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Recognizing and Eliminating Shame Culture in Health Professions Education

Sklar, David P. MD

doi: 10.1097/ACM.0000000000002770
From the Editor
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Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

When I was 15 years old, I left home to enter a prep school in New Hampshire, and quickly went from being a top student at my inner-city public school to someone struggling to reach the middle of the class. My parents were convinced that my attending this school was an opportunity that would open doors to a world I could barely glimpse at home. But during those initial weeks all I could think about was how hopelessly behind my classmates I was, in class after class, and how long I would last before failing and being sent home. I felt out of place and different from the other students, many of whom had attended private schools all of their lives. My classmates made fun of my lower-class Boston accent, the clothes I wore, my short stature, my Jewish religion, and my lack of athletic skills. I felt totally unfit academically, culturally, and physically—but it was about to get worse.

During my second week at school I was told to report to a large auditorium with my other classmates. I waited nervously until my name was called, wondering what new challenge awaited me. I was ushered into a small room with five other boys. A photographer told us to take off all of our clothes. I can remember the shock and disbelief of watching as my classmates disrobed. The blinding lights of the photographer’s camera flashed as he gave directions to each boy to turn and stand on a line and look at a dot. I remember that no one smiled as the photos were snapped.

As I watched, awaiting my turn, I wondered what the purpose of these photographs could be. Who would look at them? When my time came, I took off my shirt and then my shoes, socks, and pants. But when it came to my underwear, I froze. I just couldn’t do it. It felt so wrong, so shameful, not just the nudity but the idea of my naked body being on view on a wall somewhere. The photographer yelled at me to strip off my underwear. He would not tolerate any resistance or delays. If I did not comply, I would have to go to the dean’s office, and I imagined immediate dismissal. Finally, I did as he asked. I stood looking into the bright lights, naked and trembling, as I was photographed from front, back, and side views.

Later I learned that the photographs were related to a study of body type and personality using a theory known as somatotyping developed by William Sheldon,1 a physician. He had photographed hundreds of young men and published a book with a picture of each one, his somatotype, and a description of the personality associated with it. Somatotyping was related to eugenics theories popular at the time that classified people either as having characteristics to be encouraged for future generations or as having characteristics, such as low intelligence, to be discouraged and even eliminated through sterilization. The classification of body types using somatotyping provided a pseudoscientific measurement meant to identify those most fit for leadership.

Many years later when I attended my 50th class reunion, my former classmates were still talking about those photographs. Some laughed about them and made jokes about their potential use as blackmail to get us to give donations to the school. Others discussed the humiliation and shame of being photographed and how that seemed to be connected to other experiences of bullying, racial and cultural bias, belittling, and in some cases sexual abuse that they had endured at the school. My way of dealing with the abuse was to write a novel, Atlas of Men,2 that explored some of the issues raised by the photographs and research theory, and in which shame and the assault on the identity of the students figured prominently. My hope was that the book would promote conversations about shame and abuse and help prevent them in the future.

The association of shame and humiliation with nudity has a long history going back to biblical times when Adam and Eve went from a state of innocence (“Adam and his wife were both naked and they felt no shame,” Genesis 2:25) to experience the shame of nudity after they ate the forbidden fruit (“Then the eyes of both of them were opened and they realized they were naked; so they sewed fig leaves together and made coverings for themselves,” Genesis 3:7). The inducement of shame and other elements of psychological distress associated with forced nudity is so strong that it has been used as a component of torture in various wars and conflicts. Leach3 notes,

Stripping a person of his or her clothes begins the process of stripping them of their identity and their personality, a process that saw its complete expression in the Nazi concentration camps.

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Shame in the Medical Encounter

While forced nudity provides an example of how induced shame can lead to threats to identity, there are many other common experiences that can also create shame and threaten identity, some of which occur in the health care environment. Lazare4 described shame that occurs during the medical encounter. He defined shame as “distress concerning the state of the self that the person describes as no good, not good enough, or defective.” Lazare noted,

Once in the examining room, patients must reveal personal information, often about their weaknesses, expose their bodies, place themselves in undignified postures, and accept handling of their bodies, including intrusions into orifices.

