more.

But it's, it, it doesn't work and it doesn't work, because it's unpredictable

how people will respond to that message.

So you will always find people, and doctors is a good example, who will

say, oh, I told that patient they were overweight and do you know what?

They went and just lost loads of weight.

So it works, it's great.

And that's one example.

What they're not seeing is all the other examples of people who will have

responded extremely differently to that particular way of addressing things.

So we can fool ourselves that shaming is a, is a useful tool,

but I guess you have to kind of trust the evidence that across a

big population, it really isn't.

And it can drive all sorts of negative behaviors in terms of people

withdrawing, becoming depressed, or it can make them aggressive

or it can make them, um, totally compliant and unquestioning, which

again is, is difficult in itself.

So, you know, it, it, it's something that organizations use and we use, but

not, not a good technique, I would say.

And it's the same when you are addressing the behavior of a

colleague, shaming them is a very dangerous thing to do.

I would, I would say,

Yeah, because I presume what happens is you immediately precipitate, precipitate

the fight, flight, freeze response.

You get backed into corners, like they said with Putin.

You know, he talk about that rat in the cage.

The rat comes out and bites.

You know, you might get bitten really quite badly by shaming somebody.

Because in my experience, almost never have I given feedback

in a not very helpful way.

And that person has felt shame and they've gone, oh, you know what?

You're absolutely, totally right.

Yeah, let's work together.

Let's change it.

Thank you so much for that.

That's great.

You know, never, never, never happens.

And you end up very damaged because of the, the fight, fight response.

They either just completely with draw, don't talk to you about it, but

then become very passive aggressive and you, you feel it in other ways

or, yeah, incredibly defensive.

Then you get a, a ton of shit jumps on you about how bad you are.

And I think probably 99% of the time it is accidental.

I'm not sure 99% of the time, no.

I think there is, is more deliberate shaming that goes on that because

people mistakenly believe it will drive better behavior.

Right, okay.

I was thinking it's accidental 'cause you don't want to cause the

other person problems, But you are saying, some people, they don't

wanna be evil, but they actually think that that behavior works.

That's why they're using it.

Oh, Yeah, absolutely.

No, it doesn't come from an evil place.

It comes from a, a long held belief, because they may, well,

obviously this is, these things are all cyclical, aren't they?

They may well have been shamed as, uh, you know, by, historically,

by, uh, parents or by teachers or by, uh, institutional

figures through their life.

So it feels like, well, that's the method

Yeah, I mean, look how we learn.

Look how we learn at med school and, and as junior doctors, right?

That was literally the, the educational technique that was used, wasn't it?

So then we think, well, it, it did work on me.

You know, I might be, I might be a shell of a person now, but it works.

'cause I learned it.

Well, the evidence is you'll learn the bit that you were shamed about, but

it affects all your other learning.

And that was definitely my experience.

You know, I, I was not a great learner at medical school, I have to say.

I'm a be much better learner now than I was because I think that

fear of shaming was, uh, was driving me away from learning.

That's interesting.

Yeah, I could, I could recite to you the causes of pancreatitis.

'Cause one of my mates was very severely shamed by the surgeon

that asked her, and she'd done no reading, so she hadn't got a clue.

We were like, Ooh, thank God he didn't ask me.

I would love to just ask you, Sandy, what are the different ways and reasons

that we feel shames at, at different sort of stages within an organization?

Because I think there are different people groups that feel different,

different types of shame.

Or, the reasons for shame are probably more common.

I think you've got trainees who are learning, people that are leaders and

managers and, and in charge, and I'm thinking of, you know, team leaders,

clinical directors, PCN directors, GPs, senior nurses, but then there's that,

there's other groups and I know you do a lot of work with international medical

graduates who we know are having a really, really difficult time navigating

our, our system at, at, at the moment.

So I'd love to hear with those different, different

groups, what are the causes?

Because I think whether you, whatever group you identify with, you might

identify with all three, because either I can identify it when I feeling

shame and then question those stories.

Or I can think, okay, well how, how will my actions make that person feel shame?

And how, how can I avoid that?

Okay.

So Yeah.

so taking each of those groups, I guess.

So trainees are their particular issues, I guess are, they

are being very much judged.

So they're in a, they're in a stage of their career where they're being,

I mean, super monitored, right?

