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Addressing the Elephant in the Room

A Shame Resilience Seminar for Medical Students

Bynum, William E. IV MD; Adams, Ashley V.; Edelman, Claire E.; Uijtdehaage, Sebastian PhD; Artino, Anthony R. Jr PhD; Fox, James W. MD

doi: 10.1097/ACM.0000000000002646
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Problem Medical schools face the challenge of developing efficacious resources to promote well-being and foster resilience in students. The authors developed, implemented, and evaluated a shame resilience seminar for second-year clerkship medical students.

Approach In February 2018, the authors conducted a 2.5-hour seminar (part of a longitudinal series) about shame, a common and potentially damaging emotion. The seminar consisted of a large-group session to introduce the psychology of shame, during which speakers shared their personal experiences with the emotion. Next, a small-group session allowed students to discuss their reactions to the large-group content in a safe and familiar environment. Before the seminar, faculty development was provided to small-group leaders (upper-level medical students and faculty) to increase their comfort leading discussions about shame. Students completed a pre/post retrospective survey immediately following the seminar.

Outcomes The authors found statistically significant increases in students’ confidence in identifying shame and differentiating it from guilt; in their attitudes regarding the importance of identifying shame reactions in themselves and others; and in their willingness to reach out to others during a shame reaction. Surveys of group leaders revealed no reports of significant student distress during or after the seminar.

Next Steps This seminar represents a reproducible means of promoting shame resilience in medical students. The speakers’ personal shame experiences and the safety of the small groups for discussions about shame were central to the seminar’s apparent success. Next steps include developing an empirically derived, longitudinal shame resilience curriculum spanning the medical school years.

W.E. Bynum IV is assistant professor, Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina; ORCID: https://orcid.org/0000-0003-3796-9301.

A.V. Adams is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

C.E. Edelman is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

S. Uijtdehaage is professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-8598-4683.

A.R. Artino Jr is professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0003-2661-7853.

J.W. Fox is professor, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.

An Academic Medicine Podcast episode featuring this article is available through iTunes and the Apple Podcast app, Spotify, GooglePlay, Stitcher, and SoundCloud.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: The study portion of this seminar was approved by the Duke University institutional review board (reference number: Pro00091896).

Disclaimer: The views expressed in this paper are those of the authors and do not reflect the official views or policies of the United States Government, Army, Air Force, Navy, or Department of Defense.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A642.

Correspondence should be addressed to William E. Bynum IV, Department of Family Medicine and Community Health, Duke University School of Medicine, 2100 Erwin Rd., Durham, NC 27705; email: william.e.bynum@duke.edu; Twitter: @WillBynumMD.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

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Problem

To confront the dire state of physician wellness at the earliest stages of medical training, the Liaison Committee on Medical Education requires that medical schools include programs to promote student well-being and address the emotional demands of medical education. Accordingly, medical schools face the challenge of developing efficacious resources to foster well-being in students. In this Innovation Report, we describe a seminar centered on shame resilience as a novel approach to promoting student well-being.

Shame is a negative emotion that occurs when an individual self-evaluates after a triggering event (e.g., medical error); it is associated with feeling globally flawed or deficient with no distinction between the behavior and the self.1 In contrast, guilt, a related emotion, occurs when an individual attributes a triggering event to something specific (e.g., a behavior or circumstance) rather than to the global self.1 Guilt is generally a constructive emotion that can stimulate personal growth through attempts to repair the causative behavior or circumstance.1 Shame, however, is a potentially destructive emotion1 that may lead to negative outcomes in learners, including social withdrawal, impaired empathy, and psychological distress.2 It has been called the elephant in the room, and its presence and effects in medicine often go unrecognized.3 Shame resilience is defined as the ability to proactively confront shame in a way that enhances one’s beliefs about oneself, increases one’s sense of power and control, and restores one’s sense of interpersonal connection and social standing.4

The clerkship year during medical school poses a unique set of challenges for students, such as intense patient encounters, complex team dynamics, perceived inadequacy in clinical knowledge, and frequent transition periods. These challenges may contribute to feelings of shame.2 Further, hierarchical pressures, feared impact on grades, and lack of vulnerability demonstrated by role models5,6 may prevent learners from reaching out about difficult experiences that can lead to shame. Complicating this situation further, shame itself may impair a learner’s motivation to seek help.2

Past strategies to promote learner resilience have focused on mindfulness techniques, organizational changes in the learning environment, and enhanced self-care, with mixed results.7 Reports of seminars focusing on shame experiences are rare in the medical education literature; however, Case and colleagues8 recently published a cautionary tale about presenting this topic. Their seminar opened with an introduction to shame, after which students, working in small groups, discussed experiences in medical education that are likely to induce shame. Sharing these experiences in the large-group discussion that followed triggered complex shame reactions and distress in numerous participants. The authors emphasized the challenge of broadly discussing shame without unintentionally inducing shame in participants.8

In this Innovation Report, we describe how we developed, implemented, and evaluated a shame resilience seminar for medical students at the Duke University School of Medicine. We aimed to avoid pitfalls such as those described by Case and colleagues8 and to produce meaningful changes in students’ attitudes, confidence, and willingness to seek help.

