Shame in Medicine: The Lost Forest

Podcast with Luna Dolezal and Emily Silverman

Shame in Medicine The Lost Forest vignette

 

In today’s podcast, we look at the lasting consequences of shame in Medicine with Nocturnist creator Emily Silverman and Professor Luna Dolezal.

Emily Silverman, MD is an internal medicine physician in San Francisco, Assistant Volunteer Professor of Medicine at the University of California San Francisco (UCSF), and creator of the independent medical storytelling live show and podcast, The Nocturnists. Nocturnist podcast series, Shame in Medicine: The Lost Forest, is an award-winning 10-part documentary podcast produced by The Nocturnists in collaboration with the Shame and Medicine project at the University of Exeter. Drawing on the stories of over 200 healthcare workers across the United States, the United Kingdom, and beyond, this series explores how shame manifests in medical culture.

Professor Luna Dolezal, Associate Professor in Philosophy and Medical Humanities, is based in the Wellcome Centre for Cultures and Environments of Health. Her research is primarily in the areas of applied phenomenology, philosophy of embodiment, philosophy of medicine and medical humanities. Dolezal’s work is driven by an interest in understanding lived experience and embodiment, and how these intersect with, are co-determined by, the socio-political and technological frameworks in which we are enmeshed. She is the PI on the Shame and Medicine project (Wellcome Trust Collaborative Award, 2020-2025) and a co-I on the Imagining Technologies for Disability Futures project (Wellcome Trust Collaborative Award, 2020-2024).

The Shame and Medicine Project is funded by the Wellcome Trust and runs from 2020-2025. The Speical Issue Dr. Dolezal edited with Barry Lyons for Medical Humanities in 2017: https://mh.bmj.com/content/43/4

Listen to the podcast on Soundcloud.

 

TRANSCRIPT

DR BRANDY SCHILLACE: Hello and welcome back to the Medical Humanities Podcast. Today we are speaking with Luna Dolezal, who is a Principal Investigator at the University of Exeter and also Associate Professor in Philosophy and Medical Humanities. I’ve worked with Luna before on Shame and Medicine. And that’s a project, but also, it’s been some publications we’ve done at the Medical Humanities Journal. Some of you hopefully have read that and are familiar with it. But today we’re also bringing on Emily Silverman, who is Assistant Volunteer Professor of Medicine at UCSF and who began The Nocturnists, Medical Storytelling. So, I’m really excited to have both of you here today. Welcome, Luna. Welcome, Emily.

DR LUNA DOLEZAL: Thanks for having us.

DR EMILY SILVERMAN: Thanks, Brandy. It’s nice to be here.

SCHILLACE: So wonderful to have you. So, I’m really quite interested. I was new to The Nocturnists Podcast, which I realize is live, is it not? It’s a live show.

SILVERMAN: The Nocturnists is a live show and a podcast. So, we produce theatrical experiences, storytelling experiences. But then we have our podcast, which sometimes will feature stories from the stage, but sometimes has separate content and separate series.

SCHILLACE: That’s fantastic. So, I actually run a live show, too, that’s also a podcast called The Peculiar Book Club, and our focus is on literature that talks about science and medicine. So, I can’t believe that I haven’t run across you before! So, many, many thanks to Luna for putting you on my radar. And I know both of you have done a lot of really interesting work in the direction of shame in that you have a Shame in Medicine series with The Nocturnists. And I just, I’m fascinated because I think this is such fertile ground, especially now. And I think me personally, seeing the way long COVID and extended illnesses have become tangled up in concepts of shame, I just think now is a really, really good time, and it’s incredibly fertile soil. So, I wondered if the two of you could just tell me a bit more about how you are seeing shame come into, how are you sharing it with people so that it bears fruit?

DOLEZAL: I could start. I have a research project about shame and medicine at the University of Exeter, and we’re researching the role that shame plays in health and health care. So, that’s an academic project where we’re collecting data about people’s shame experiences in medicine and doing research through literature, art history, and philosophy as well around shame. And I I’m a big fan of The Nocturnists, and a couple years ago I reached out to Emily to suggest the idea that we do a series about shame in medicine where health care workers could tell shame stories. Because the thing about shame is that it’s quite, you know, it’s taboo to talk about shame.

SCHILLACE: Mmhmm.

DOLEZAL: So, it’s often underground, or people keep it secret. It’s not often explicitly spoken about. And Emily was game, and we started collaborating with another doctor at Duke University, Will Bynum, who’s a shame researcher. He does a lot of research around shame experiences in medical learners. And that was the kind of start of a wonderful kind of over-two-year collaboration, which has led to this amazing, award-winning ten-part podcast series, which Emily can tell you more about.

