Embracing Vulnerability

In this emotionally intense episode of The Only Life You Could Save, Dr. Cassie Ferguson explores vulnerability—the uncertainty, risk, and emotional exposure that accompany the practice of medicine. Drawing on a powerful story from her own training, she reflects on the first time she pronounced a child dead and the lessons that experience taught her about grief, perfectionism, emotional avoidance, and the cost of carrying difficult experiences alone.

Why do so many physicians armor themselves with productivity, cynicism, perfectionism, or emotional distance? What would happen if we learned to recognize and name our emotions rather than suppress them? And how might emotional literacy make us not only healthier people, but better physicians?

This episode challenges the hidden curriculum that teaches future doctors to appear invulnerable while offering a different path—one grounded in self-awareness, authenticity, connection, and compassion.

Whether you're a medical student, resident, physician, educator, or simply someone navigating uncertainty, this conversation is an invitation to consider what becomes possible when we stop running from vulnerability and begin turning toward it.

In this episode:

• The first patient death that changed how I understood medicine
• Brené Brown's definition of vulnerability
• Perfectionism versus healthy striving
• Why physicians armor themselves against difficult emotions
• Emotional literacy as a critical clinical skill
• The relationship between vulnerability, empathy, and connection
• How naming emotions can improve well-being and resilience
• What medical education often forgets to teach

The grace we offer our patients, colleagues, and loved ones is meant for us, too. Learning to face vulnerability with honesty and self-compassion may be one of the most important skills we develop as physicians—and as human beings.