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Approach

During their clerkship year, second-year students meet for discussions in small groups of seven to eight students facilitated by faculty and upper-level medical students. These sessions occur weekly for four consecutive weeks during every eight-week clerkship period and are part of a two-year longitudinal course called Clinical Skills Foundation (CSF). CSF seminars follow a specific format: a 30- to 60-minute large-group session followed by a 60- to 90-minute small-group breakout session. Each CSF seminar covers a specific topic, and the longitudinal small groups provide a familiar and safe environment for students to share their feelings and experiences. As part of this course, we developed a 2.5-hour seminar entitled “A Resilience Seminar: Recognizing and Constructively Engaging With Shame.” Our seminar was developed from November 2017 to February 2018 and was executed on February 14, 2018. Participating in the seminar were 113 students and 31 small-group leaders. List 1 describes the curricular resources we developed to plan and execute the seminar.

The seminar goals were to help students differentiate between shame and guilt, introduce the concept of shame resilience, and enhance students’ willingness to seek help when experiencing shame (see List 2 for the specific learning objectives). The lead seminar planner (W.E.B.) first sought input from CSF course directors, advisory deans, and upper-level medical students about the ways shame might manifest in the local student population (optimizing the relevance of the seminar), the ways to effectively deliver the content (promoting student engagement during the seminar), and the ways to align the seminar with ongoing advisory and wellness initiatives (maximizing the impact of the seminar).

To prepare group leaders for discussions about shame, we provided a faculty guide and held an in-person meeting to field questions/concerns, clarify points of confusion, and reiterate the seminar learning objectives. Numerous group leaders expressed concern and hesitation about facilitating discussions on such a personal and sensitive topic. We discussed these concerns as a group and suggested strategies for navigating sensitive discussions and student distress (see List 2). We encouraged the group leaders to openly share their personal struggles, thus modeling vulnerability and promoting a safe environment for students.

One of us (W.E.B.) opened the seminar’s large-group session by sharing two personal shame experiences: one following an error and one related to a transition period. Building from these personal anecdotes, he outlined the psychology of shame and guilt using Tracy and Robins’s9 model of self-conscious emotions. Next, he highlighted a recent study on shame in medical residents2 and presented specific strategies for achieving shame resilience. Throughout the presentation, he emphasized the importance of community, seeking help, and normalizing feelings of shame as specific ways to promote shame resilience within the learning environment.

Next, two upper-level medical students (A.V.A. and C.E.E.) shared their own shame experiences with the large group. They discussed feelings of inadequacy compared with their fellow classmates, struggles with imposter syndrome, difficulty sharing emotions with colleagues and supervisors, and personal strategies for constructively dealing with shame. The large-group session ended with a question-and-answer period and a short video on four basic principles of shame resilience.10 The students and group leaders then met with their small groups and engaged in guided discussions (see List 2 for the discussion prompts).

We evaluated the perceived effectiveness of the seminar with a pre/post retrospective questionnaire that students voluntarily completed immediately after the seminar (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A642 for the survey instrument). The web-based questionnaire included 13 Likert-type questions and two free-response items; it assessed students’ satisfaction, likelihood of implementing the seminar content, and changes in attitudes, confidence, and willingness to reach out for help.

We calculated descriptive statistics and compared pre/post responses with paired t tests (using SPSS version 25; IBM Corp., Armonk, New York). The Duke University institutional review board approved the evaluation component of this project.