So they're, so their every move is being scrutinized, which is

really challenging, unless you've, unless you have the support.

Alongside it.

So I kind of think about this support challenge balance really.

So if the challenge is vastly outweighing the support, those

people are gonna really struggle.

So they're vulnerable to shame for that reason, um, in that they are

being very closely scrutinized.

I think the nature of training, it's very well recognized that

your highest vulnerability is when you move to a new environment.

So you don't know people, you are just in innately vulnerable 'cause you

don't know the system, you don't know the people, you dunno how the kind of,

uh, hidden curriculum, if you like, of how an organization works, so you

might have read all the protocols, but how does it actually work?

And also they're kind of having to establish themselves.

People are making a judgment, they're making an assessment

of them when they move to a new organization, are they any good?

Are they not good?

Are they difficult?

Are they a problem??

That all happens very quickly, very early on.

And also if someone's gonna be bullied, if you, if you are a, a bully,

let's say you are gonna pick on the most vulnerable member of the team.

And by nature they have that innate vulnerability.

So they are more likely, I would argue, to be in that position.

That's the particular issues, I think for, for trainees.

And they are still establishing their medical identity.

They're still figuring out what kind of a doctor am I, what are my values?

What's important to me?

And does this organization fit with that?

'Cause they haven't chosen to work in the organization,

they've been put there.

So they're also now having to think about, right, well, what

does the organization, I'm.

Long term gonna work, and what does that need?

So there's a lot of reflection and uh, and chaos going on in

their heads, uh, beyond the kind of medical learning really.

I would, I would argue it's a very intense time.

So what can we do to protect ourselves if we're trainees and

if, if we are not, if we're the people supervising trainees?

So I think as a, as a supervisor, as a, as a trainer or as an educational

supervisor, first of all, acknowledging that risk, acknowledging that

that's a possibility that will happen to people, both with them

and with the rest of your team.

'cause when you're training a, you know, when you're training a gp, it's

a whole practice endeavor, right?

So, educating the whole practice around that is important.

I think, uh, for the trainee, helping them in those first few days, you

know, that the quality of their welcome is, is massively impactful.

So if they're just kind of put in a room and said, right, well here's,

you know, your first day you're here, this is that, and bye, we'll

see you at lunchtime, is not kind.

And, and kindness needs to be in large supply early on, even if a person

seems very confident on the outside and people have different things.

But, and often, naturally for a lot of trainees, they're experience coming

into general practice that, you know, people actually know their name.

They're interested in getting to know their name.

They're interested in getting to know who they are.

They're no longer a kind of a ST1 or an ST2 in a hospital setting where nobody

really bothered to find out their name.

So we have got an opportunity, I think, when they come to general

practice, is to overload that kindness and to try not to make a

very, very early judgment on people.

You know, recognize that they will be unsteady.

It's a new environment, a new place, and it may take them

a while to find their feet.

So forgiveness, kindness, and I think avoiding deliberate shaming, so not

calling them out, if you're talking about things that they might wanna

do differently, not doing that in a public space, you know, that happens

in a private space where they have the opportunity to discuss it fully.

Yeah.

I think for me it's just as a, as a leader or the trainer, educational

supervisor, the one really simple thing you can do is just make

sure this person is introduced to everybody they're working with.

And in secondary care, if you're on a ward round, right, let's just stop.

There's new people here.

Tell us who you are.

Tell us one thing about yourself.

You know, one, you know, one fact that nobody knows.

You know, or every time you're in theater just checking is everybody.

You met such and such person here, they're my new trainee.

It's brilliant to welcome on the team, blah.

You know, they're being positive and, and just over, over introducing them

so they automatically feel at home.

I think if you are the, if you are that trainee and no one's done that

for you, firstly, I'm really sorry.

But secondly, you know what's in your zone of power?

You go and introduce yourself to people you know, theater manager.

Hi.

I just wanted to put my head around the door and say, I am, you know,

let's call, let's don't call ourselves Doctor So and so, first name.

This is me.

I don't know how things work around here.

I'm new.

Please come and tell me if I get it wrong or, you know,

whatever, and let me know.

How the tea and coffee rotor works.

All that sort of, you know, that sort of thing.

And over introduce yourself, um, share some stuff there.

I, I found I read some research or heard some research about the

thing that builds up trust the most is not just pleasantries, but

a little bit of self-disclosure.

