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Absolutely Maybe

Absolutely Maybe

Evidence and uncertainties about medicine and life

Vulnerability as strength: Thoughts on changing medicine’s hidden curriculum

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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.

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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.

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

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