SILVERMAN: Yeah. So, what was amazing was when Luna reached out to me, she pointed out that the topic or the emotion of shame was already so present in the stories that clinicians were telling on The Nocturnists. I actually went back and listened to a bunch of our old stories and realized, oh my gosh. This has been front and center the entire time, and I just never noticed it. I never saw it. It’s just invisible. And so, it was so exciting to have this opportunity to just focus on the emotion itself directly, and that’s what we did.

So, the way that we embarked on this project was we announced the collaboration, and then we put out a call for shame stories. And that was kind of it. We didn’t say what type of shame stories or give people topics or suggestions. We just said, “Shame is ubiquitous in health care, or at least that’s our hypothesis. Share with us your experiences of shame in the workplace or having to do with your professional identity.” And we got hundreds of people who responded. And some of them responded with a written response, some of them responded with an audio recorded response, and we as a team started meeting once a week to kind of sift through all of this material that had come in. We ended up going on hiatus for a few months just because COVID happened and everything, [chuckles] everything got a little bit upended. But in the end, we came back together as a team, hired an amazing documentary filmmaker to serve as audio producer. This was his first time venturing away from film and into audio. And so, that was really great to get that perspective. And then Molly Rose-Williams, our head of story development, was sort of the keeper of the stories. She knew those stories inside and out and exactly who and what and things like that.

So, we would meet once a week and begin this process of how do we organize this, and how do we make sense of this? And from those meetings emerged a rough sketch, a rough outline of what the series was gonna look like, how many episodes, what theme for each episode. And then slowly but surely, we started to fill in those gaps, fill in that outline. And then by the end, we had this really beautiful ten-episode podcast documentary series, which was a mix of three elements. So, first was the primary source, the raw audio that we received from our community. Second was Will and Luna’s voices as shame experts. And third was my voice as the host of The Nocturnists, sort of like the guide who is guiding the listener through naive ears, through the experience. And that’s what we did.

SCHILLACE: It’s really, really a complex and interesting project. And the artwork also is very interesting to me. When I go to your website, you have this amazing collage of different images, which I think is fascinating too. And if you wanna talk about that, I think that’s maybe worth talking about as well.

DOLEZAL: Yeah. I mean, the artwork is award winning as well as the podcast! We worked with an artist, Beppe Conti, and he’s Italian. And I think Emily had loads of back and forth with him about how to create these amazing images where we wanted to depict health care workers and the theme of shame. But it’s actually a really hard thing to depict shame visually without just resorting to like images of people with their heads in their hands.

SCHILLACE: Mmhmm.

DOLEZAL: And I think the kind of motif and the metaphor of the forest and The Lost Forest, which is the subtitle of the series, is really powerful to convey the kind of like, you know, being lost in the emotions and the, I don’t know, the secrecy and the complexity of these experiences. Emily, do you wanna say more about the art ‘cause you worked so closely with Beppe to bring it to the place it is.

SCHILLACE: And I should probably just for a quick minute, describe what it is to some of our—

DOLEZAL: [laughs]

SCHILLACE: And we’ll also try to include the image along with. If you send it to us or send us a small version, we can include it in the podcast or on the blog. But just for our listeners, it’s like a forest scene, but there are doctors and faces and eyes. Eyes is a big motif. There’s animal images, sort of a blue heron in the front that has an eye on its wing. There’s a doctor looking at himself in a mirror and seeing instead, a kind of, I think it’s a praying mantis. And so, it’s a really, really interesting visual story.

SILVERMAN: Yeah. I learned so much about the phenomenology of shame from Will and Luna, how it presents in the body. What is the physical experience of acute shame? And that ranges from flushing of blood to the cheeks, a downward movement, a sense of being exposed under a spotlight. And so, these were the concepts that we were looking toward as we developed the illustrations. Of course, we didn’t wanna fall into like the Google image stock picture of like doctor just sitting with their head in their hands ‘cause if you type that into Google images with “shame” and “doctor” or whatever, “health care worker,” that’s all you get. And so, we were like, okay, how do we take this idea and put a creative spin on it and maybe infuse it with some mystery, maybe some magic, a sense of curiosity, a sense of organicity? And that’s how this concept of The Lost Forest emerged. And I just could not be more thrilled with what Beppe, our collage artist, came up with.

SCHILLACE: It’s really incredible.

SILVERMAN: Continually to this day, yeah, I love looking at it.

