Why we need trauma-informed medical education

It’s time we started thinking about designing a trauma-informed curriculum for medical trainees, writes Dr Jocelyn Lowinger.

At a recent job interview I was asked the question, “can you tell us about a time you made a mistake and what you did about it?”

On the face of it, this question seems to be trying to identify people with a growth mindset, which was defined by author Carol Dweck. It describes those who are open about having made a mistake and using that to learn and grow from the experience.

I make mistakes all the time and have previously reflected on this (here and here). But in that moment, all my interview preparation flew out the window and I couldn’t think of a single mistake I’d made that I could actually talk about in this growth mindset way. Instead, I was instantly back in the deep, wordless and soul-destroying shame of being publicly yelled at in the middle of an emergency department about some mistake I made during my internship almost 30 years ago. And this of course carried echoes of other episodes of bullying in medicine and earlier in life. I certainly wasn’t going to share all that with the interview panel. This is just one small example of the long term impact teaching by shame had on my career. But I know I’m not the only one whose career has been affected by this. This is not just my bad luck as a junior doctor 30 years ago. It is still happening today.

Every week I hear doctors tell me stories about being bullied or shamed at work. Shaming on ward rounds, exam preparation tutorials, in operating theatres. It seems to be happening everywhere. Shame is often explicitly used as a driver of change, and the potential for shame exists in all relationships where there is a power differential. Whatever the context and intention, doctors tell me how an incident of public shaming undermines their confidence and results in them losing belief in themselves. Going to work becomes a dread- and anxiety-filled ordeal. Some change training programs, some delay exams (or find exam preparation completely derailed), some leave clinical medicine. And these are just the doctors I know about.

There are many discussions about imposter syndrome and related issues in the many online medical fora in which I participate. I have heard so many times in those groups, from many doctors, how lack of confidence or imposter syndrome passes with time. How being vulnerable makes you a better and safer doctor. All true in the growth mindset framework of the world. If that has been your experience, then you might assume that this type of growth mindset advice is a global rule that can help everybody.

When I first learned about growth mindset, I thought it (together with related positive psychology approaches) was some kind of magic bullet. At that time, I thought it doesn’t matter how much anxiety or shame or fear you feel about work or how much of an imposter you feel – learning a growth mindset is what you need.

I have had several clients who have had great success in dealing with imposter syndrome through shifting towards a growth mindset. But I’ve had just as many, if not more, tell me a growth mindset has not made a long term impact on the shame and anxiety they carry about making a mistake or not being good enough.

What it took me a long time to realise is that growth mindset just doesn’t work in a sustained way where there is unhealed underlying trauma. It doesn’t work when you fundamentally don’t feel safe.

It’s hard to unpick cause and effect here. But I suspect those of us who do move on in a growth mindset kind of way have some kind of buffering – perhaps any previous adverse events were buffered by things such as healthy relationships and connectedness with family and community, or perhaps there is a difference in genetic vulnerability. It’s hard to know. This was discussed by Dr Bruce Perry in his recent book.

But over the past five years working with doctors (primarily in issues related to building confidence), it has slowly dawned on me that when growth mindset strategies aren’t working, it may be because there is some kind of underlying and unhealed trauma, either the shaming incidents themselves or further back into childhood.

Many of my clients have courageously shared with me some of the adverse childhood events or child maltreatment that may have primed their nervous system to respond to public shaming as an active threat (versus a teachable moment). Many more have not wanted to talk about childhood incidents (and I don’t blame them) but, as the recent Australian Child Maltreatment Study found, many children have had some kind of maltreatment. If we extrapolate the findings, almost two in three future and current doctors may have experienced one of the five forms of child maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence) during their childhood. Like the general community, they have an increased lifetime risk of major depressive disorder, alcohol use, generalised anxiety disorder and post-traumatic stress disorder.

There is emerging evidence of a link between previous trauma and experiences of shame. Shame leaves us feeling under threat, inferior and powerless.

It’s not a long bow to draw between previous experiences of trauma (whether in childhood or during medical training) and the implicit threat of public shaming triggering a response by the autonomic nervous system into fight, flight or freeze, as outlined by polyvagal theory. Although there are no diagnostic criteria for chronic shame, it makes sense that repeated instances of shaming (no matter how well meant) may result in “the nagging and persistent possibility of shame, and … a persistent sense of inadequacy, defilement, failure and lesser self-worth … where one’s entire personality and character is structured around shame and shame avoidance”.

And it’s worth considering trauma responses and the risk of acute mental distress and suicide following an Australian Health Practitioner Regulation Agency (Ahpra) notification (here and here).

So how many doctors struggling with managing imposter syndrome, performance anxiety, or burnout have had underlying trauma that contributes to the adult workplace struggles? How many doctors have left medicine because medical training and work is so traumatising, and retraumatising for those with a background of childhood maltreatment? Only research will tell.

In the meantime, if the medical profession as a whole wants to be part of the solution, then perhaps we need to be getting our own house in order and lead by example. In the spirit of first do no harm, isn’t it time we rethought how we teach and support each other knowing how many people may have been harmed in childhood including developing a shame-sensitive practice where, at the very least, we reject shame as a behavioural tool in any context? Isn’t it time we embedded more compassion into our curricula and the way we treat ourselves and each other?

It is time we started thinking about designing a trauma-informed curriculum where we can all learn how to “support learners who are living with the outcomes of complex trauma”.

Dr Jocelyn Lowinger is a former GP and now works in medical professional development including coaching health professionals. Visit www.coachgp.com.au

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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