Like, not, not like, hello, I'm just going through this most dreadful

relationship breakdown and this and that, but like, just, hi, you

know, actually life's a bit tough at the moment 'cause you know, oh

my gosh, my daughter's going through something there, or whatever.

And it just, it just creates a human connection.

It's, it's harder to shame, it easier to shame an inanimate object or

someone who's the other, isn't it?

Totally.

Because actually part of shaming is that dehumanizing.

So as soon as somebody, you learn who someone is as a human, as a, you know,

and they, and they have that sense of belonging, they're much less vulnerable

to bullying and shaming for sure.

And also I think slight side notes.

Um, and someone said this to me the other day, and I remembered

hearing a great podcast about the South Star with my Rob Bell, who

I just think is, is wonderful.

We'll put the link in the, in the notes about.

Looking at other people's behaviors and you know, there's, we've always

got mentors or people that behave really well that we want to copy,

we think, yeah, that's great.

But watch other people's behaviors.

Think, who do I really not want to be?

Like what's, what's my, so they're my north, the people I really wanna

be like, they're my north suburb who's my south star around here?

And I'm watching that person treating that person like shit.

And I don't want, I don't ever want to be like that.

What is it that they've just done that I'm going to try my best not to be like?

And sometimes, uh, someone said to me the other day, they thought they

learned more by watching how they don't want to be like than they

did by how they do want to be like.

'cause sometimes when someone's behaving really well, it's quite difficult to

really tease out what they're doing.

But when someone's not, you can work out exactly right.

That is so true and, and it's something I work with educational

supervisors and it's a question that I invite them to ask their trainees.

You know, who's your positive role models, but who are

your negative role models?

Because actually often what comes from that discussion are those

stories where either they have been bullied or, or receive bad

treatment or they've witnessed other people experience it, which

it can be equally damaging, frankly.

Um, so Yeah.

it's a really useful question to ask people.

I agree.

So, so that's some ways of thinking things around sort of trainees or in

training or professionals in training.

Um, what about if you are more senior in the organization?

So I guess there's a kind of a, you know, we're all living within

some kind of pyramid, aren't we?

So there's, unless I dunno what, who the top of the pyramid is,

actually now I think about it, but there's usually somebody above us.

And I think if we, when we're in those positions of authority feel helpless

and feel that we are being shamed, all we can really do is go back up the

chain and say, this is my capacity.

You know, shaming me is not gonna improve my ability to do this role.

And, and kind of calling it out in the way that I think you could call

out bullying and, you know, you'd hope that people could call out bullying

and scapegoating and all those things.

I think you can only do that if you have a trusting relationship

with the person above you.

So that's the step that's often lacking.

People don't feel safe to call it out.

With all the guardians and whistle blowing stuff, people

still don't feel safe to do it.

They feel they're gonna be punished.

I think as an individual, if you start to recognize that because of

the pressures on you, you are starting to shame and scapegoat other people,

you need to stop, you know, you need to recognize that that's what's

going on, you need to acknowledge it in the first instance, really.

And it can happen kind of quietly, or it can happen kind of loudly.

But if you are feeling threatened, how do you respond to threat?

Are you therefore going ahead and threatening other people

and expanding that impact?

So I think as a, as a leader, you need to have that awareness of yourself.

And it might be that you resolve, you then have to look at, well,

am I being, am I doing a good job?

Go back to your kind of zone of power, zone of control, you know, are there,

am I doing the things that are within my control and are the things that

are happening with this organization, are they within my control or not?

And if they're not, well, you can't do anything about it.

And, and starting to draw those boundaries around yourself.

But I think first of all, acknowledging that shaming other people is a

very, not uncommon response to feeling under pressure yourself.

Um, and you do have control over that.

And then the longer term project is addressing that shaming.

And I think what we are all embedded in now is this system of targets.

Every time I see somebody talking about a target, my heart sinks a little bit.

Um, because they're, you know, they're kind of shame tools.

I mean, everybody's sat through meetings where you've got a graph

of, I dunno, 50 practices and yours is at the bottom of the pile.

And I'm always just like, why, why are we doing that?

That is shaming, isn't it?

Isn't that what it is?

I don't, I don't really know.

Is it information giving?

I don't know.

I, I read it in a different light and everybody thinks it's gonna drive good

behavior, but you listen to how people respond to that and it's not necessarily

gonna drive good behavior at all.