Transcript

SPEAKER_00 0:16

We're going to be focused on vulnerability today, what it is, how we try to avoid it, and why it's important to those of us training to be physicians. One of my earliest lessons in vulnerability was as a third-year fellow. It was the first time I pronounced a child dead. I'd witnessed people dying before, as a resident and a fellow in the pediatric intensive care unit and on the oncology floor. Before that, as a medical student on trauma surgery or in the surgical intensive care unit and in the emergency department. But the first time that I had the authority to say those words out loud, to look at the clock, and choose the time of death was 10 years into my medical training. The child was four years old. He was the only child of Russian immigrant parents who had decided that afternoon to take a short walk to the ice cream parlor down the street from their apartment. He was sitting at a table waiting for his ice cream cone when he was hit by a car that crashed through the store window. That car had been hit by another car that was being operated by an intoxicated driver. Our EMS providers reported to me by phone that the little boy was pulseless and apneic on scene, but regained a pulse after being intubated and getting a dose of epinephrine. He was brought into our emergency department with several other injured pedestrians, and I was the team leader, caring for him with a pared-down team of two nurses and a senior surgical resident. We all knew right away that his injuries weren't compatible with life. The force of the impact from the car had nearly decapitated him, and he had lost most of his blood volume to the ground before he was brought to us. We worked quickly and efficiently, but we knew we couldn't save him. After I pronounced him, I walked briskly to the nearby quiet room where his parents waited and told them that their child was dead. What I remember most clearly was how loudly they screamed. I sat in the room with them and answered questions that had no good answers. I heard their demands that I couldn't meet. And at some point, when the questions and demands paused long enough for me to stand up without interrupting, I left the room. To this day, I can see myself closing the quiet room door behind me and kneeling on the tiled floor of the back hallway of the emergency department, my face in my hands. I remember fighting so hard against falling apart. I knew I had a department to run, and I wanted so badly to show everyone I could handle it. A nurse walked by and asked if I was okay. I quickly stood up, nodded, and immediately went to see the next patient. But for hours and then days and then weeks, I would obsessively revisit the story of a four-year-old who was killed waiting for his ice cream. This, of course, isn't the only child I've pronounced dead. He was just the first. This isn't the only family I've shared devastating news with. Not the only storyline that's taken up residence in my brain for weeks. The practice of medicine provides ample opportunity to witness the suffering of others up close. Whether you choose to care for patients in a primary care clinic, an operating room, an ER, or through images or tissue samples, you'll have a front row seat to the full spectrum of the human condition. And this brings up all sorts of emotions. When I think back to telling those parents that their only son was dead, I remember feeling afraid that I would say something wrong. Worried that I had missed something that could have saved him. Angry that a child died because of the recklessness of an adult. And yet I said nothing about any of those feelings. Not to the nurse who asked me if I was okay, not to my colleagues down the hall, not to my husband when I dragged myself home after my shift. As a student and trainee, it felt too vulnerable. Like if I acknowledged how I felt, my life would collapse like a house of cards. I was sure someone would say to me, You chose this life. Didn't you understand what it would be like? Which would then inevitably lead me to questioning whether or not I had the stomach for a profession in which people died, sometimes right in front of you. Dr. Brene Brown defines vulnerability as the emotion we experience during times of uncertainty, risk, or emotional exposure. Today we focused on the emotions that come up when we as physicians or physicians in training witness the suffering of patients and their families. But I want to be clear that our profession grants us access to the full range of difficult emotions. Embarrassment when we don't know the answer, envy when someone else does, loneliness when we miss out on a family event because we're studying, bitterness when we look back at years of missing those same events again and again. Vulnerability shows up when we're allowing our feelings or our true selves to be seen and we're not sure what people will think. Or when we're trying something new that makes us feel uncomfortable or awkward, or when we put ourselves out there without being at all sure of the outcome. It's recognizing that sharing about ourselves authentically makes us susceptible to emotional harm or pain and then choosing to share it anyway. A few years ago, I asked medical students to share what they think vulnerability looks like in medical school. These are some of the things they said. It looks like understanding and accepting that you may not be the smartest person in the room and that that's okay. It isn't pretty. It's having the uncomfortable back and forth with yourself and sincerely answering the question, how are you really feeling? It's sharing and accepting how you feel, even if everyone around you seems to feel otherwise. It's admitting how close you came to failing an exam and looking for help. So, yeah, it's hard. And it's really no wonder that many of us armor up to avoid feeling vulnerable or less susceptible to attack, more likely to be deemed acceptable or worthy. Armoring up can look like a lot of different things from the outside. One of the more common ways we avoid feeling vulnerable is by numbing, drinking, binging Netflix, scrolling on our phones, anything to dull the intensity of or divert our attention away from whatever's coming up. We might use anger or cynicism, criticism, or cool. Some of us just try and hide out under the radar. And many more of us, myself included, use productivity to provide us just enough of a sense of self-worth that we feel protected from vulnerability. Maybe some of these resonate with you. My personal favorite next to cynicism, which is a favorite of ED Doctors everywhere, is perfectionism. So I used to get really nervous before the first day of school. And when I started a new school in the seventh grade, I was out of my head panicked. I had purchased all my school supplies, laid out my outfit on the bed. I woke up three hours before I needed to leave for school. I rehearsed my schedule because if I looked right or had the right binder dividers, or looked like I knew where I was going, I could avoid people making fun of me or judging me. But let's be honest, perfectionism is an uphill climb when you're in middle school. What I felt during that time was