3. Golden Ticket
Episode Synopsis
We all arrive at the gateway to medicine carrying baggage from our past. We’ve had different hopes, hurts, and childhood arcs. How do these early life experiences guide us toward our careers? And once we “arrive,” how do they impact the way we experience shame in the workplace?
Behind The Scenes
The train station metaphor really helped bring this episode together. We knew we wanted to discuss the way our pre-medical lives impact the way we experience shame in our profession, since Will’s research shows that shame narratives are often set up very early in life—as early as childhood. During an organic team discussion, Will came up with this train station metaphor and we ran with it. It also offered a great opportunity for sound design and world-building.
CONTRIBUTORS
Drea Burbank, MD
Pedro Gallardo
Arifeen Sylvanna Rahman, MD
And other healthcare professionals who wish to remain anonymous
PRODUCTION TEAM
Host & Co-creator: Emily Silverman, MD
Co-creators & Research Leads: Luna Dolezal, PhD & Will Bynum, MD
Producer, Editor & Audio Engineer: Sam Osborn
Producer & Assistant Editor: Molly Rose-Williams
Additional Producing: Adelaide Papazoglou
Production Coordinator: Penelope Lusk
Medical Student Producers: Corinne April Iolanda Conn, MPH & Nikhil Rajapuram, MD
Impact Campaign Manager & Assistant Producer: Carly Besser
Executive Producer: Alison Block, MD
Chief Operating Officer: Rebecca Groves
Exeter Team Coordinator: Alice Waterson
Series Illustrator: Beppe Conti
Music: Blue Dot Sessions
SPONSORS
Shame in Medicine: The Lost Forest is made possible in part by the Shame and Medicine project at the University of Exeter, funded by the Wellcome Trust.
The Nocturnists is supported by the California Medical Association, and people like you who have donated through our website and Patreon page.
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Download the discussion guide for Episode 3, "Golden Ticket" here.
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READ:
Bynum WE 4th, Varpio L, Lagoo J, Teunissen PW. ‘I’m unworthy of being in this space’: The origins of shame in medical students. Medical Education. 2021.
Dolezal L. Gibson M. Beyond a trauma-informed approach and towards shame-sensitive practice. Humanit Soc Sci Commun 9, 214 (2022).
hooks b. Moving Beyond Shame in Teaching Community: A Pedagogy of Hope. 2003.
Mantoo S. Vulnerability and Shame in Medicine. FemInEM. 2019.
WATCH:
Ngozi Adichie C. The danger of a single story. TEDGlobal 2009.
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The Nocturnists – Shame in Medicine: The Lost Forest
Ep. 3 Golden Ticket
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
So, just imagine for a second a train station. There are people rushing back and forth, times clicking by on the train schedule, platforms leading to all sorts of different destinations. And you're looking around for the right platform—the train with medical school listed as one of its stops, with a final destination of the medical profession. As with any train, you need a ticket and you look down at your hand and you're holding a ticket. You've put an immense amount of time, energy, effort, and sacrifice into getting this ticket. So you rush through the crowd, clutching your ticket in one hand and your luggage in the other. You finally find the right platform. As you await the arrival of the train, you look around at the others crowding the platform with you. And you can't help but notice that at this gateway into the medical profession, some people have gilded luggage carried by butlers and others carry their own baggage and knapsacks tied together with string. Some carry massive cartloads of luggage, and others are waiting for the train with nothing but the shirt on their backs. In this luggage are your childhood experiences, your educational achievements and failures, your hopes, your desires and your flaws. And there you all are, waiting for the same train that will take you to the same destination. While boarding the train has been your focus for years, you also wonder, “Will there be room for my luggage on board? Will I be able to carry it all to my final destination? How will its contents change along the way?” You hope it all fits.
And so it goes with admission to the medical profession. Through this gateway walk people from a myriad of backgrounds and experiences that define the road already traveled and will shape the journey ahead. You see, to understand the role of shame in healthcare, we have to understand where this journey began—how our origins shaped the way we know ourselves and interface with the exhilarating and grueling trip to a medical life. So that's where we begin—on the platform waiting to board the train. You're listening to Shame in Medicine: The Lost Forest. I'm Emily Silverman.
Drea Burbank
So, it's kind of hard to describe the way that I grew up because most people in North America have never seen it. But one time I was on a medical mission in Uganda and I went to an Ugandan slum. So I was in Kampala and I went to the slum where we were working with street kids. And I was grabbed by one of the women in the slum and taken into their house. And when I walked into the house, I thought, “Shit, this is like the first time I've been in a house that reminds me of where I grew up,” because the floor was dirt, and the whole family was living in one room, and the wall hangings were like, you know, blankets hung up, and it smelled really bad. And I felt very, like, comfortable. And I was, like, I sat down on the bed and I was talking to them. And the med students that I was in the slum with came in the door and they're like, “What's the matter with you? Why are you sitting down in this person's house? It's so unsanitary.” And I had this really strange moment where I realized how much of a trajectory I had crossed into medicine.
