Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of Last Resort

Abstract

This Invited Commentary highlights the prevalence of adverse childhood experiences and the potential effect that such experiences can have in the medical education setting on trainees, colleagues, and faculty. The author draws on 20 years of experience working in organizations devoted to helping physicians with disruptive behavior learn new behavioral skills to enable them to function within the complex medical environment. A case example—an amalgam of individuals who have presented for remediation—is used to illustrate the issues that result from adverse childhood experiences. There is a broad and well-understood literature demonstrating a correlation between early life trauma and medical and mental health issues. Adverse early life experiences can also contribute to attachment-related difficulties including problems with boundaries, trust, and suspiciousness; lack of reciprocity; lack of attunement with others’ emotional states; as well as regulation issues, including difficulties labeling and expressing feelings and internal states. Difficulties with self-concept, including a lack of continuous and predictable sense of self, low self-esteem, and shame and guilt, are also associated with exposure to adverse childhood experiences. Given the documented high proportion of health care workers, including physicians, who are trauma survivors, trauma-sensitive education must be a priority, not only in medical school but across the educational continuum.

I have spent over 20 years working with medical students, residents, and physicians whose careers are in jeopardy because of a variety of behavior issues. I work in an organization devoted to helping physicians with disruptive behavior learn new behavioral skills to enable them to function within the complex medical environment. Our clients are frequently described as mean, nasty, arrogant, narcissistic, unprofessional, unchangeable, and a lost cause. Some refer to our services as “charm school” or “the island of last resort.” However, I see things very differently. To me they are amazingly resilient and adaptive people who have accomplished astonishing things. Providing remediation for these individuals is an opportunity to work with some of the most remarkable individuals I have ever met. We work on an island of possibilities and promise.

Take, for example, a physician I’ll call “Dr. Brown,” an amalgam of individuals who have presented for remediation. He is a 62-year-old surgeon working in an academic medical center. He is on the verge of losing his job because of his behavior in the operating room—behavior that used to be tolerated but no longer is. He has a long history of yelling at scrub techs, nurses, and residents who do not perform up to his high standards. He has little to no tolerance for anything less than perfection. Dr. Brown, when asked, relates his own difficult, often hostile, process of training, where he was yelled at and pimped if he did not know something or did not get it just right. As the recipient of this behavior during training, Dr. Brown believes this approach was contributory to elements of his current success. He thus sees his behavior as instrumental in his outcomes.

Everyone he works with, even those who complain about his behavior, say that technically and procedurally there is no one more skilled than Dr. Brown. Now he finds himself referred for remediation because of a lack of professionalism and poor interpersonal and communication skills. Can you imagine how he might feel?

When he arrives in my office, he is rude, dismissive, and prickly. He asks me what I could possibly know about surgery. One might wonder, why on earth would he be rude to someone who is trying to help him? Later, he participates in a small-group exercise and is surprised to find himself crying as he talks. He asks aloud why he’s crying, apologizes to the group, and then asks why we are talking about these things that happened so long ago, and what does anything from his past have to do with what is going on now? So, how do we understand him, and how might this inform our approach to providing medical education more broadly?

As Dr. Brown shares his history, it becomes apparent that he experienced early life trauma, sometimes referred to as adverse childhood experiences. Examples of adverse childhood experiences include physical, sexual, and/or emotional abuse and/or neglect; household dysfunction, such as witnessing domestic violence or growing up with family members who have significant mental health or physical health difficulties; and parental separation or divorce. Dr. Brown’s childhood was a checklist of many of these experiences.

Effects of Early Life Trauma

There is now a broad and well-understood literature demonstrating a correlation between early life trauma and medical and mental health issues. Adverse early life experiences can also contribute to attachment-related difficulties including problems with boundaries, trust and suspiciousness, lack of reciprocity, and lack of attunement with others’ emotional states. There can be affect regulation issues including difficulties labeling and expressing feelings and internal states. Difficulties with self-concept, including a lack of continuous and predictable sense of self, low self-esteem, and shame and guilt, are also associated with exposure to adverse childhood experiences.^1,2

Developmental exposure to trauma may set the stage for problems appropriately responding to subsequent trauma. Individuals previously exposed to trauma may become self-protective, exert excessive energy scanning their environment for threats, and experience ongoing low levels of fear and vigilance which can contribute to decreased curiosity, exploration, and learning.³ It appears that those exposed to trauma in early life might also be more susceptible to the effects of subsequent exposure to stress and traumatic events.

A recent systematic review⁴ evaluating studies from multiple high- and middle-income countries indicated that 57% of respondents acknowledged experiencing at least one adverse childhood experience. College students are also vulnerable to experiencing new and potentially traumatizing events,⁵ and elements of the medical training process and environment might contribute to the deterioration of mental health in developing physicians.^6,7 Consideration of elements of the training environment is important as those exposed to trauma might preferentially apply to study medicine.^8,9 In a recent review of our own experience, we found that 70% of our clients report adverse childhood experiences.

