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Shame in Medicine

10/16/2020 2:37 PM | Anonymous

I have been thinking about shame lately, both on a personal and professional level and about its role in our lives. It seems that, just like stress, shame does have a place in cultures that is both positive and negative.  With stress, too little tension in our lives leaves us apathetic and disengaged; too much, and we can snap under the pressure. Similarly, every culture has a set of “rules and expectations” that shapes behavior the majority feels is appropriate in order to belong to it. That can be beneficial.

And then of course is the toxic side of shame, where it is used abusively against people for being less educated, less able, or just being human and making mistakes. This is the kind that can leave somebody feeling demoralized for and trap them in failure mode for not living up to the standards of those who validate their sense of self-worth.

Debilitating shame can be internally induced by not being able to pick yourself up, be honest about your failures, dust yourself off, and move ahead. Throw it into a group of people with perfectionistic standards for themselves and others (aka medical training) and it is frequently used as a blunt object to motivate, correct, and discipline with unintended consequences.

Many physicians can recall personal experiences when they were humiliated in front of patients, other peers, or superiors. Or when a bad medical outcome (or a few in a row) leaves one with crippling doubt over your medical judgment or lack thereof. When physicians are left with unrelenting remorse, guilt, and depression, it could even lead to impairment in clinical practice. Traditionally, impairment has been defined by our medical institutions as strictly related to chemical dependency, cognitive function, and diagnosable mental illness. But shame is probably one of the largest factors in many physician suicides, especially by trainees.

The good news is that the topic of shame and how it functions is being broken open. Undoubtedly, best-selling author and “shame researcher” Brené Brown has contributed greatly to this. Her writings and online presentations, not the least of which is a 75 minute-long talk on Netflix, are beginning to unmask and unravel something in our American culture of exceptionalism and productivity that has an ugly underbelly.

Also emerging is a conversation around how shame functions in U.S. medical training and cultures. Dr. Will Bynum is the leader here. He is an Assistant Professor & Associate Residency Program Director at the Duke University Department of Family Medicine and Community Health. Together with other healthcare providers and educators, he has launched The Shame Conversation Project. At its core is a seven-minute film that highlights some of the feelings that many physicians in a vulnerable moment might admit to having experienced.

Dr. Bynum draws a distinction between shame and guilt. The former produces feelings like “I need to fix myself. I am bad. I am not enough.” vs. “I need to improve. The thing I did was bad. I made a mistake.” These two self-conscious emotions spring up from different mindsets. The first is a sense of oneself that says, “I can’t change this about me!” The second recognizes an ability in oneself that says, “I can change this” and gets to it.

This winter, ACMS intends to launch a series of watch parties to view the Shame Conversation Film together and talk about what feelings it evokes. Our hope is that these conversations continue to bend the local medical culture in a direction that serves patients well by developing the most capable physicians intellectually and emotionally. Stay tuned.

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