Addressing Shame in Medical Education

More than 20% of the nearly 16,000 first-year residents participating in the 2022 Medical School Graduation Questionnaire administered by the Association of American Medical Colleges (AAMC) reported one or more experiences of being publicly humiliated during medical school.¹ Thirteen percent had been publicly humiliated once, 8% had been humiliated occasionally, and 1% had been humiliated frequently. Moreover, 21% had been publicly embarrassed once, 18% occasionally, and almost 1% frequently when they were medical students. And more than 20% of the survey participants reported witnessing other students being subjected to mistreatment. Experiences of mistreatment most often occurred on clinical clerkships, and faculty, residents, and fellow students, nurses, and other personnel in training settings were reported as the “sources” of the demeaning behaviors.¹

Humiliation and embarrassment relate to shame, a state of negative self-evaluation in which a person feels inadequate or unworthy, dishonored, and disconnected from others. Sometimes shame is felt briefly, if intensely. More often, an experience of shame may resonate for some time, becoming tied to past events or creating the expectation of future negative experiences.

Shame is associated with feelings of fear, worry, and worthlessness and with physical manifestations such as nausea, sweating, tunnel vision, and lightheadedness.² In the moment, shame can disrupt cognition, and a person may feel disorganized, have negative thoughts, and find themselves ruminating and fretting over small things.² Over time, shame may also be associated with harmful outcomes, including isolation, burnout, and depression.² For those reasons, even a single experience of shame can have effects that are detrimental and enduring.

This phenomenon of shame is a salient, if underappreciated, topic in medical education. The field of medicine has been described as rich with shame “borne of the body, of illness, vulnerability, difference, disability…”³ Physicians who have made a medical error, for instance, may be overwhelmed by feelings of shame, as described in a recent Lancet Perspective.⁴ The threat of acknowledging shame may be so great that clinicians “may conceal the problem; they may be aggressive and deflect blame elsewhere; they may feel unworthy of being a doctor and ‘drown in shame.’”⁴

Similarly, being the victim of bullying can very unfairly produce feelings of shame, as reflected in narrative comments captured in a recent survey by Iyer et al,⁵ published in our journal, of women physician leaders in academic medicine. Most of the 354 women respondents in that study had experienced mistreatment and bullying in professional settings, and many had negative psychological effects of losing confidence and feeling fearful, discounted, demoralized, ignored, or excluded. A scoping review⁶ of 58 articles found evidence of bullying and other examples of “incivility” among medical students, residents, and physicians, causing difficulties in the learning environment and at work.

A recent qualitative study of shame⁷ among medical students found 4 categories of “shame triggers” related to interactions with others:

supervisor mistreatment (e.g., derogatory comments, body shaming), peer mistreatment (e.g., dismissive treatment, derogatory comments), revealing something personal about one’s self to others (e.g., revealing sexual identity, showing emotion) and [having] challenging interactions with patients (e.g., feeling like a burden, performing an examination on the wrong patient).

Individuals who identify as underrepresented in medicine also describe how feeling different or not belonging contributed to their experiences of shame.⁷ For these reasons, shame may undermine student learning or create unequal learning conditions.³

Medical student narratives remind us that students worry about many things. Medical students worry about not doing their part to help patients, about being perceived as useless or annoying, or about performing improperly in medical settings.^7–9 A recent letter⁹ by medical students published in Medical Education suggests that the pandemic contributed to these concerns:

Although many students have found meaningful ways to contribute and many clinicians have continued to welcome us, our education has undoubtedly been affected by the cancellation of clinical placements and the pressures on health systems. More than ever before, our presence on wards has been regarded as a nuisance or worse an infection risk.

These worries may contribute to a sense of vulnerability and potential for shaming experiences in the training environment. Moreover, when clinical trainees’ supervisors do not act with professionalism toward patients or give them proper care, trainees who witness such behavior feel distress and may feel shame.⁸

A novel exploration of experiences of shame among premedical students is the subject of an exceptionally elegant qualitative report¹⁰ by Bynum et al appearing in this issue of our journal. The authors describe how shame appears to destabilize the self-concept of premedical students, altering their sense of themselves and their feelings of worthiness. Many participants described “hyperfocusing” on obtaining high scores to meet imagined expectations (“Who am I? What do I do if I don’t do well in my studies?”) and abandoning other aspects of life to focus on premedical studies (“I canceled [my extracurriculars] and laser-focused on my studies and made them my entire life”).¹⁰ Negative cognitions that can accompany shame, such as “feeling like nothing,” may overwhelm or discourage learners.⁸ Such pressures work against embracing the ideals of self-care and life balance, which have been found to be important to well-being and resilience over a professional’s lifetime in medicine.¹¹

Some degree of shame may be expected for individuals in training, as learners in the health professions are always at the edge of their knowledge and skills, particularly when just beginning to care for patients. As noted by Lusk,³ “learning itself can be shameful… Sometimes it is hard not to know.”

In the past, some have suggested that shame plays a prosocial role, motivating physicians to do their best. A study¹² of 54 physicians noted that many live with the shame of real and imagined mistakes, holding themselves to the highest standards of perfection and demanding self-improvement in patient care: “Contemplat[ing] old scenes of shame, they reinhabit the past while engaging with present worries, and they spur themselves to vigilance for the next case.”

Such observations reflect old ways of thinking, and while they may be accurate in some cases, shame is increasingly understood to be damaging to physicians’ performance and well-being.⁴ Indeed, making a patient care mistake can lead to persistent self-doubt and dread when there is no opportunity to address the negative consequences for the patient or the physician. As noted by Klein et al,¹³ shame thus can create a situation in which the physician “effectively [becomes] the second victim of an error.”

Humiliation and embarrassment are commonly experienced during medical training, as shown in annual findings of the AAMC’s Medical School Graduation Questionnaire.¹ Bullying in medicine is commonly experienced by physicians in practice and in training, including those who attain positions of leadership.^5,6 Through superb work by Bynum et al,¹⁰ we are now learning more about how the experience of shame may affect premedical students. In sum, shame is an experience that runs as a thread across workplace and formative educational experiences in academic medicine.

As educators and role models in academic medicine, we should remember that sincere and unwavering regard for the dignity of others is an essential attribute of an excellent physician. We should endeavor not to collude with the negative rationale that legitimizes and perpetuates shame experiences in medical training, whether due to being mistreated by others, encountering the limits of one’s knowledge, or making mistakes. Instead, Dear Reader, we should embrace our responsibility for creating a supportive learning environment and identifying better ways to foster excellence in clinical care.