Now, I grew up in the US. I grew up in central Idaho, off the grid, no power, no running water. We were homeschooled. I lived in a religious commune, anti-government commune. And I wasn't very comfortable there and I didn't fit in very well. I was into Dostoevsky and I read the encyclopedias. So I tested into University and at 18 I left and I really never went back.
And when I got into med school, the first thing I did was I called them and I said, “I know you've made a mistake. I totally understand. Mistakes happen. You can take my, you can take my name off the list.” And they were like “No, it really wasn't a mistake. Like, you actually are supposed to be here”. So I felt like the kid in Charlie and the Chocolate Factory who gets the golden ticket and gets to go to Charlie's chocolate factory. Like, it was the, you know, the chance of a lifetime. And I had worked hard for it, but I don't think I really understood what it meant at the time. And to show up at the chocolate factory and be told that everything about you is wrong…. It felt like I had slammed into a brick wall going sixty miles an hour, and they hated everything about me—just hated the way that I talked, the clothes that I wore, how I did my hair, you know, I was a very, very, very ugly duckling.
You go to med school and they assign a doctor to you. And they assign a doctor to be your family doctor. So I have a family doctor for perhaps the first time in my life. And I go to see the family doctor, and the family doctor tells me, “You shouldn't be here.” She said, “You should be a social worker, not a doctor, because you identify more with the patients than you do with the doctors.”
And I realized very quickly that I was the wrong social class. It was that simple. And so I immediately began to, like, observe other people's behavior, and the clothes that they wore, and the things that they talked about, and, you know, what they thought was important, and kind of model it. Not so that it could be like them. I wasn't that interested in being, you know—I would say, I would describe med school as upper middle class mostly—I wasn't that interested in being upper middle class. I just didn't want any friction. It was like you go to a foreign country, you know, you don't want to wear the clothes from your country, you just want to wear whatever clothes allow you to fit in so you can actually participate in the culture. And when I went to med school, I started, like, assuming the class of the other students so that they wouldn't stare at me and say stupid things about me, because they were very, very disparaging of, of me as a human.
I was considered to be pathological. And it took me many, many years to realize that, in many ways, they were right. I mean, 90% of physicians come from upper middle class family backgrounds, many of them whose parents are doctors, and, you know, most of the patients are coming from lower middle class backgrounds. And so, so often in medicine, the markers of class become markers of pathology. And in order to not be identified as somebody who was sick, I had to pretend to be somebody who was from a different class. And, you know, over time, you kind of adapt to any, anywhere you are. And I felt like I was in a foreign country and I adapted. I had culture shock. And I learned how to appreciate the people around me and engage with them in a deeper, meaningful way.
I think now I've come to terms with it. And I perceive of it more as, like, the ability to be a code switcher. So I can code switch between a patient and the doctor in conversations. And I can be a very strong, powerful advocate politically, as well as, like, clinically, for people who can't communicate effectively outside of their class barrier. But at the time, it didn't feel like that. At the time, it just felt like, it felt like I had the chance of a lifetime and I was blowing it, is really how I felt.
Arifeen Sylvanna Rahman (contributed as a medical student)
I grew up in the heart of the Silicon Valley, the most Asian congressional district in all of California. My neighborhood park had Asian grandmas doing tai chi at the break of dawn. Back then your average upper middle class South Bay citizen was an immigrant trying to ensure their visions of the American dreams were realized in their children. That took on a new and fascinating flavor in the realm of private elementary schools. When I was four, I was enrolled as a student at Challenger School. It was conservative, patriotic, and required every teacher to write an essay about why they loved America. And yet Challenger was a private school with the student body of almost all first generation immigrant children. My classmates were ethnically Indian, Chinese, Japanese, Pakistani, Vietnamese, Bangladeshi, Korean, Taiwanese, Filipino. At lunch, we traded seaweed snacks for Hello Panda. Our parents wanted us to be one of three acceptable professions: a doctor, an engineer, or a doctor. “Knowledge, Work, Virtue” was Challenger’s motto back in the day. Now, according to their website, it’s “Start Early, Start Right”. Competition was imbued in every activity and lesson plan. Starting from kindergarten we had speech contests, art contests, math contests, writing contests, spelling bees, geography bees, science fairs, presidential fitness awards. There was even an award for perfect attendance. None of these were optional. They were mandatory parts in the curriculum. Competing was like breathing, and I never thought twice about it. Unless I was worried about losing.