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Outcomes

Of the 113 students in attendance, 80 attempted the survey (71% response rate), 62 (55%) completed the entire survey, and 18 failed to complete both sections because of an online formatting glitch. The results are listed in Table 1. Seventy-one students (89%) assessed the seminar as quite effective or extremely effective, and 60 students (75%) reported being quite likely or extremely likely to enact the shame resilience strategies discussed. Participation led to statistically significant increases, with large effect sizes, in the level of importance students ascribed to being able to identify a shame reaction in themselves (Mpre = 2.74, Mpost = 4.18, P < .001, Cohen d = 1.46) and in their colleagues (Mpre = 2.79, Mpost = 4.10, P < .001, Cohen d = 1.30), as well as the importance of sharing shame feelings with others (Mpre = 2.80, Mpost = 3.97, P < .001, Cohen d = 0.99). Also increasing to a statistically significant degree was students’ confidence in their ability to do the following: to recognize a shame reaction in themselves (Mpre = 2.89, Mpost = 3.97, P < .001, Cohen d = 1.22) and in their colleagues (Mpre = 2.53, Mpost = 3.65, P < .001, Cohen d = 1.20); to distinguish shame and guilt from one another (Mpre = 1.94, Mpost = 3.81, P < .001, Cohen d = 1.97); to recover from a shame reaction (Mpre = 2.79, Mpost = 3.69, P < .001, Cohen d = 0.87); and to assist a colleague in recovering from a shame reaction (Mpre = 2.69, Mpost = 3.50, P < .001, Cohen d = 0.85). Finally, we found statistically significant increases in students’ willingness to reach out to others following an error, including to supervisors (Mpre = 1.79, Mpost = 2.23, P < .001, Cohen d = 0.42), peers (Mpre = 2.80, Mpost = 3.28, P < .001, Cohen d = 0.39), and others outside of medicine (Mpre = 3.34, Mpost = 3.64, P < .001, Cohen d = 0.25).

Table 1

Table 1

We conducted an inductive thematic analysis of the two free-response questions (“What worked well in the large-group setting?” and “How will participating in today’s seminar influence your resilience as a medical learner, if at all?”). Our analysis revealed that students found the personal stories and vulnerability displayed by the speakers effective at establishing psychological safety and normalizing shame. They appreciated the important distinction between shame and guilt, voiced a newfound ability to recognize shame, and discussed an increased willingness to reach out to others when they experience shame.

We also surveyed the group leaders to ask about the presence of student distress during the small-group discussions (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A642 for the survey instrument). Fourteen group leaders (response rate 45%) completed the survey, which included the following three questions: “Did any students express or display emotional distress during the small-group session?” “What was the general nature of the student’s (or students’) emotional distress?” and “How can the seminar be altered in the future, if at all, to avoid the risk of similar emotional distress?” Four group leaders (28%) reported student distress during their small groups; it manifested as tearfulness, feeling that the topic “hits very close to home,” and having intense feelings due to the relevance of the topic. Group leaders saw these emotional reactions as productive, appropriate, and not overly distressing to students; they did not identify a need to change the seminar in the future.

Follow-up communications with advisory deans, course directors, and medical school leadership revealed no reports of student distress in the two months following the seminar, though unreported distress may have occurred.

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Next Steps

Our seminar represents a reproducible means of promoting shame resilience in medical students. It normalized the sharing of difficult emotions and appeared to increase the likelihood that students would seek help during times of future distress. Each of these outcomes suggests that our seminar may help students overcome barriers to seeking help5,6; engage with setbacks in a resilient manner; and become change agents that transform the culture of silence in medical education to one of open, shared engagement with difficult emotions such as shame.

Two key features of our approach likely enabled these outcomes. First, the vulnerability modeled by the speakers who shared their personal shame experiences seemed to establish open, honest dialogue during the small-group sessions. Second, using the large-group portion as an informational session and the small-group portion as a discussion allowed students to reflect on their own shame experiences prior to sharing them in the relative safety of trusted small groups. This approach helped us avoid the pitfalls of discussing shame in a large-group setting.8 In future iterations of this seminar, we will provide more robust faculty development and will attempt to conduct the seminar earlier in the academic year—a request levied by numerous students.

Our evaluation of the seminar’s effectiveness was limited by the pre/post retrospective questionnaire study design, which surveyed students’ attitudes and confidence at a single time point. Administering the survey immediately after the seminar left little time for emotional processing, and it is possible that students’ perceptions of the seminar changed over time. Our evaluation also did not assess changes in actual behaviors or the impact on student wellness and resilience, both of which deserve further study.

As a next step, we plan to research how medical students experience shame and use those data to develop a longitudinal shame resilience program spanning the medical school years. This program might begin with an introductory seminar providing basic definitions and applications of shame and guilt. Later sessions might use peer small groups to explore shame experiences in the clinical learning environment in a periodic, longitudinal fashion. A final seminar prior to graduation might seek to prepare fourth-year students to address shame occurring during the transition to residency.2 By addressing shame in a deliberate, direct, and longitudinal fashion, we hope to help learners build a foundation of shame resilience that extends well into residency training and clinical practice.

