How shame tried to hijack my medical training [PODCAST]

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“I’m smart enough to be a physician. As if being the smartest person in the room makes you the best physician in the room. Hint, it doesn’t. Being a good physician is a culmination of knowledge, skills, and strengths that you, as an individual physician, uniquely brings to the field.

It’s taken some rewiring to pull shame out of my professional narrative. Shame is not there to serve you. It’s there to diminish you and to prevent you from fully embracing and accepting all parts of yourself, flaws and all. It chokes off growth and evolution.

It starts with subtly shifting the narrative in difficult situations from who you are to what you did. You can deal with what you did. You can learn and do differently next time.

On that first call night of my formal medical career, I wasn’t a mistake. I made a mistake.”

Tracy Asamoah is a child and adolescent psychiatrist and can be reached at Tracy Asamoah Coaching.

She shares her story and discusses her KevinMD article, “How shame tried to hijack my medical training.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Tracy Asamoah. She is a child and adolescent psychiatrist, and she wrote the KevinMD article “How shame tried to hijack my medical training.” Tracy, welcome back to the show.

Tracy Asamoah: Thank you, Kevin. I’m happy to be back.

Kevin Pho: So we’ll get into the article in a little bit, but for those who didn’t get a chance to listen to our first episode together, can you just share your story and journey to where you are today?

Tracy Asamoah: Yeah, absolutely. So like you said, I am a child and adolescent psychiatrist, and I’m also a physician coach. I focus on supporting women physicians going through career transitions and life transitions, to help them be able to design the life they want to have going forward and design an action plan to get there. I’m also a child psychiatrist, and I have a small private practice here in Austin, Texas.

Kevin Pho: We are speaking toward the end of August, and by the time this episode comes out, we’ll be in the midst of the fall school season. So we are 18, 19 months in the midst of the pandemic. From your perspective as a child and adolescent psychiatrist, what are some common issues that you’re seeing in the people that you’re seeing, and what’s some advice that you have for parents in this upcoming school year?

Tracy Asamoah: Yeah, you know, it’s really interesting, because obviously over the last 18 months what I’ve been seeing has shifted quite a bit. At the beginning of the pandemic, it was a lot of dealing with big changes, uncertainty, and stressful situations, and all the changes of not being able to do what teens and kids do developmentally. That wasn’t really happening when they weren’t seeing their friends and in those environments that support their development.

It’s shifting now. Kids are going back to school, and some are ready for it. They want to be there, they’re excited to be with their peers, and they want to get back into what feels like a normal routine. Some are struggling. A lot of kids have not left the house very much in the past 18 months, and they certainly haven’t been on a school campus. They are returning to that from a period of being relatively isolated to full swing, and having to not just get back into school and what school brings with academics and teachers, but also deal with the social issues that come up during that developmental period.

And then on top of that, a lot of the kids that I work with deal with anxiety, depression, ADHD, and autism spectrum disorders, and all of that is now culminating, front stage, right now. I’m seeing a lot of kids navigating that, and some struggling with getting all of that back into full swing again. So the next couple of months will be interesting, to see how this plays out.

On top of all that, kids are worried about the pandemic too. They see their parents’ stress, and they understand something about what all of this means, depending on how old they are. The ones that don’t often see their families stressed, and they see adults fighting and arguing, and uncertainty about what to do. And they’re also taking that back into their school days and into the classrooms, so teachers certainly have their hands full helping support the students and trying to really bring education to where we want it to be, but knowing that there are a lot of other factors that are mixing in and impacting how kids are able to learn and adjust to their school day.

Kevin Pho: So from a behavioral health standpoint, any tips and advice for parents whose children may have to reacclimate back to a social setting again?

Tracy Asamoah: Absolutely. You know, one of the big things is really being able to be open and receptive, and listening to whatever your kids bring to you. If they’re bringing things that they’re worried about, stressed about, or uncertain about, just being able to listen and hold the space with them is really important. We as parents really don’t understand what our kids are going through. None of us had to go through school in this way. So while we know our kids really well, and we often understand our kids really well, we don’t quite know what this experience might be like for them, and it can change day to day. Certainly their emotions and their moods can change day to day. So just being a place where they can really express themselves and talk about what they’re feeling, and being able to listen and maybe not always judge and try to have the answer, but just being a better listener, will be really important.

Also, be very clear about what your expectations of your kids are. We do want our kids to learn, we do want our kids to get an education, and we do want our kids to be able to focus on that. So really let our kids know that this is why we’re doing all of this: We want our kids to have an opportunity to have an education, and we’ll figure this out. We’ll work through it. It might be tough, it might be difficult, but we will be able to figure this out. Just reassure them that the whole purpose is for them to be able to have as much normalcy as possible, to be able to go to school if that’s safe to do, to do so in a safe way, and for them to be around other kids, because it is really important for kids to be around kids. So just have kids understand these really basic things.