fear. Fear of not fitting in, fear of being called out as uncool, fear of not being invited, none of which I will admit were unfounded. I didn't fit in, I was called uncool, and I wasn't invited. Not coincidentally, this is when I started to get all A's. Fast forward to six years later when I graduated from high school, third in my class with a 4.0 GPA. Not out of a desire to learn or to create opportunities for myself. This was all primarily driven by my need to please people. And I was still afraid of not fitting in, of being called out as uncool, of not being invited, even though by then I had found my people. While none of my colleagues or students that I teach would claim to be perfect, many of them readily claim to be perfectionists, a complicated label that we cling to and reject simultaneously. Claiming to be a perfectionist signals to other people that I will not tolerate mistakes, that I can be trusted to do my best, that I will sacrifice my own well-being and service to getting it right. It also suggests that I believe I am capable of perfection, a suggestion that alienates us from other people, even though this is paradoxically not a belief most perfectionists hold. I think it's important to distinguish between perfectionism or the personality trait associated with striving to be flawless, which often involves being critical of imperfections, and something called healthy striving. While the latter is internally driven and self-focused and adaptive, perfectionism is externally driven, other focused, and maladaptive. While healthy striving acknowledges that failure is part and parcel of working towards excellence, perfectionism sees even a small misstep as an indication of unworthiness. This in part explains why perfectionism is one of the strongest predictors of psychological distress in medical school, and why it's correlated with depression, hopelessness, suicidal ideation, burnout, and neuroticism. What I'm asking you to distinguish between here is being driven by the fear of not being enough, which is self-serving and potentially problematic, versus being driven by the desire to become better, to become exceptional even. Perfectionism remains understudied in medical students, but the existing studies show that y'all have similar rates of perfectionism to your peers, including undergraduate art students and dental, nursing, and pharmacy students. Much less is known about the development and implications of perfectionism for students from groups historically excluded from medicine, students for whom perfectionism may be used as a way to cope with prejudice and harmful stereotypes, or as a way to armor up against the pressure of being your family's great hope. There are also currently no studies that track perfectionism levels over the entirety of medical training, nor any that describe how the relationship between perfectionism and well-being changes throughout medical school. Two qualitative studies focused on professional identity formation in surgery and internal medicine residents suggest that there are aspects of medical training that may exacerbate perfectionistic tendencies and contribute to the development of negative outcomes. Through interviews with surgical residents, researchers showed that the residents had learned that perfectionism is an important attribute of a surgeon and that faultlessness was to be valued. Internal medicine residents interviewed for a separate study identified perfectionism as one of the reasons why certain aspects of learning, being pimped, attending morbidity and mortality conferences, providing incorrect answers during rounds, and receiving negative feedback, all triggered feelings of shame. These studies imply that while medical students may not enter medical school with outsized perfectionistic tendencies, these may be learned once they've been immersed within the medical culture. Teaching methods that glorify perfectionism, shame, guilt, humiliation, ensure that healthy striving gives way to perfectionism, transforming a trait that supports our motivation to learn and to help others into a self-focused survival mechanism. The pressure to reduce, sometimes in the setting of insufficient mentorship or guidance, particularly in individuals with a tendency toward perfectionism, can exacerbate these tendencies. Many of us also absorb a message that if we work hard enough, honor our clinical rotations, get first author on a manuscript, get into the right residency, that uncertainty and ambiguity will vanish. A message which is blatantly untrue. Finally, I want to throw this question out to you. To whom is embracing vulnerability available? It's important to recognize that it's difficult to ask people to set down their armor and be vulnerable when racism, homophobia, transphobia, ableism all may demand armor. When people have been made to feel, as Tirana Burke writes, that they have to cover and hide and keep away from the world in order to survive, in order to exist. It's important to note that Brown's research, which is highly visible and often quoted, is largely based on interviews with white women. Out of the 750 research participants that she interviewed for her research on vulnerability, all were women. 225 were black, 135 were Latina, 68 were Asian American. Much of her other data come from interviews with her master's and doctoral social worker students, and the field notes from the trainings she's conducted with medical health professionals, which also clearly limits the generalizability of her findings. Now I do feel that there's a lot to be learned from her research, and it's resonated with many, many people. The concern being raised is that perhaps the power of vulnerability that Brown's research has uncovered may only be accessible to white women, that women from the global majority who exist in marginalized spaces in the U.S. may have little safe space to be vulnerable, and that men from all racial and ethnic backgrounds, many of whom were raised in a culture that values men who show no weakness, men who are confident, never admit doubt or mistakes, and suppress any vulnerable emotions, are not ever given permission to be vulnerable. When someone tells you to man up, it's clear what they're asking of you. I would also put out there that these same qualities have also traditionally been valued in the medical profession as a whole. Men and women from all backgrounds who choose to enter medicine are subject to the same masculine expectations, show no weakness, put work first, demonstrate strength and stamina, compete ruthlessly with one another. In medicine, we place shame on the expression of uncertainty. Who wants an unsure doctor? And yet we're left with a good amount of solid research that points to significant benefits of embracing vulnerability, of leaning in when it would be easier to distract or disappear, to pick up the phone and explain instead of ghosting someone, to ask the question in class when you believe you're the only one who's confused. One of the most useful questions I ask myself in those moments, when I feel myself hesitating to be vulnerable, is what am I afraid would happen if I let go? When we allow ourselves