DOLEZAL: Yeah.

SCHILLACE: It is wonderful.

DOLEZAL: And I think the eyes, like, the thing about shame is when you are in a shame event, like you’re having the really strong experience of shame, one of the really strong feelings is that everyone can see what you’ve done or who you are and that, you know, you’re so, you feel so conspicuous and self-conscious and visible and like there are eyes everywhere, looking at you and judging you. And so, I think the motif of the eye is really important to kind of convey that feeling of hyper-visibility that often comes with the experience of shame and the kind of overriding concern that others are looking at you and judging you. And that can be really paralyzing and disempowering to live with that feeling, in the short term or if you live with chronic shame in the long term.

SCHILLACE: Right. Well, and of course, in a way, because this is a place for medical storytelling by practitioners, which is different than, say, it would be if it were specifically focused on patients, even though shame affects both categories of people. So, I think the other thing that, at least here in the United States, I know I encounter this a lot, I used to work with medical students who would tell me they’re expected to sort of know everything, you know? We put doctors on a pedestal in the United States, I think, worse than almost anywhere else. And so, there is a real sense that you have to have the answer, and everyone’s looking to you for the answer. And yet there are frequently not answers. And I wonder, too, how COVID has played a role, ‘cause you said it sort of interrupted the work to begin with. But also, I know just the incredible burden that has been placed on people in the front line of health care through all of this and the inability to kind of, it’s often the feeling like you can’t turn the tide of it must be causing all kinds of very self-conscious emotions.

DOLEZAL: Yeah. I mean, one of the things about COVID that we’ve done some research about is doctor shaming, so how health care professionals, not just doctors, but health care professionals, were actually the recipients of a lot of shame and stigma because of fear of contagion, especially in the early part of the pandemic, when we didn’t really know how the virus spread or how serious it was, and there were PPE shortages and just a lot of fear and uncertainty. And while doctors were lauded as heroes and angels, and everyone was thrilled they were working on the front line, kind of fighting the virus, they were at the same time, often the recipients of quite a lot of shame and stigma. And in the UK, that was through violence, like attacks on the street and verbal abuse and online shaming. So, I think there was a huge affective toll alongside this grueling work that doctors are facing during COVID. And The Nocturnists has done two amazing series about COVID, Stories From the Pandemic, which is actually how I got to know their work. And it’s just so powerful to hear stories from the front line of the COVID pandemic as the pandemic was kind of rolling out in April and May of 2020. And yeah, I think that there’s just so much intense emotion to kind of unpack about COVID.

SCHILLACE: Yeah, absolutely. And I think, too, then you had the follow-up, which doctors who were saying, “Go get vaccinated,” and then there’s such a huge anti-vaxx trend, I know in the United States, that then there’s a blaming of the doctors as though they were somehow responsible for not fixing the plague so that they didn’t need vaccine, all sorts of things. But a sense that the doctors were to blame at the beginning and the end.

DOLEZAL: Yeah. Emily did you have any experiences when you were working in UCSF in the hospital?

SILVERMAN: Yeah. I remember walking into the hospital during the first wave of the pandemic, preparing to take care of people. And this was very, very much in the pre-vaccine era, and just the fear and the uncertainty and the anxiety. And that was definitely something that we captured in our Stories From a Pandemic documentary series, which was acquired by the US Library of Congress as a historic document, really trapping in amber this moment straight from the mouths of frontline workers, what it was like to live through that time. So, we’re really proud of that work. And I think the Shame series in some way is a transitional narrative where we take a lot of the unmasking that happened during COVID, so much unmasking related to just the dysfunction of the health care system—economic dysfunction, political dysfunction, cultural dysfunction, inequities, injustices, labor rights and conditions, the lack of sick leave for health care workers, the lack of any kind of redundant staffing, understaffing—all of these things that were unmasked from the pandemic are absolutely sources of shame and were even before the pandemic arrived. And so, things that we see in the shame series, stories that unfolded years before the pandemic even hit.

We have a story about a physician who came to work and was actively vomiting and was sick and was afraid to go home. And she just kept working. We have stories about people who were targeted at work because of their identity, for example. We have stories of people who had things happen to them in previous, childhood experiences and how that showed up for them in the workplace. We have a ton about shame and learning, the way that we wield shame as a pedagogical tool in the hospital. And how does that work, and what does that do to people, and is that effective? We have things about shame and medical error, shame and failure, shame and testing. And by testing, I mean standardized testing, MCAT, Shelf Exam. Those are the American versions of the tests. What does that do to people? Things like shame and litigation. I’m sure the US and UK have different cultures around this, but what is it like to be sued as a provider? And so, all of these just such profound emotional experiences that were happening even before COVID, and then when COVID came, it all just really intensified.