And then let your kids get home and relax. Please let kids just get home and decompress and unwind, even if they have homework or activities. Having a chance to come home, especially for those kids who haven’t been around a lot of stimulation for a long time, and just being able to allow the day to dissipate and melt a little bit is really important for a lot of kids. So if your kids don’t want to come home and talk about their day, tell you everything that happened, and jump into their homework, that’s fine. Give them some time. Let them get there, let them get their headspace straight, and then they can step into whatever the evening needs to look like for them.

Kevin Pho: All right, let’s transition now into your KevinMD article that you wrote. It’s titled “How shame tried to hijack my medical training.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Tracy Asamoah: Yeah. Well, I’ll say why I decided to write it. I wrote it because I realized, not until after having started partnering with women, coaching around all sorts of issues that come up for physicians, and especially women physicians and physicians of color, I really started to understand that shame, and my experience with shame at different points, not just during training but things that I experienced during childhood, really impacted how I was showing up as a physician. I was also seeing it in how the women that I partnered with were showing up. I understood that recovering from shame, and what that showed up as, really was an important part of the journey of becoming a different type of person in who I was and who the women that I partner with are, both as physicians and also in their relationships and in their time by themselves.

So I really wanted to take an opportunity to step back and share what I experienced, and why I thought it was so important for all of us to be able to bring this out in the open, take off the covers, and not allow shame to take center stage in how we move through the world.

In training, the one episode that has always stood out was when I was a brand-new psychiatry intern and I was doing my first shift admitting patients from the ER onto the inpatient unit. I was excited, I was happy, and I felt good about where I was, but I was also overwhelmed. It was a busy night in the ER, and there was a lot going on. I didn’t know how things worked at that point. I was there with my senior resident, and a lot of patients were there for psychiatric evaluations, so he gave me one to go see.

This patient was just a complicated patient. This patient had been diagnosed with AIDS and also had a history of some different psychological issues, and was coming in with a very bizarre presentation. I just didn’t quite know what to make of him, but I did my best and got him admitted. He had already been seen by the ER team. I evaluated him, presented him to my resident, and thought I came up with a pretty good plan to get him admitted, assessed, and treated on the unit.

The next day, my resident told me that after he had taken another look at the patient, he had sent the patient for some imaging, which I had not done, and the patient had a finding on MRI that explained a lot of his symptoms. The way it was presented to me was basically that I’d screwed up. I had missed something big. It could have turned out really horrifically if he hadn’t caught it, and I needed to be more careful.

What didn’t happen was any teaching around what I had seen or how I could have caught it, or the fact that, “Hey, you’re here to learn. This was a big deal, but what can you learn from this? How is this not going to happen again? Let’s talk about what you need to look for. We all make mistakes. Don’t let this get to you. You’re going to make mistakes, but you want to learn from them.” That’s where the focus should have been. But at that time the focus was on me feeling bad about missing something that I should have caught. And whether or not I should have caught it, I don’t think, was the point. I mean, it was my first day as an intern seeing patients, so I was focused on just making sure that I covered all the things that I needed to cover and doing the assessment in the ER, and maybe not quite so good yet at catching the things that were a little bit more like the unicorns or the zebras in the room. I was looking for the horses, not the zebras.

So it could have been a great learning opportunity. Maybe I would have become super interested in working with that particular group of patients, because I actually found him really interesting when I evaluated him. But it actually created a lot of fear and anxiety in assessing patients in the ER that followed me through a lot of my training, because I thought I was always going to miss something really important if I didn’t overdo it. And it fed into the tendency that a lot of us have of being perfectionistic, and maybe doing things that aren’t quite so necessary, because we’re so worried about what happens if we don’t do all the things.

So that’s why I wrote it. I wrote it because I really had not reflected on the meaning behind that until recently, until I started seeing shame in a lot of the clients that I partner with. I reflected back on some of my past experience and realized, “Wow, that has sat with me all these years, and I never really peeled it apart and looked at it and dug in there.” I had never really even given myself a break around it. I kind of always felt like I had really screwed up, and that was a shadow that has lived with me through all of my career, through all of the other things that I’ve done that have been fabulous and things that I’ve done that have been screw-ups. That has always sat there. So I really wanted to pull that out, so other people could say, “Hey, yeah, I get it. I’ve been there. Maybe I need to forgive myself about something too. Maybe I need to understand how shame is showing up so I can show up a little bit differently going forward.”

Kevin Pho: So you mentioned that that episode of shame lasted for a while after that particular episode. Was there anything specific that happened that helped you recognize it for what it was and helped you overcome it?

Tracy Asamoah: Yeah, I mean, I think what helped me recognize it for what it was was some of my own coaching, and really starting to understand some of my roadblocks and some of the things that were getting in my way of really showing up as I wanted to as a physician, and saying, “Wow, shame is there. There’s something there.” And then just getting curious about what were some of the more memorable experiences in my training and my education, and how have they impacted me.

