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Vulnerability as strength: Thoughts on changing medicine’s hidden curriculum (Guest Post)


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Guest post by Michelle Munyikwa

Image of white lab coats

I recently read this article in Health Affairs regarding the effects of the hidden curriculum on patient safety and, in my usual fashion, have been thinking about it ever since.

Dr Joshua Liao describes an experience he had as a medical student on labor and delivery, when the dynamics of his team contributed to his fear of speaking up about not knowing how to do something. He highlights the importance of subtle team dynamics and pressures:

“Egregious behavior is just the visible tip of a much larger iceberg. Far more prevalent are the subtle behaviors that threaten patient safety but go largely unnoticed and unaddressed… Progress in patient safety may be hindered as much by such subtle behaviors as by overtly inappropriate physicians.”

I share his concern about the challenges of eliminating the hidden curriculum. My medical school’s patient safety curriculum included several small group sessions, during which I heard my own concerns echoed by classmates: how should we navigate hierarchy? Who can we turn to for support? How do we avoid retaliation – both overt and subtle?

Many students had stories to share, and it was clear that this problem was a widespread part of the clinical experience. Though we had been taught that open, honest communication was the best option, it seemed like this advice was given with an ideal situation in mind.  In practice, our teams were not always so receptive, and we were often scared into silence.  We must change this, because as Liao and his colleagues so artfully articulate, subtle team dynamics have the potential to cause serious harm.

I believe that one element of this problem is the shame placed on the expression of uncertainty. It is clearly communicated, though rarely explicitly, how we are to behave. With exceptions, of course, our supervisors communicate that: we are meant to be strong, we are meant to be self-assured, and we’re meant to know that ‘there are no stupid questions.’ That is only true if you never, in fact, ask any stupid questions. In a competitive, hierarchical environment, how could we ever speak up?

In medicine, we often use the term vulnerability to refer to our patients or the communities we work with. I wonder if considering ourselves to be vulnerable and imperfect could contribute to the way we learn, teach, and interact with patients. I’d like to imagine what it could offer to build communities in medicine that embrace (perhaps even celebrate) vulnerability and imperfection. What might it look like to replace cultures of shame and humiliation with those in which we accept that we are all works in progress?

A while ago, I was first introduced to the work of “researcher-storyteller” Brene Brown. To her, vulnerability and shame are connected concepts. Vulnerability is necessary for connection. Perfectionism is counterproductive. Shame, far from helping us to succeed, actually prevents us from reaching our potential, as individuals and as organizations. In reading her work, I have come to believe that medical culture would be improved by the recognition that vulnerability is not a weakness, but a strength. This understanding would, I hope, help us realize the ineffectiveness of shame-based learning.

Emphasizing the elimination of shame-based techniques may also affect the well being of medical trainees. Cultivating healthy, honest communication can only be beneficial within a career that demands so much of us emotionally, mentally, and physically. Creating teams in which every member feels comfortable to speak up is not only good for patient safety, but for physician safety and suicide-prevention as well.

Of course, it is not so simple as admitting vulnerability and calling it a day. Medicine is life-or-death, and in a litigious society, the stakes of making a mistake are high. But mistakes are inevitable. As Brian Goldman notes, doctors make mistakes and neglecting that reality is not helping to decrease medical errors. Rather than sweep this under the rug, we need to be open about the reality of medical imperfection. Additionally, increasing comfort with our own imperfection may make us better at communicating with our patients.

Embracing imperfection on an institutional level is challenging work. Many schools, including my own, are working through ways to teach communication techniques that help us build safe spaces and more effective teams. It is hard, but it is necessary work.

