During some personal soul-searching a few years back, I discovered the concept of the vulnerability gap. A vulnerability gap exists between two people when one person is more willing to be vulnerable — to let him/herself be seen in an open and authentic manner — than the other. For many, being vulnerable is risky and difficult at baseline, even when it’s returned by another person. Engaging in unrequited vulnerability? That’s particularly rough, and in my experience, the gap created by disparate levels of vulnerability can create self-doubt, impair open and honest communication, and lead to missed opportunities for connection. Conversely, self-confidence, trust, and connection can flourish when two people share the same willingness to be vulnerable.
Our clinics and hospitals are places where vulnerability gaps abound. As health care providers, we care for people with physical and mental health challenges that are highly personal, private, and not easily shared. We often receive this information as on the “vulnerability high ground”: our patients share their personal stories with us as we sit behind a computer or stand by the bedside in our buttoned-up, pressed white coats. We listen intently, ask clarifying questions, and show empathy. But the flow of vulnerability is most often uni-directional, and we rarely, if ever, share our own personal stories, problems, and challenges in return.
The vulnerability gap opens.
As we listen to the intimate details of our patients’ stories, our brains process a dizzying amalgam of clinical data, “can’t miss” diagnoses, and meaningful use requirements. We battle, futilely, the electronic medical record that sits like a towering wall between us and the patient. As we process the cognitive crush that comes with complex clinical thinking, our attention is directed away from the human being in front of us.
The vulnerability gap widens.
Some patients evoke strong emotional responses in us: sadness, fear, elation, frustration, and guilt, among a host of others. The voices of past mentors and teachers echo quietly but impactfully:
- “Don’t get too attached to your patients or you’ll get hurt.”
- “Don’t show too much of yourself or your patients will take advantage of you.”
- “Don’t show your emotions to your patients (or your colleagues). It makes you look weak.”
We suppress our emotions, and the vulnerability gap widens.
Sure, being on the high side of a vulnerability gap is safer and less emotionally draining place to be, but is that really where we want to be as physicians? Most of us came into the profession seeking consistent, intimate connection with others, and there is something sacred and cathartic about receiving our patients’ vulnerabilities and responding with our own. Unfortunately, the system and culture of medicine make this increasingly difficult to do.
'Revealing parts of ourselves'
So, how do we go about narrowing the vulnerability gap in medicine? First, we should allow, encourage, and nurture open and bi-directional displays of emotion within our hospital and clinic walls. Occasionally adopting some degree of emotional distance with our patients and our colleagues is undoubtedly a necessary coping mechanism. But adopting it as a matter of routine practice all but ensures a permanent vulnerability gap, and it erodes our connection to our patients, our colleagues, the practice of medicine, and — most importantly — ourselves. As humans, we seek and rely on connection with others, and blunting our emotional responses in emotionally-charged situations is antithetical to our core nature.
With the open sharing of emotion, the vulnerability gap narrows.
Second, we have to allow ourselves to be humans who have emotions and shortcomings ourselves, many of which are not particularly flattering or desirable. Like anyone else on the planet, we get sick, too; we get depressed; we make bad decisions; we feel shame; we forget important information; we get hangry and snap at people; we wish we were smarter/thinner/better/better/better. Our families certainly know this (they are too often the sole recipients of our “humanness”); why can’t our patients?
I’m not advocating for over-sharing; our patients obviously don’t need to know all the details of our lives, especially if it’s irrelevant to their health problems. But revealing parts of ourselves and our own struggles can go a long way in building trusting and connected relationships with them. So, I sometimes tell my patients with depression or anxiety that I’ve been to a therapist and it helped. I tell them that about my awful sleep hygiene and that I can’t remember to take my own medicines. I tell them when I’m tired, when I’m frustrated, when I don’t know how to solve their problems, and when my brain just isn’t working. I don’t tell every patient these things, but if I can sense the presence of a vulnerability gap, especially one that undermines the trust required in our relationship, I do. And never once has a patient received this information and turned on me. Quite the opposite, actually: they really seem to appreciate it, and they seem to genuinely care about my experiences, as well.
The vulnerability gap narrows.
Third, I try to learn about my patients’ lives, their families, and their communities. Twenty minutes is an appallingly short amount of time for a clinic visit, but I can often squeeze in at least a couple minutes to understand my patients’ stories, and at least one to two more to tell them one of mine: where I’m from, how much cooler my wife is than me, what I’m working on to better myself. Trying to know my patients as people and not medical problems is a simple but powerful endeavor; letting my patient know me as a person and not just a medical problem-solver is quite a bit more challenging, but equally as powerful. After all, isn’t the sharing of our stories one of the great equalizers and paths to connection?
The vulnerability gap narrows.
Finally, I try to be kind to myself. I have my own internal vulnerability gap to fight: on the high side sits the well-trained, buttoned up doctor who seems to (and often does) have the answers and knowledge to make people better. He is compulsive, detail-oriented, hard-working (too much sometimes) and a perfectionist, and this breeds a sort of inner self-confidence that minimizes his vulnerability. On the other side sits the doctor who is acutely aware of how little he knows; who feels like an imposter at times; who knows how complicated and devastating disease can be, and how inevitable failure is in medicine. He forgets his mom’s birthday, constantly loses things, and is highly prone to self-imposed burnout, to the detriment of his relationships with others. Bridging this internal vulnerability gap is only possible through deliberate self-kindness and a consistent willingness to reach out to others for help, both of which are inherently vulnerable things to do. When I do them, the gap within myself narrows, and with it comes a love of myself that lets me be more vulnerable with others.
With that, the vulnerability gap with my patients narrows further.
On occasion, it closes, and those days are, by far, the best days.
Will Bynum, M.D., is associate program director of the Duke Family Medicine Residency Program. Email william.e.bynum@duke.edu with questions.
Editor’s note: A member of the Duke Family Medicine Residency Program faculty guest blogs every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.