So there are.

Things that leaders can do to minimize shaming of their, uh, their people

they're leading, but equally they can go up the chain and start to

think about, right, what is being used to shame me, because it will be.

So that's more sort of like direct shaming, isn't it?

And you know, having those conversations with, with your, with your bosses or

the, you know, the people that give you the money or the funding or whatever.

But what about the internal shame that we feel as leaders when there's just

not capacity within the whole system?

So, you know, a GP we could slag off the local hospital or the

hospital, you know, when the, when they haven't got enough capacity

in primary care or beds to get out, could slag off everybody else.

But there's nobody, there's no one person to go and talk to.

It's just the system that is broken and, you know, you can trace it

all back up to lack of funding and, you know, et cetera, et cetera.

And then the, the stories that we are actually shaming ourselves because

we're telling ourselves stories of, you know, I'm not good enough 'cause

the patients aren't happy, well the patients aren't happy because of

the system that we are working in.

I just think people live in this cacophony of shame and guilt.

And I did a podcast recently with Sarah Coope talking about, you

know, can you feel guilty for stuff that's outside your control?

And I don't, I think that's actually the wrong question to ask.

Can you feel guilty?

'cause I think the reality is we do, whether, whether or not you should

or not, I mean, don't like the word should, but we feel guilty and

we feel shame for, for that stuff that's outside our zone of power.

And then we feel desperate and that's where the overworking comes.

Just trying to, trying to make up for the lack of resourcing

funding in the system.

Yeah.

And I think, you know, going back to that idea of why do medics feel shame?

And I think part of that is because we are, we are the system.

You know, we are the, the health system or, or a significant part of it.

So we feel a vicarious shame when the organ, when the, when

our colleagues can't deliver.

So, you know, you've got, had patient discharge from hospital and the, you

know, the information is inadequate or they've, or they've frankly had

the wrong treatment or whatever.

We're frustrated and we're angry, but we will also feel shame 'cause we've got to

explain to a patient that somebody else in our, of our type of our family, of

our, of our group has, has let you down.

And that happens a lot.

But I think, you know, in all of this we do, there's a risk

that we only see the bad, right?

So with the, there are lots of joyful moments within medicine and

there are successes and there are people who get better and there

are people who have good treatment.

And I think it, you know, we need to keep hold of that balance.

And that for me is what helps me get through and, and, and thrive is to,

is to be able to get some joy out of the patient encounter that, that I

have got control over, rather than to feel totally helpless that a loss.

Because the system itself is obviously not providing what we have been kind

of brought up to think is acceptable care, that we've been sort of sold

this, we know what the drugs are, we know what the operation is, we

know people have the, the ability to solve lots of problems, but we don't

currently have the capacity to do that.

And that, that mismatch is causing a lot of distress for

patients and doctors obviously.

So, but I think within all of that, there are still good stories and there

are still joyful moments, which we need in order to balance some of that.

It made me laugh earlier when we were just chatting before the podcast,

when we were talking about this and you said, well, actually, how do

we determine what's a me problem?

Like something that I could have done something about

or I, I I, I, I could do.

And, and what's a you problem?

Like actually I don't have responsibility for this, I

can't do anything about it.

It's either the system or the patient themselves.

Um, and made me laugh 'cause literally a couple of days ago I

recorded a, a quick did podcast on you problems versus me problems.

How does that help with all the shame stuff?

It's a good analysis to do.

I think.

You know, when you're struggling, when you're grappling with something

and something's not gone well or can you separate that out?

So if it, if it's a problem of the, of the other party, be that a patient

or another member of staff or the organization, then that experience of

shame shouldn't come anywhere near you.

There's no reason for, for you to feel any form of shame, even if other people

are telling you it's your problem.

You know, if you can analyze it in the cold light of day and

think really challenge that.

And often I think it needs or it helps to have another person with you to,

to, to do that analysis, uh, because they will have a different perspective.

The problem I think, with shame is.

It can make you lose your perspective.

So you can start to think that everything is a me problem.

And you just kind of stack one thing on top of the other if you like to, to,

and the, and the conclusion you then come to is that you are not a worthwhile

individual or you are not a good doctor or whatever term you want to use.