SCHILLACE: Mmhmm, mmhmm.

SILVERMAN: So, we view these two series as being in dialogue with each other.

SCHILLACE: Right. Well, here at the Medical Humanities, we have a very considerable focus on social justice, issues of social justice, particularly that means folks who are LGBTQIA or minority status, Black scholars, Black providers. And it strikes me that this is, [chuckles] this is exactly the place where you would expect to see shame operating, right? Particularly shame against those who are from another country, shame against people— And right now, because of the pandemic, there was quite a lot of aggression geared towards those from Asian descent, for instance. But I feel like racism must surely be part of these narratives as well.

SILVERMAN: Yeah, definitely. Actually, during our pandemic series, you know, the pandemic hit around March, and then we were in the throes of part one of our pandemic series, March, April, May. And then June rolled around, and George Floyd was murdered in the United States.

SCHILLACE: Mmhmm.

SILVERMAN: And the pandemic was subsiding a bit. And so, we as an organization had to ask ourselves like, oh, God. You know, we thought…we thought we were maybe gonna take a break from some of this pandemic programing, but we really don’t feel like we can. We feel like we need to meet this moment as well. And one thing that’s really nice about being such a small, nimble, scrappy non-profit indie organization is that we can pivot, and we can meet the moment in that way. And so, what we ended up doing that summer was I reached out to a couple of my friends in the medical humanities here in the States, Dr Ashley McMullen at UCSF and Dr Kimberly Manning at Emory in Atlanta, Georgia, both amazing Black women physicians. And I said, “Hey, I don’t know really what I’m asking, but I have this platform. It’s called The Nocturnists, and I would really love to do something to platform Black voices in health care.” And so, that summer we released another documentary podcast series that was sort of modeled after the pandemic series, where we put out a call, received voices, we picked a theme for each episode. And with Ashley and Kimberly really driving the ship on that project, we were able to put together that piece as well.

And so, the pandemic series, the Black voices series, and now the shame series, that was really the work that we were able to do during the pandemic in the absence of live shows. And I think it’s certainly a bummer not to be able to do live shows anymore. But man, what an amazing creative experience it was to really lean into this audio diary format, collect voices that were not limited to the Bay Area, but were coming from all corners of the country, and make some of this new work during lockdown.

SCHILLACE: So, I have a question for you. I said earlier that I have a live show, but I actually have a livestream, and it is a video show where it’s like a variety show, in a way, it’s got music. And I’m wondering, have you ever thought about moving some of this into—you were working with someone who is a film person, even though they were doing the documentary as audio—have you thought about moving this onto a kind of filmic or livestream landscape?

SILVERMAN: That’s such a great question because you’re right. Our creative activities have historically been live storytelling shows in the style of The Moth: very simple, several people, about ten or 15 minutes per story going up one by one. That’s the format for the live shows. And then for the podcast, yeah, it’s really been the voice, you know, audio storytelling. But moving forward, just thinking about the trajectory of The Nocturnists as an organization and what we aspire to, we are interested in branching out to other mediums. What kind of films could we make, whether that’s documentary or perhaps something even fictionalized? What kind of written, a book or something that we could write? Or what about different types of theatrical experiences? So, instead of storytelling in the old ancient style, what about a full-length play of some sort? What about a musical? We’re very medium agnostic. [laughs] We really think more in terms of story first, and then it’s like, all right, what is the, in what way does this particular story want to be expressed in the world? And it would be so amazing to have all those different types of art and artistic medium available to our team.

SCHILLACE: Well, and I ask partly because you have such a wonderful visual medium, visual dynamic to the Shame in Medicine series with The Lost Forest. And I was looking at it thinking it resonates with me. The Peculiar Book Club show that I run, it’s what it sounds like. It’s a little odd. [chuckles] So, we basically do books that are non-fiction and a little bit on the sidelines, science and medicine, but things that might be peculiar, considered peculiar to other people. What I mean by saying that is we’re drawing in this kind of collage effect, and we actually use stop motion animation and mini videos, so videos that are about two minutes long. They’re not that, the production values aren’t so, are high. They look like they’re high, but they’re not so much investment on the front end because I actually make all of them. [laughs]

SILVERMAN: Mmhmm!