Recognizing and Addressing Childhood Trauma in the Medical Education Setting

What, then, might be behavioral indicators of prior exposure to childhood trauma in the learning or practice environment? In our experience, unprofessional behaviors such as difficulty with collaboration, difficulties with self-regulation, difficulty accepting feedback, difficulties establishing and maintaining appropriate personal and professional boundaries, poor self-reflective awareness, and poor self-care can be reflective of a previous history of exposure to childhood trauma. Shame is a frequent, often poorly recognized sequel to trauma, occurring as a result of the meaning the individual places on the traumatic experience and on subsequent interpersonal and environmental events.¹⁰ Bynum and colleagues^7,11 have eloquently discussed shame in the context of medical education including its potential role in unprofessional behavior, the feedback cycle, and potential implications for remediation efforts. In medical education, the Socratic method of teaching, pimping, and feedback is delivered in a manner that may reinforce the feelings “I am a failure” or “I am inadequate.” These are interactions that can be retriggering and contribute to heightened anxiety, a sense of the need to be self-protective and the need to defend oneself through attack or withdrawal if the individual has had previous exposure to traumatic childhood life events. Observations of a response that seems overly aggressive, impulsive, or disproportionate to the situation (e.g., passionate denial, impulsively getting up and leaving, bursting into tears) should all raise concerns about the potential presence of previous exposure to one or more traumatic events.

Being sensitive to and aware of the possibility of trauma helps inform interactions with trainees and physician colleagues, particularly those demonstrating signs of emotional distress and/or performance issues. Responding to reactivity with reassurance, and providing reassurance more broadly—talking about specific behaviors and tasks, inquiring about and acknowledging feelings, fostering a sense of choice and control, talking about specific behaviors and tasks—are helpful approaches. The adoption of a growth model focusing on self-reflection and fostering self-regulatory beliefs and behaviors can be helpful,¹² particularly if augmented by other supportive services including therapy. Many individuals, like Dr. Brown, do not appreciate how their early life experiences continue to have an influence in their life. However, trauma is like undigested food: If it is not properly chewed on and digested, it may continue to cause heartburn.

Conclusion

So how did knowledge of Dr. Brown’s early life experience impact Dr. Brown’s remediation experience? What became of him? In providing remediation to him, it was important that I recognized that the reactivity he demonstrated early in his interactions with me was about him and his high level of distress. Recognizing this allowed me to respond in a kind, caring, reassuring fashion rather than in a way that he could have experienced as retraumatizing, which would not have been conducive to engagement, collaboration, and learning. The initial part of his remediation experience was to help provide him insight into the potential factors that contributed to his difficulties and to help him understand how his behavior was impacting those he worked with and, potentially, patient safety more broadly. He learned that he defined himself in terms of his ability to meet the high standards he set for himself, which in turn contributed to his difficulty setting reasonable expectations for himself and others, and responding inappropriately if those standards were not met. He was encouraged to reflect on the emotions he was experiencing in that moment and on why his response was so strong. He was provided with readings and had the opportunity to learn and talk about childhood trauma and shame with other physicians experiencing similar issues. Having the opportunity to address his developmental challenges with other highly accomplished individuals allowed him to assimilate that experience and grow from it. As a result, he became better able to accept feedback about the problematic nature of his interpersonal and communication style and develop new skills. He is currently the high-functioning physician that he always had the capacity and capability to be. His improved level of functioning has been substantiated through the collection of collateral data including the results of multisource feedback. His colleagues no longer think of him as an abusive jerk.

As educators and clinicians, we must recognize the prevalence of exposure to trauma in our trainees and colleagues. This recognition highlights the importance of creating a learning environment that is safe, avoids retraumatization, and appreciates that indications of distress and problematic behaviors, particularly those that are reflective of difficulties with interpersonal and communication skills and professionalism, may be understandable attempts to cope with past trauma. We must further study the potential presence of trauma in ourselves, our colleagues, and our trainees so that we can provide clarity and direction to inform the developing literature on shame, burnout, remediation of problematic behavior, and emotional distress. This will inform our efforts in medical education particularly as it relates to providing feedback, dealing with professionals in difficulty, and promoting health and well-being. As part of faculty development efforts, it is important not only to increase understanding and recognition of cognitively complex emotions such as shame¹¹ but also to increase recognition of exposure to trauma as a potential contributory factor. Given the documented high proportion of health care workers, including physicians, who are trauma survivors, trauma-sensitive education must be a priority, not only in medical school but across the medical education continuum.

Acknowledgments:

Many thanks to Fred Hafferty and Michael Williams for their comments on an earlier draft.