That one has always stood out. It stood out because it was so early in my training, and because the way that attention was brought to it felt so harsh at the time, and so unforgiving. It set up an early expectation that I should have walked into training having it all figured out, that I should have walked into training as a psychiatrist ready to see patients, even though I was there to learn. My training was five years with residency and fellowship. I had lots of time to figure things out. The purpose of having teams in training is that not only are you there to learn, but there’s backup, because of course you’re not expecting the people who just got there in July to know it all.

But in my head, through the rest of my training, it was, “No, you are supposed to know it all. Or if you see it for the first time one day, you’d better have it all figured out by the time you show up in rounds the next day.” So it set up this really unrealistic expectation in my head that I wasn’t allowed to make mistakes, that I wasn’t allowed to not know things or to miss things. That was something that I carried through a lot of my career. It’s been well into me practicing independently as a psychiatrist for a couple of decades now to just be open to the fact that sometimes I might have to look something up, I might actually miss things, and things may not go the way I had intended them to go. And that is absolutely part of evolving as a physician through our entire life cycle of practicing medicine.

Kevin Pho: Now, for those physician clients who come to you with similar episodes of shame, what kind of advice do you give to them?

Tracy Asamoah: Yeah. Well, I mean, one of the things that we always look at is what it did to protect you when it first showed up, because there’s always a reason that we develop these patterns of behaviors and these ways of thinking, even if those patterns no longer serve us. There was something very important that it did for me during training. I was at a program that really did focus on being really productive, and on performance, how well you did, and how much you knew. So in that program, fitting in and feeling like I was doing what was expected of me meant that I would live up to my own expectations of what perfection and having everything figured out looked like.

So I think it was protective back then, because it pushed me, and I felt that I needed to push myself so I could keep going and keep doing all those things that the other people in the program, everyone who was responsible for bringing me up in medicine, expected of me. But what I do with clients is to say, “OK, so yeah, it had a purpose. We have to honor what that is and what that was, and now we have to understand if it’s still serving you, or if it’s now becoming a barrier to you being able to do what you really want to do.” And so when my clients are able to see how the shift has occurred and how it’s a barrier, then we can start pulling it apart and finding other ways of doing the things that allow us to feel like we’re working and performing with excellence, meaning, joy, and fulfillment, in a way that shame doesn’t allow us to do.

Kevin Pho: We’re talking to Tracy Asamoah. She is a child and adolescent psychiatrist, and she wrote the KevinMD article “How shame tried to hijack my medical training.” Tracy, this episode clearly lasted with you for a long time, and now that you have the perspective of being an attending, what kind of advice do you give to other attendings when they’re trying to mentor, teach, and educate residents? And just speak about how your words can have such an effect on the people that you train.

Tracy Asamoah: Yeah, I mean, I think one of the main things is that we need to acknowledge mistakes, or learning opportunities, much differently. I do think they need to be addressed, and they need to be brought out in the open, but from a standpoint of learning, and from a standpoint of, “OK, so this was the outcome of the decisions that you made. What might have happened if you had a different set of knowledge, if you had judged the situation differently? What can look different? What’s going to be different next time?” So bring the focus back to learning, really bringing the concept of having a growth mindset in medicine, and again, through the entire life cycle of our careers.

I remember when I was studying for the boards, and I don’t remember which attending told me this, but they said, “If you’re ever in a board situation,” oral boards, for the boards I was preparing for, “and they ask you a question you don’t know the answer to, you have to tell them that you know how to get the answer: I know where to look it up, I know where to find it, I have resources.” And that’s a mindset that we should carry. We are going to be learning and understanding through our entire careers. That concept needs to start in training.

And I think that attendings who are mentoring trainees, residents, and fellows need to also be very open and transparent about their own experiences with adverse outcomes, or mistakes, or judgments or decisions that they wish they had done differently, and then model a way of navigating those choices or those mistakes in a healthy way. So even as trainees and students are going through their own decisions and experiencing negative outcomes, they can understand that there is a way that they can hold that experience and grow from it. You’re going to feel bad about it. Nobody wants to have a bad outcome for their patients. Nobody wants to hurt their patients. We want our patients to do well, and we want to always make the right decision, but we won’t.

And so when we are mentoring and raising up the generation behind us, we need to have them understand how you navigate those waters in a healthy way, and in a way that in the end is going to help you and your patients down the road. That needs to be modeled, really directly modeled, and we need to have that idea of a growth mindset be at the foundation of how we educate in medicine.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Tracy Asamoah: Yeah, my take-home message is that, to some degree, so many of us carry these scars from our education and training, whether it be shame or other things, that really can impact how we show up as physicians and in whatever we do in our current day, our current lives, our current professional lives. And that we can be kind to our past selves and try to see what the lesson can be, even now, from those. How can we start to shed some of those barriers that come up from those things that scared us, and move forward in ways that really help us shine, and really practice and live with joy, meaning, and purpose?

Kevin Pho: Tracy, thank you again for coming back on the show, sharing your time and insight, and thanks again for your time.

Tracy Asamoah: Thanks, Kevin, for having me.

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