SCHILLACE: So, you know it can be done quite cheaply. But I just was thinking, even if it was something as simple as you having mini-episodes, 1 to 2-minute videos. There’s video editing software is so easily available these days, even on your iPhone. So, I just think that it seems like this would be the perfect place to express that because you have so many interesting things. I could see something about disability being done. I could see something about, you know, and I feel like you have, I’m sure, all sorts of ideas. My last question was going to be, where do you see the future going? And we’ve kind of already gotten there, so maybe we’ll just keep going with that. What’s the future of, what does the future of this look like?

SILVERMAN: Yeah. I love your suggestion of animation. I recently have been diving into this American animated show called BoJack Horseman. And I don’t know if you’ve ever heard of it, but what I love about it is the characters in the show are like half-humans and half-animals.

SCHILLACE: [laughs]

SILVERMAN: So, the main character, BoJack Horseman, like, he’s just a horse walking around. And he’ll talk to the cat, he’ll talk to the octopus, he’ll talk to a human, you know, a man, a woman. And nobody really comments on the fact that these are animals! It’s just kind of accepted in the world of BoJack Horseman. And that’s something that animation makes possible because that would be very difficult to do in a live action film. And so, there’s so much availability there in the animated medium to be playful and to venture into magical realism and things like that.

SCHILLACE: Exactly. Mmhmm.

SILVERMAN: So, I would love the opportunity to work on an animated film project or short film project. I think that would be really, really fun. And you’re right, the illustrations that we’ve commissioned for our podcast series have been such a big part of our identity as an organization and are so much in the DNA of our, you know, of what we do. So, that seems like a natural extension of that.

But yeah, in terms of the future, I think we certainly wanna keep doing what we’re doing. But I think what I said earlier about expanding into different artistic mediums and thinking about what sort of long-form projects we might wanna create, I could see our organization really sitting at the nexus of health care and the arts and storytelling and serving as a hub where we can surface some of these narratives, inspired by true narratives or even documentary style that are coming out of that interface of that clinical encounter between a doctor and a patient or a nurse and a patient or a doctor and a nurse, whatever it is. And just continue to make art because making art for art’s sake is something that I love doing and that I think the world needs.

But then there’s also the whole social impact layer of this where you make the art, and you put it out in the world and enjoy it. But then there’s also things you can do around the art to cause it to penetrate the community and have an impact. And as an example for our Shame in Medicine documentary podcast series, we have the ten episodes, which is the art, but then we have a whole social impact and engagement campaign where medical residency program directors or chief wellness officers or even med students can come to our website and access discussion guides for each episode. They can access facilitator toolkits if they want to spark conversations about shame at their home institution. We have resource lists, just so much there for people to sink their teeth into and engage with around this topic of shame. And so, I really love that one-two punch of making beautiful art, but then finding ways to let the art have an impact in the world.

SCHILLACE: Right. Absolutely. And I also think it’s important to say, so, to our listeners and also those who are in our readership, the Medical Humanities has three different platforms. We have the journal itself; we have the blog; which we run a bit like a magazine; and then we have this podcast, which is probably our most public-facing, kind of least academic way of doing things. But the whole point is our brand, our way of handling medical humanities is typically not necessarily looking at clinical, but it’s much more looking at culture and looking at the cultural relevance of health and how that happens and how that, where access problems are, who has access to health care and who doesn’t. And so, we end up doing something that is, it runs alongside what you’re doing but actually doesn’t really overlap very much, except in the sense that we’re all working towards this kind of lifting up of justice issues. And I think that’s really valuable because the more of these types of platforms exist and the more often we connect with each other as a sort of nexus, I think the more powerful they become. And that’s just a really exciting thing for us, and we’re really excited to have had you on the show and also just to have introduced our readership and our listeners to what you’re doing here. And I hope that we can continue to follow what you’re doing and see what the next chapter is going to be. And I have Luna to thank for that because Luna’s the one who turned me on!

DOLEZAL: That’s absolutely my pleasure. I’m just thrilled to have been a part of the creation of this amazing series and all the resources that accompany it. And I really hope it makes some small change to medical culture. And we’ve received so much amazing feedback about the series and the episodes, and I hope it just has a far reach and people engage with it. So, thanks for having us on the show, Brandy.

SCHILLACE: Oh, it is really wonderful to have you on. And again, for those of you who are joining us, this is Luna and Emily, and we’re talking about The Nocturnists. There will be an accompanying blog post with a transcript for the show, and we’ll have links to all of the fun things we’ve been talking about. So, thank you once again for joining in and being part of the conversation.

SILVERMAN: Thank you.

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