Lazare also recognized shame that can occur in physicians who made errors in diagnosis or treatment of a patient, and he questioned why it is so difficult to talk about shame, concluding that to talk about it is also shameful. I believe that the shame of discussing shameful events may partially explain the paucity of literature related to shame in the medical literature. Fortunately, there has been recent renewed interest in shame and why it needs to be discussed openly in health professions education.

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Shame Associated With Medical Error

Davidoff5 described the connection between shame and resistance to improvement in health care, and suggested that moving from a focus of shame of individuals involved in a medical error to a recognition of the contribution of systems in the occurrence of medical error could lead to a more open and comprehensive improvement approach. He encouraged transformation from a culture of blame to a culture of safety. Through the open sharing of information about errors there could be less shame in being involved in an error and greater chances to identify ways to reduce them in the future.

Bynum and Goodie6 further explored the effects of shame associated with errors upon the wellness of learners. They described differences between shame and guilt in the health care learning environment and the importance of recognizing these emotions and their potential for occurring in association with a learner’s error. They explained that shame involves a negative reaction to the worth of the self, while guilt involves negative reactions to an action or behavior without implicating the value of the self. If learners and their teachers could focus on a behavior leading to a medical error, such as misreading an X-ray, rather than automatically assuming that the learners are defective, learners could concentrate on how to improve their performance and avoid future errors rather than dwelling on why they were such bad and inadequate persons.

I believe that scholarship on shame associated with errors can help create healthier environments for quality improvement and learning as we begin to dissect the contributions of individuals and systems to the patient and population outcomes related to health care. All of us will make mistakes during our learning and as we practice, and we need to do our best to see that those errors do not create shame or harm our patients. Open discussion of our errors and a supportive learning environment can be part of the process of improvement of care and the development of resilient health professionals.

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Shame Reactions

Bynum et al7 described various shame events and their effects through a qualitative study of 12 medical residents who experienced shame in medical training. They described the events as intense and damaging. One resident felt “like I was swimming in my own body.” Another felt “like the wind was taken out of you.” Another described the desire to escape: “I just want to go home. I don’t want to see anybody. I want to go to bed.” Bynum et al suggested that shame reactions are

sentinel emotional events for many learners … unexpected jarring experiences that can have significant physical and psychological effects on medical learners.

They concluded by urging open discussion about shame in the health professions education environment so that it could be recognized and its harmful effects prevented.

In an Invited Commentary in this issue, Hoskison and Beasley8 describe their own shame and humiliation as medical students 30 years ago and how those experiences have inspired them to provide a better, more supportive educational environment for students. They conclude with a call to action:

We call on our colleagues—those who round with and educate our students, residents, and fellows—to join us in our pledge to end humiliation as a learning tool, to monitor ourselves and our partners for unprofessionalism, and to learn about and employ the cutting-edge science brought to us by our medical education research colleagues.

In this issue, Bynum et al9 offer an example of the type of medical education research advocated by Hoskison and Beasley, describing a seminar for medical students that provides a venue to share some of what was learned in their study of residents and to help develop resilience to shame. LaDonna et al,10 in a qualitative study of practicing physicians, also provide some insight about how practicing physicians address failures and shaming events and how their strategies may be of value to medical students and residents. “We’re not very good at doing it [admitting mistakes], which is one of the reasons we’re not very good at learning from them.” Learning from failure also seemed to rely on participants’ ability to rebound from an error without becoming paralyzed by fear, guilt, or shame. Sometimes this meant reassuring themselves that “I may not have done the best possible job, but as far as I knew, I was doing the best job that I could do, and that was enough for me.”

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Shame and Personal Identity

In addition to shame associated with errors, shame can also involve humiliation based on our personal characteristics—how we talk, our social class, or what we look like (as exemplified by the nude photographs and the categorization of body types described earlier). We can receive messages about whether we have “the right stuff” to be successful in our future aspirations. Biases, both implicit and explicit, can create messages about our fitness based on race, gender, culture, physical or mental health, and body type. These biases can affect our judgments about ourselves and others, and others’ judgments about us. Williams and Rohrbaugh11 in this issue describe an incident of a patient’s explicit racist behavior and discuss how residents, units, and institutions should respond to these types of events. Such incidents can be seen as sentinel events, as described by Bynum et al,7 requiring an institutional reaction similar to that which follows a serious medical error.