So I think if you are starting to notice that you are having a go at

yourself a lot, using a trusted other, be that a partner or a friend or a

colleague to just sense check it and say, actually is is this me or is

it, is it the organization or the patient or the other person who's,

who's made you feel uncomfortable?

It doesn't stop you caring, but you don't need to pin all

the responsibility on yourself.

And it's just that labeling, isn't it?

And you, you talked about labeling before, and actually shame

cannot survive being spoken.

I think that's what, what Brene Brown says about it.

And if we just sort of say, and like you said to a friend, I'm

feeling really bad about this.

That's, that's what people use.

And I think, you know, my experience is, if the more senior you are, the more,

the higher risk of you shaming other people, I would say, and, and you kind

of need to transform the, the shame that you as the leader are feeling.

Otherwise, you do transfer it to other people.

That is what happens if you've not recognized or acknowledged

it, discussed it, considered it, you will pass it on by default.

Not deliberately, but you just will.

That's another very good reason for either being part of like

a, a mastermind or having some coaching or something like that

so you can actually, or even just have some trusted colleagues, you

can just go check stuff out with.

I wonder whether, I don't know, 'cause I'm not a very, very senior person,

but I wonder whether very senior people, you know, does the, does the

pool of people that you trust that you can talk to, does it shrink as

you, as you kind of climb that ladder, is it harder to find people that you

can have those discussions with, and therefore harder to resolve those

issues and, and avoid passing them on?

I think it is Sandy, but I also think to find those people

sometimes you need to go external to your organization, don't you?

Find someone in a different organization that the sames their level as

you, or in a completely different.

I'm in a mastermind group with people that work in completely different

industries, but we're all women running largely online organizations

and stuff like that is so, so helpful Just to, to share and sense

check stuff from someone who had a completely different perspective.

It's really helpful and you know, mastermind I'm in, it's an informal

thing between some people that have just got together and so sometimes you

just need to go seek out those people.

Yeah.

And I guess as a senior leader, you may feel, you know, if your,

if your leadership model is all around kind of being strong and

being invulnerable, um, then asking other people's opinions might be.

Counter to that, that doesn't feel comfortable to be even in that kind

of supportive group for, I imagine some people would find that difficult,

so that that is gonna increase that risk of shaming others, for sure.

It's interesting though, Sandy, you said, oh, I've never been, I'm not

particularly senior, I've never been a senior person, but I know you have

been a GP partner, you're a salary GP now, you know, you teach and I

think part of the thing is actually recognizing when you are a senior

person, 'cause I would say you are, um, you don't, but you don't see yourself.

And I think that's the problem a lot of us.

I don't see ourselves as senior people, but I think by the time you've been,

you know, I dunno how old you are, but I'm heading up to the wrong side of 50.

Um, by the time you've been doing stuff for a while, you are just senior because

you've been in the organization a while.

You know what you're doing.

You probably are supervising people, you've got juniors, you've

got, you've got other staff, and we, we don't see ourselves

as senior, but other people do.

And if we forget that,

that's that is very true.

That is very true.

And I kind of have this phrase that you, you know, you can't see your

wake, you know, you, you, you can't see the impact you've had on people

through your career or over time.

And you know, in a way you can't get too hung up on ly, what

does my wake look like today?

That would be far too stressful.

But I just, I'm aware that you impact people in ways that you can't know

and never, probably never will know unless they turn around and tell you.

And no matter how great the culture you provide, no matter what a wonderful

leader you are, it is the thing that that juniors, that trainees, that

other staff will see a hierarchy.

Of course they will.

Whether you want them to or not.

I think it's just really important to, um, remember that.

But I know that there still is quite a lot of discrimination

towards international medical graduates and you work with teaching

communication skills and you.

Said to me earlier that you think that one of the things that, that

they feel quite a lot is shame.

Maybe for some extra reasons on top of everything else that we've talked

about, I just thought it might be really useful if we could understand a bit

more about what, what you've observed.

Yeah.

So, so I, uh, the role that I have here is I work with a, a, a colleague,

a friend of mine who's an actor.

And we've worked with think 16 years now, we've been doing, um, courses

for, uh, international doctors.

And the numbers are increasing hugely.

Everybody would be very much aware of that, and I think that brings positive

stuff for that, for that group in that they are less isolated in some ways.

But there's also the ongoing challenges I think, of feeling vulnerable.