I used to think that when I grew up into a fully-fledged doctor, I would no longer feel so vulnerable. I imagined that I would know so much that it would protect me from making mistakes. But the wisdom of others makes it clear that we cannot escape vulnerability, particularly as physicians. Despite our white coats and fancy degrees, doctors are human. To be human is to be vulnerable.

~~~~

Photo of Michelle MunyikwaMichelle Munyikwa is guest blogging at Absolutely Maybe this month – catch up on the posts. She studies at the University of Pennsylvania, and has her own blog at Michelle Munyikwa. You can follow her on Twitter: @mrmunyikwa.

Image: Lab 15 – Lab coats, from Pi via Wikimedia Commons.

Hilda Bastian About the Author: Hilda Bastian likes thinking about bias, uncertainty and how we come to know all sorts of thing. Her day job is making clinical effectiveness research accessible. And she explores the limitless comedic potential of clinical epidemiology at her cartoon blog, Statistically Funny. Follow on Twitter @hildabast.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. plswinford 3:12 pm 02/19/2014

    The complexity of the human body, or of just one cell, is so complex we may never understand things. Doctors will never know it all; which we patients need to keep in mind.

    Link to this
  2. 2. Whatiffer 3:19 pm 02/19/2014

    Learning and school are representatives of two unrelated categories of concepts. There seems not to be ways to escape this phenomenon in any of the levels of our recent model of formal education. The roots of the problem are difficult to detect but could with well stated groundings be called The Central Dilemma of the School. For wider perspectives, please have a look at http://bit.ly/1bEQpoM

    Link to this
  3. 3. tlahey 6:52 am 02/21/2014

    Thanks for your post. I appreciated particularly your ideas about the importance of being more comfortable with our human imperfection and uncertainty as necessary to the prevention of systematic error. I couldn’t agree more: we cannot prevent or rectify our errors if we are trying too hard to hide them.

    You may also enjoy my blog at the Health Affairs website in response to the same article by Liao et al:

    http://healthaffairs.org/blog/2014/01/31/the-hidden-curriculum-changing-the-water-in-which-we-swim/

    It is interesting that some of the themes we sounded – like the importance of high functioning teams – are the same, but others are different.

    Glad to be part of this conversation with you!

    @TimLaheyMD
    Geisel School of Medicine at Dartmouth

    Link to this
  4. 4. MMunyikwa 2:50 pm 02/22/2014

    Hi Dr. Lahey,

    I really appreciate your response to this post. After reading yours, it is interesting to me where our thoughts on this issue intersect.

    I’m very curious about your curricular reform efforts – particularly around integrating multiple aspects into the curriculum, bringing people from different departments into conversation with one another to foster teamwork. It reminds me of some of the efforts that my school has made around educating nursing students, medical students, and pharmacy students together about patient safety and teamwork.

    I’m looking forward to see where these conversations about cultural change in medicine take us – luckily I have a long career ahead!

    Link to this
  5. 5. LouiseKinross 8:14 pm 03/4/2014

    This is brilliant! It levels the playing field when we emphasize the humanity of both patients/families and doctors, leading to better care.

    http://bloom-parentingkidswithdisabilities.blogspot.ca/

    Link to this
  6. 6. DonnaThomson 2:48 pm 03/26/2014

    As a parent, caregiving activist and author, I welcome the discussion on vulnerability within the medical profession. Our son is a complex care patient with a long history of frequent hospitalisations, multiple team involvement and community care. We ran a home hospital until he moved into a local care facility two years ago. The unwillingness to embrace vulnerability and uncertainty within the professional environments where we operated proved to be a barrier to best practice. I craved an honest, intelligent and equal conversation about our son – a conversation that put us on equal footing as far as vulnerability is concerned. Few professionals are able to interact that way with longterm caregivers in the community. How does medicine look when vulnerability is a given for all parties? It looks this: http://www.tyze.com. We use this highly secure web platform to discuss all matters related to our son’s care (both personal and medical, because you can’t separate those out in someone complex who wants a real life). All the professionals involved are in a network of communication together with family and a very few (very involved) best friends. That’s the vulnerable way of the future and I like it. So does our son.

    Link to this

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