to be vulnerable, we practice being more comfortable with what typically makes us uncomfortable. We reduce shame, we foster connection with our patients, with our colleagues, our friends, and our family members. Being vulnerable is accepting that we have no control how others respond to us, but we choose to speak or act in a way that's authentic to us. When we share how we feel, we give somebody the power to either hear us or hurt us. But without it, our relationships risk being superfluous and superficial. When we attempt to manage or control the uncertainty that is part of life with perfectionism or cynicism or numbing, we lose out on all kinds of important experiences that are by their very nature uncertain. Things like joy and creativity and belonging and love. And emotional vulnerability, the willingness and ability to address and articulate emotions, especially those that are uncomfortable or painful, or that challenge our identity as someone who's supposed to know things. That's the pillar of self-awareness. And self-awareness is a key to mental health and well-being, and a skill we'll return to again on this series. Before we go on, I want to pause and be clear about a couple things. Not every emotion deserves a microphone. Not every mood needs to be honored. What I'm talking about here is not emotional overindulgence. What I'm advocating for is emotional literacy, a capacity that is wildly important in medicine, but not taught. Why we assume that you need hundreds of hours of lectures about the compliment cascade and the Frank Starling curve, but leave no time or space for learning about how you might sleep at night after declaring a patient dead for the first time is ludicrous. It's ludicrous, and frankly, I think it's morally reprehensible on our part as medical educators. What I hope you'll find as we talk over the next few sessions is that ultimately to walk toward emotional literacy takes such a slight pivot. It really just starts with a shift in our attention, with a turning toward discomfort as it's coming up instead of away, with a noticing of the urge we all get to grip tighter when the ground starts to feel shaky. What's incredible is that in turning towards, it's possible to see how fleeting these emotions really are. And this brings us full circle. Had I known what I know now, when I first had the responsibility to declare a child dead, I would have done things differently. Before going to speak with a child's parents, I would have asked my attending for help choosing what to say. I would have allowed myself to cry in the room with the parents, to tell the nurse who asked me if I was okay that I was not, to walk away from the department for five minutes and ask a colleague to cover for me. And to talk to my husband about how it felt to pass this inevitable but incredibly sad milestone in my training. Because the thing is, the grace we give everyone around us is meant for us too. It's human nature to avoid experiences that hurt us or bring us pain. So this kind of vulnerability feels counter to our programming. One of the ways I've deprogrammed myself is to practice naming the difficult emotions that come up for me. A practice called affect labeling, which helps me to learn what I can from these emotions and then get some distance from them. Functional MRI studies show that this labeling of emotion decreases activity in the brain's emotional centers, including the amygdala, and allows our frontal lobe to have greater sway over solving the problem in front of us. With some practice, it now takes me just minutes to recognize the feelings coming up for me after a difficult resuscitation or a confrontation with a parent, and then I can imagine those feelings as clouds floating by. If I notice emotion is stickier. I'll talk to one of my colleagues or to my husband or to my sister. The moments that bring us to our knees are sacred, says meditation teacher Corey Muscara. We're asked to let go, to surrender, to go deeper. It's an initiation to life beyond control. Here's the thing whether you've spent the last 25 minutes nodding at everything I've said or have already decided that this course is bullshit and a waste of time, you will at some point very soon be faced with choices around how to deal with the emotions that naturally come up for us as human beings when our job is to take care of other human beings. You will be forced to figure out how you will continue to be present for your family and friends, how to continue to find joy and meaning in all the corners of your life while experiencing all of these emotions. My goal as someone who's made many of these same choices and whose career focus has been on helping students and residents and colleagues navigate them as well is not to tell you what to do. I've worked with enough people to know that there is no one right way to deal with the discomfort and uncertainty inherent in the learning and practice of medicine. But I also have been practicing medicine long enough to know what it looks like when physicians and physicians in training attempt to avoid these choices altogether. Attempt to deal with difficult emotions with hand waving or overwork or bravado. I've seen careers destroyed by alcoholism, surgeons fired for throwing instruments in the OR, marriages and relationships ruined by disengagement. I've seen medical students become residents, become doctors who take crappy care of patients whose lack of insight into their own emotional lives whose unwillingness to see themselves as vulnerable human beings results in pity for their patients rather than empathy and hubris instead of humility. I choose to speak to all of you because I care deeply about each of you as individuals. I care deeply about the patients that you will one day serve. And I care deeply about the profession of which you have been selected to be a part. Whether you listen to me or seek out advice from trusted mentors and peers, I would ask as one of your future colleagues that you take responsibility for this part of your medical education just as you would for learning how to take a history or for passing step one. I promise it will make you a better doctor. And as always, please keep reaching out the only life that you could save podcast is only a thing because Cam Collins, a musician, producer, and now medical student, made it a thing. I'm grateful that he reached out to ask whether I might record these lectures and grateful for his talents that made it possible to do so. Thank you also to Dr. Ashley Pavlik, a friend and colleague and the course director of the Good Doctor at MCW, who makes space for this content in our curriculum. To Dr. Dave Margolis, the chair of the Department of Pediatrics at MCW, who pays for my time to teach medical students about well-being. To my pediatric emergency medicine colleagues who take exceptional care of kids and of one another. To my family who reminds me that medicine comes second and to my students past, present and future for keeping me honest always. Finally thank you to Alex Brown for creating our theme song, Cam Collins for his sound production skills and to Madeline Sturm for her brilliant art and design working