One December afternoon in middle school, I stood on our cafeteria stage, sweating through my burgundy uniform sweater and green and yellow plaid skirt while five hundred students looked at me. I had made it to the finals of the school-wide geography bee. I was twelve years old. The stakes were infinitely high. “What is the only sub-Saharan member of OPEC?” The principal asked. My hand trembled as I scribbled my answer onto my personal whiteboard and glanced at my competitor. This was geography sudden death. Whoever had the right answer would win bragging rights and a chance to move on to state championships in the suburbs of Sacramento. My competitor was another short Indian kid who also won all the things. I wonder now, if either of us really cared about the capitals of faraway countries, about their cultures and peoples. But there we were contemplating the only sub-Saharan member of OPEC. “Angola,” my competitor said. I was so thrilled I started to twitch with my own answer. You see, I knew that the only sub-Saharan member of OPEC was, in fact, Nigeria. I won the school-wide geography bee, and qualified to state championships, and made my parents drive to the suburbs of Sacramento. It was the absolute pinnacle of my academic pursuits. At least for the moment, until I fixated on the next best thing to accomplish or achieve. Because the truth is there never was a pinnacle. It was always a moving target. There was always another hoop to jump through.
Now I'm in medical school. In medicine, there will always be more boxes to check, achievements to cross off the list: matching into residency, scoring a fellowship, being on track to a career in academic medicine or industry, or what have you. Sometimes I ask myself, “Why am I even here? Is it because I want to be, because it was the right fit? Or because I'm on a track where I will always be chasing down challenges.” Truth is, I'm afraid that if I stop I won't know who I am anymore, that I will just disappear. I haven't really ever failed–not in the life-altering, crazy-disappointing ways that I know will one day happen, when I fail myself, my loved ones, my patients. And it terrifies me. While I'm waiting, I just keep working my hardest, desperately hoping that every gold sticker I accumulate will be my armor when it happens. Even if I know better.
I would be lying if I said jumping through hoops didn't matter to me. I think the furthest, highest hoop will always, always feel the most attractive to me. But I realize there comes a point where it lacks meaning in and of itself. And it's up to me to find inherent meaning in everything I do, instead of always searching for that gold sticker. The process isn't really over. I'm in remission. And sometimes that competitive spirit just pops up out of the blue. Just like I never expected that one of the next times I would run into my middle school geography bee competitor will be walking across Harvard Yard. “It wasn't Angola,” I thought to myself as I waved at him. Basically what I realized is that you may leave Challenger, but Challenger never leaves you.
Pedro Gallardo
My name is Pedro Gallardo, and I am a first-year medical student. I was diagnosed with leukemia at three years old in 2000, which sent my family for a tailspin. As a three-year-old I had no understanding of the disease that I had, but I understood it in very physical and very emotional terms. Physically, I had the symptoms, both from the leukemia, as well as the side effects from the chemotherapy regimen. I was fatigued. I was nauseous. I hated the taste of chemotherapy pills, which my mom would crush up and mix with condensed milk. And I absolutely detested blood draws. Each time it was such a fiasco. It would be one parent putting one arm down, another parent the other arm. And I distinctly remember this Eastern European nurse—she must have been the strongest person in the world—who had pinned down my legs just for a single blood draw.
I think emotionally, as a child, I understood that whatever it was that was happening to me was serious enough for my aunts and uncles and grandparents to fly in from Mexico City, especially to take care of my two older brothers, who still had our projects to turn in for elementary school. I also knew that whatever it was that I had really stressed and saddened my parents. I could tell that it was, it saddened them to see me the way that I was.
Luckily, the cancer came and went. But there are a lot of ways in which it kind of stayed with me and kind of has followed me. Most notably, I have a thick, two-inch velvety scar, right between my nipples—and it's just off center—which has followed me forever. My earliest memories, I can't remember a time when I didn't have that scar. And as a child, it was really embarrassing and shameful to have that scar. I think it was a constant reminder that I was born different, and should be embarrassed about what happened. We also never figured out a way to talk about my experience with cancer in my house. My parents never called it leukemia. It was always, “tu enfermedad” (your illness), or “cuando estabas enfermo” (when you were sick). I'm not sure if this was intentional or not. But it felt like what I had had was something that had only happened to me. I was the only person in the world who had gone through what I went through, in my young mind. My m.o. was to keep it quiet and to pretend leukemia never happened.
Because my parents and I never talked about leukemia, I started to learn about cancer biology through my high school class. And that kind of normalized what I went through, when I realized that other people had had the same thing. It's a very common pediatric cancer. And I decided that I would go into medicine to not only learn about my past medical history, but also help others in a similar position.
Richelle
As far back as I can remember, I wanted to be a writer, a dancer. I wanted to draw and I wanted to compose music. My parents knew this. But for as long as I remember, my mother told me I had to be a doctor. Because someday, when I got married, and my husband left me, I'd have to have a way of making decent money to support myself. And being a doctor, I'd have money, respect and prestige. And that's what it was all about. And my father just went along with it.