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List 1

Curricular Resources Developed to Plan and Implement a Shame Resilience Seminar for Second-Year Medical Students, Duke University School of Medicine, 2018

Seminar map

  • Two-page document outlining the seminar’s goals, objectives, timeline, stakeholders, and a description of the included content
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Faculty guide

  • Seven-page document outlining the seminar’s goals, objectives, and timeline; tips for navigating sensitive conversations about shame, including input from upper-level medical students; an overview of the psychology of shame and guilt; an overview of relevant findings from new research on shame in medical learners; strategies for promoting shame resilience in medical education; and suggested prompts for the small-group discussions
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Large-group presentation

  • PowerPoint presentation: Depiction of two personal shame stories from the main speaker; overview of the psychology of shame and guilt using Tracy and Robins’s9 model of self-conscious emotions; overview of pertinent findings from new research on shame in medical learners2; and an introduction to the concept of shame resilience
  • Video of the basic tenets of shame resilience10
  • Student panel: Two upper-level medical students seated in the front of the room provided personal experiences of shame (approximately five minutes each)
  • Question-and-answer period with the speakers
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Small-group discussions

  • Small-group prompts (see List 2)
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Evaluations

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List 2

Learning Objectives, Suggestions for Small-Group Leaders, and Small-Group Prompts From a Shame Resilience Seminar for Second-Year Medical Students, Duke University School of Medicine, 2018

Learning objectives

By the end of the seminar, students will be able to …

  1. Define shame and guilt and distinguish them from one another
  2. Report increased confidence in recognizing shame when it occurs, either in themselves or in others, while learning medicine
  3. Report increased confidence in their ability to recover from a shame reaction
  4. Report increased willingness to reach out to others should they experience shame in the future
  5. List specific strategies that may enable them to constructively engage with shame when it occurs
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Suggestions for group leaders facilitating the small-group discussions

  • Begin the small-group session with affirmations of confidentiality and trust within the group.
  • Consider sharing a personal experience with shame as a way of modeling vulnerability and normalizing the emotion.
  • If you are hesitant to share your own shame experiences, reflect on the sources of this hesitation and the possibility that students may experience similar feelings. Consider acknowledging the sources of your hesitation in the small-group discussion.
  • Acknowledge, rather than avoid, difficult discussions that may arise during the small-group session, and seek input and personal experiences from students in the group.
  • Encourage and allow authentic displays of emotion by students, even if they may be uncomfortable. Avoid diverting from, or minimizing the significance of, difficult emotions if they arise.
  • Encourage students to consider and share the specific strategies they have used to address and recover from shame.
  • Remind students of the resources available to them should they develop distress during or following the seminar.
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Suggested small-group prompts

  1. Explore and discuss your reactions to the information presented in the seminar. Consider sharing any experiences you have had with shame or guilt as a medical student (or that you have encountered in others). How did you feel, and what contributed to your feelings?
  2. Brainstorm and discuss specific strategies that you have utilized or would utilize to adopt a shame-resilient approach to learning medicine. Consider not only individual strategies but also ways you might positively influence the learning environment to promote open, safe sharing of shame experiences.
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References

1. Kim S, Thibodeau R, Jorgensen RS. Shame, guilt, and depressive symptoms: A meta-analytic review. Psychol Bull. 2011;137:68–96.
2. Bynum WE 4th, Artino AR Jr, Uijtdehaage S, Webb AMB, Varpio L. Sentinel emotional events: The nature, triggers, and effects of shame experiences in medical residents. Acad Med. 2019;94:85–93.
3. Davidoff F. Shame: The elephant in the room. BMJ. 2002;324:623–624.
4. Van Vliet KJ. Shame and resilience in adulthood: A grounded theory study. J Couns Psychol. 2008;55:233–245.
5. Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. Learning from mistakes. Factors that influence how students and residents learn from medical errors. J Gen Intern Med. 2006;21:419–423.
6. Houpy JC, Lee WW, Woodruff JN, Pincavage AT. Medical student resilience and stressful clinical events during clinical training. Med Educ Online. 2017;22:1320187.
7. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388:2272–2281.
8. Case GA, Pippitt KA, Lewis BR. Shame. Perspect Med Educ. 2018;7(suppl 1):12–15.
9. Tracy JL, Robins RW. Putting the self into self-conscious emotions: A theoretical model. Psychol Inq. 2004;15:103–125.
10. Brené Brown on the 3 things you can do to stop a shame spiral [video]. Oprah’s Lifeclass: Oprah Winfrey Network. http://www.oprah.com/oprahs-lifeclass/brene-brown-on-the-3-things-you-can-do-to-stop-a-shame-spiral-video. Published October 6, 2013. Accessed January 23, 2019.

Supplemental Digital Content

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© 2019 by the Association of American Medical Colleges