The selection processes for both medical school and residency represent other opportunities to consider effects of bias and shame on applicants who look, speak, or act differently from the majority of applicants. In this issue, Mian et al12 describe an admissions process to increase the matriculation of Indigenous students at their medical school through revaluing characteristics of Indigenous applicants to align with the school’s social accountability to the region’s population. Finally, in this issue, Derrick Paul,13 a medical student, discusses the continuous assault of current events and personal traumas on his and his classmates’ personal identities resulting from racial, anti-immigrant, and other hatreds. He concludes:

Buffeted from the outside, we can be hardened in our values of decency, truth, diversity, and equality. These ideals may be the necessary tools to approach the tasks before us that loom enormous but are made conquerable by the growing strength of our voices and our practice in the art of fighting for ourselves, our families, and our patients. Among the many lessons I have learned in the early years of medical school, one stands out: that justice for all people, health equity for all people, and the push for progress on our most difficult health epidemics are not areas of peripheral interest to a life in medicine; they are essential to it.

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Addressing Shame

The study of shame in the health care learning and services environment can provide a window to the broader challenges that need to be addressed to provide health equity within our population and a healthy environment for our health professionals. In this issue, two special articles describe possible antidotes to a culture of shame by offering a focus on humanism and compassion. Thibault14 urges a focus on humanism to help health professionals resist bullying and other dehumanizing forces in the society around us as “we strive to make the health professions the model for humanism.” And Snyderman15 shares an extraordinary conversation with the Dalai Lama about the importance of compassion in health care, the role of mindfulness, and the need for dedicated time with patients for physicians to engage in compassionate care. If we were to encourage more humanism and compassion in medical care, I believe that shaming might diminish or even disappear from our training environments.

Addressing shame is as much about recognizing who we are and the differences we bring to the health care environment as it is about what we do and how we communicate safely and honestly with each other about our uncertainties and errors. Discussions of shaming can help us address power hierarchies and biases that get in the way of our service to our patients. Such discussions can help us to support each other, so that each day when we look in the mirror, we can take pride in the person staring back at us.

David P. Sklar, MD

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References

1. Sheldon WH. Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages. 1954.New York, NY: Harper.
2. Sklar DP. Atlas of Men. 2018.Phoenix, AZ: Volcano Cannon Press.
3. Leach J. Psychological factors in exceptional, extreme and torturous environments. Extrem Physiol Med. 2016;5:7.
4. Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med. 1987;147:1653–1658.
5. Davidoff F. Shame: The elephant in the room. BMJ. 2002;324:623–624.
6. Bynum WE 4th, Goodie JL. Shame, guilt, and the medical learner: Ignored connections and why we should care. Med Educ. 2014;48:1045–1054.
7. 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.
8. Hoskison K, Beasley BW. A conversation about the role of humiliation in teaching: The ugly, the bad, and the good. Acad Med. 2019;94:1078–1080.
9. Bynum WE IV, Adams AV, Edelman CE, Uijtdehaage S, Artino AR Jr, Fox JW. Addressing the elephant in the room: A shame resilience seminar for medical students. Acad Med. 2019;94:1132–1136.
10. LaDonna KA, Ginsburg S, Watling C. Shifting and sharing: Academic physicians’ strategies for navigating underperformance and failure. Acad Med. 2018;93:1713–1718.
11. Williams JC, Rohrbaugh RM. Confronting racial violence: Resident, unit, and institutional responses. Acad Med. 2019;94:1084–1088.
12. Mian O, Hogenbirk JC, Marsh DC, Prowse O, Cain M, Warry W. Tracking Indigenous applicants through the admissions process of a socially accountable medical school. Acad Med. 2019;94:1211–1219.
13. Paul DW Jr.. Medical training in the maelstrom: The call to physician advocacy and activism in turbulent times. Acad Med. 2019;94:1071–1073.
14. Thibault GE. Humanism in medicine: What does it mean and why is it more important than ever? Acad Med. 2019;94:1074–1077.
15. Snyderman R, Gyatso T; the 14th Dalai Lama. Compassion and health care: A discussion with the Dalai Lama. Acad Med. 2019;94:1068–1070.
© 2019 by the Association of American Medical Colleges