No one said “No” to Mom. It was too scary. I learned early on that going contrary to her wasn't worth it. It was bad enough as it was. I just, just basically wanted to get through the day without being yelled at, berated, hit, without my hair being pulled, my toys broken. I was scared all the time–even as an adult. So for as long as I remember I said I wanted to be a doctor. But obedience for me was a matter of survival. And they controlled every aspect of my life. They picked the college I went to, I studied the major they picked, I went to the med school they picked. I didn't, I didn't mind and, it probably sounds weird, but I didn't mind because school was my safe spot. And I wasn't used to making decisions for myself. School was the one place in my life that was predictable. It was the one place I wasn't scared. And making A's and being the smart girl was my identity.
And then I got to med school and I was surrounded by classmates that were all smart and driven and focused. And they knew where they were going. They were living their dream. It seemed so empowering for them. And I was this aimless people-pleaser, with no clue who I was as a person. My whole life was about my parents. I had never asked myself what I wanted, and no one had asked me what I wanted. All I knew was to keep my parents happy, study hard, and do well. And that's what I did. I did really well.
And then it's, like, I woke up one day and realized this wasn't fun and games anymore. This, I was in hundreds of thousands of dollars of debt. And this was changing my identity. It was changing my name. People were gonna call me “doctor,” and I had no idea what that meant. The only doctor I knew was my pediatrician, who was this big, gruff man with a huge black beard, who, you know, every time my parents took me in, for, like, a sore throat, he gagged me with a stick, and I would vomit on his carpet. I had no physician role models, I had no female role models. And I went to med school at a time when it just seemed to me like all physicians were men, my professors and mentors were all men. Most of my classmates were men, like, I think it was under a quarter of my classmates were female. And I honestly wondered, was there a place in medicine for females, let alone one that was broken and damaged by life? You'd think becoming a doctor would be empowering, and most people make that assumption. But I was so ashamed that I was just literally along for the ride. It was just an extension of my ongoing obedience to my parents.
But along the way, one thing I discovered was the sheer joy of helping people. And this was the part I fell in love with. And I realized I wasn't alone in my childhood experiences. In fact, I met people who made my experiences seem like a walk in the park. And I learned, not only was I not alone, but having a broken childhood or, like, a broken, you know, family life was nothing to be ashamed of. It wasn't my fault. I was stunned by how open people were about talking about their experiences. And the reason it was kind of mind blowing for me was I had been sworn to this code of secrecy by my parents: “You never talk about what happens at home!” And shame and secrecy go hand in hand.
Gradually, hearing my patients talk about their experiences gave me the courage to talk about what I'd gone through. And studying the diagnostic criteria in the DSM helped me recognize and understand the dysfunction I had lived. And it gave me words and a language for it. I wondered if people with imperfect stories had a place in medicine. And, on the one hand, I was ashamed about living my parents’ dream–just, you know, becoming a doctor just to make them happy. But doing this was simultaneously saving me and releasing me from shame and the belief that I was damaged and different, when really all I was was human. I really believe I'm a better person and doctor today because of my colorful, broken, and utterly human experience.
Emily Silverman
Thanks for listening to Shame in Medicine: The Lost Forest. Next week's episode is called “Pass/Fail,” and it's all about the shame that comes up in relation to tests, exams and scores. How are these test scores useful? What do they measure? What do they not measure? And if we only let people into the profession who have sky-high test scores, what are we selecting for? And who are we missing? Check it out next week on The Nocturnists.
To contribute your reactions and reflections to our shame series, and to access additional resources like transcripts, discussion guides, and more, please visit our website at thenocturnists-shame.org.
Shame in Medicine: The Lost Forest was co-created by me, Emily Silverman, as well as Will Bynum and Luna Dolezal. Our producers are Sam Osborn and Molly Rose-Williams, with additional producing by Adelaide Papazoglou. Sam also edited and mixed the series. Thanks to Medical student producers: Corinne April Iolanda Conn and Nikhil Rajapuram. Production Coordinator: Penelope Lusk. Impact campaign manager and Assistant Producer: Carly Besser, and Exeter team coordinator Alice Waterson. The Nocturnists Executive Producer is Ali Block, and our Chief Operating Officer is Rebecca Groves. The series illustrations are by Beppe Conti, and the music comes from Blue Dot sessions.
Shame in Medicine: The Lost Forest is made possible in part by the Shame and Medicine project at the University of Exeter, funded by the Wellcome Trust. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.
Our show is also made possible with donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoy the show, please follow us on your favorite podcast app so you don't miss an episode. While you're in there, you can help others find us, by leaving us a rating and review. To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com.
I'm your host, Emily Silverman.
See you next week.