So I've lived and worked abroad and I know, when you go into a new

environment, you're bombarded with challenges really, you know, as any

trainee as we've just already talked about, going into a new environment.

But I think when you, you carry that sense that people might

not welcome you, um, equally so if you are being branded, um.

And international doctors cover obviously an enormous range of

people from different parts of the world, but also different abilities.

They're no different in the variety of abilities to

our, to UK graduates, right?

So, if people's expectations from the get go.

That you might be more difficult to train or you might struggle with

your communication or whatever.

You're starting from a much more vulnerable place, and you therefore,

I think in their eyes would say they have to work that much harder

to gain, uh, respect, uh, and to regain, gain acknowledgement

of what they are capable of.

But they're being judged much more harshly from the get go is their, is

what they tell me is their experiences.

Um, so bullying is very common.

So a good example would be if a, uh, a trainee uses a different technique

because that's the technique they, they used in their, in their own training

back where they grew up, and everybody's la literally laughing at them.

I've heard terrible stories of that in very, uh, open environments.

This kind of, um, very public shaming of people if they're doing things

in a way that is not the UK way.

if, if patients don't understand them, that is a real issue and

they're very aware of that and obviously they don't want that.

So they can feel uncomfortable.

If other staff members don't include them in, in chats, you know, coffee

or tea or, you know, any social events, people kind of feel, oh, I

don't know, I don't wanna upset them.

Don't wanna invite them, don't really know what to talk to 'em about.

You know, they're just human beings, right?

I mean, I, I am kind of bowled over by how Incredible these people are.

I think to myself, crack, if I was to take myself off to a GP practice

In another country of the world, how on earth would I manage that?

I think they're extraordinary in another language.

I think they're extraordinary people who've made a bold

decision to come here.

The vast majority are amazing.

And I think if you find that.

The behavior is not what you would want.

So as a trainer, for example, or as a colleague, just consider and

think, is shame forming part of that?

And we were talking earlier about how do I, how do I discuss that with them?

Because coming up somebody saying, oh, are you feeling shame?

Generally it's not.

Well, it's definitely not what I would definitely not what I would advise.

So, um, it's about storytelling.

It's about being interested in that person as a person.

So who are they?

What has happened to them before this point in time?

Being genuinely interested in them as, as a, as a human being goes a long way

to firstly building trust, which is the first step and has to be in place.

And once you have that sense of trust, you can start to explore, well,

what has happened to them, actually?

Often there are stories underlying and there may be stories.

In the country that they've come from.

It might be the reason they've come to the UK or there might be

stories about what's happened to them since they've come to the UK.

And, and My experience today is that that first few months they

are in this country is when they are most vulnerable to bullying.

People seem to instinctively know that they're vulnerable and so

bullies will take that opportunity.

So if there's a story, it might go all the way back quite a long way

from where you're at at the moment.

And I think we have a responsibility as both employers, but also as

trainers to create that sense of trust and be genuinely interested in.

I'm fascinated by, gosh, what on earth does medical

training in Egypt look like?

I have no idea.

Could there'd be stuff we could learn, right?

So I'm fascinated by where they've come from, what's happened to them.

And.

If you're gonna, if we're gonna help people feel a sense of

belonging, we have to be interested in them, not just expect them

to be interested in UK stuff.

because again, there's this vicious cycle isn't there?

So they know they're gonna be judged more harshly and they may

feel they do need to work harder.

They encounter bullies in their first few months.

All of that is gonna put them on high alert.

So trigger the amygdala response, which actually then means that

when one is in that state in the court, we cut it, backed into the

corner, you don't perform as well, therefore confirming what people

were expecting in the first place.

And then it's just this, this cycle.

And that's really hard, really hard to get out of.

And then add in the, the different culture that they're working in.

And those just like, I remember being yelled at once because I'd

used someone's mug that everyone knew, you don't use that mug.

Or how was I to know?

But it's, it's like that on a massively grand scale, isn't it?

When you move into different cultures, you make faux pas that

you, you just have no idea about.

yeah, totally.

So you, so you actually just, avoid that, you know, for most people,

most people then avoid because that's, that's the safest thing.

Yeah.

And then it becomes the other, doesn't it?

Then they are in another group.

They're not part of us.

And the trust, it's so hard, isn't it?

Yeah.

And often their personal circumstances are really challenging.

So people have got their families thousands of miles away.

I had an example recently of a somebody who'd come here, you know,

and their child was born in another country while they were here.

They haven't seen them for four months 'cause they haven't been able

to get the annual leave to go back.

You know, that type of thing.

You just think, crikey, grappling with that.

That's a big deal.

And I think this goes for anybody.

Just finding out whatever your space in the hierarchy, no matter where you

trained, whatever, just finding out bits about people, what's going on for

people at home is so, so important.

'Cause you're gonna give them a lot more leeway if you just know that there's

something really dreadful going on.

And people have all sorts, don't they?

You know, I'm thinking of people that I know when you've got a sick child or

a child with school avoidance either.

I mean, that just takes up so much mental time, head

space, all that sort of stuff.

Yeah, definitely.

Sandy, oh, we could talk so much more.

So we're gonna have to book another, another time.

Um, I'd love to know your sort of three top tips for dealing with shame

when you recognize it in, in yourself.

And also I'd love to know where we can find out more about you.

And I know you've got a storytelling project that people

might be interested as well.

So three top tips.

So I get, I think because we're starting to talk about organizational

stuff here, I think one of my top tips is that starter thing.

Is it a me problem or a you problem?

So is this uncomfortable feeling you have?

You have to acknowledge it.

Number one, you have to say, this is what I'm feeling.

Understand what that feels like for you.

Number two, you need to address it.

You need to talk to somebody else about it.

And you don't need hundreds of people, one or two, trusted colleagues or

friends or relatives, but get it out there, get another perspective on it.

And then I think longer term start to, if you are organizing something, so if

you are in a, in a role where you in, if impact on other people, consider

the shaming possibilities that might exist within that system that is being

developed, whatever that might be.

I'm not saying you can eradicate it, you can't eradicate shame.

That's not possible.

But you can certainly minimize it, take it into account,

acknowledge it, all of those things.

But first of all, we need to, when we're developing new things, consider it in

your planning, in your discussions.

I think that's so important.

Just consider.

And if, if in all of our interactions or all the ones that start,

start to go south or start to become a bit tricky, think where

is Shane playing a part here?

Definitely.

It's so helpful to have that as a, in your differential, I'm gonna

use that term, in your differential of somebody looking at somebody

else's behavior or your own, is shame playing a part in that?

And just quickly, what if you think, oh, it might be, what

should your next step be?

Yeah.

I think, I think talk about it with somebody else really,

because that's always the answer.

It's always the answer is to, is to hold it up to the light and, and

help them if it, if it's somebody else's shame that you're concerned

about, help them to tell their story.

I really, I do.

I think all the work that I've been doing, storytelling is

for most people is the answer.

We don't need a big psychological analysis.

We just need to provide comfortable, safe places for

people to tell us their stories.

And by telling us their stories, that will resolve

a large part of their shame.

So it's just a simple, tell me what happened or what's

going on for you there.

You know, what were you thinking in that moment?

did did something happen to you that started this off, or tell me more

about your, your life up to this point, or how was it when you, for

example, with international, how was it when you first came to this

country, did anything happen to you?

And I'm not saying that everybody will be able to tell those

stories on the first asking.

You might need to take time to build that trust, but it's

a very worthwhile enterprise.

Sandy, if we wanna get a hold of you, people wanna find out more about

what you do, how can they find you?

Uh, so probably, actually if you just wanna contact me by email,

so I'm sandy.miles2@nhs.net.

Great.

And you've been doing some storytelling events, I hear.

Well, so I'm gonna big up my, uh, my pal, um, Dr.

Susie Sterling up in Sheffield.

Um, so she and I started thinking about stories, and what a

powerful role they play and.

We together with some great colleagues up in Sheffield, organized a

storytelling, a live storytelling event loosely based on the Moth,

which some people may have heard of, which is a storytelling,

um, enterprise in the States.

And, um, it was a great success, thoroughly enjoyed it and we're

really hoping that we can replicate it in other parts of the country.

So if people are interested or just wanna chat about it, if they wanna

drop me a line, very happy to.

Lovely.

Thank you so much, Sandy.

Right, we're gonna get you back on the podcast again, if that's okay with you.

Um, and I look forward to hearing more about this, and thank

you so much for all your time.

Pleasure.

Thanks very much for inviting me, Rachel.

Thanks for listening.

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