Shame at the Gates of Medicine: A Hermeneutic Exploration of Premedical Students’ Experiences of Shame : Academic Medicine

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Shame at the Gates of Medicine: A Hermeneutic Exploration of Premedical Students’ Experiences of Shame

Bynum, William E. IV MD, PhD1; Jackson, Joseph A. MD1; Varpio, Lara PhD1; Teunissen, Pim W. MD, PhD1

Author Information
Academic Medicine 98(6):p 709-716, June 2023. | DOI: 10.1097/ACM.0000000000005152



Little is known about the nature of shame in students attempting to enter medical school, despite its potential to impact well-being and professional identity formation during training. In this study, the authors used hermeneutic phenomenology to ask: How do premedical students experience shame as they apply to medical school?


From September 2020 to March 2021, the authors recruited 12 students from a U.S. Master of Biomedical Sciences program who intended to apply to medical school. Data collection consisted of each participant creating a “rich picture” depicting a shame experience during their premedical training, a semistructured interview that deeply explored this and other shame experiences, and a debriefing session. Data were analyzed using Ajjawi and Higgs’s 6 steps of hermeneutic analysis.


Self-concept, composed of an individual’s identities and contingencies of self-esteem, was central to participants’ shame experiences. Through a confluence of past and future self-concepts and under the influence of external factors and the weight of expectations, shame often destabilized participants’ present self-concepts. This destabilization occurred because of events related to application processes (repeat Medical College Admission Test attempts), interpersonal interactions (prehealth advisor meetings), and objective performance measures (grades, test scores). Participants’ efforts to restabilize their self-concept catalyzed specific identity processes and self-concept formation.


Shame provided a window into the emotional experiences, identity processes, and ideologies that shape students’ attempts to enter medical school. The authors discuss the central role of contingencies of self-esteem, the potential origins of performance-based self-esteem in trainees, and the identity negotiation and identity work involved in shame reactions. They call for the adoption of contingencies of self-esteem within current conceptualizations of professional identity formation; training for faculty and prehealth advisors about the nature of shame in premedical learners; and consideration of the consequential validity of standardized tests, which may trigger damaging shame.

The road to becoming a physician is long, with its serpentine origins lying in the years before medical school matriculation. However, relative to the growing body of research into the experiences of medical students and residents, far less attention has been paid to the experiences of premedical students.1 Previous publications have highlighted the personal qualities (i.e., achievement, perseverance, and individualism1), pressures (i.e., competition2), and tensions (i.e., conflicting advice from trusted sources2) that shape the admissions experience for premedical students. Rare in the literature are descriptions of the emotions premedical students experience as they strive for admission to medical school3,4; absent are descriptions of their shame.

This absence is problematic for multiple reasons. First, while shame is a normal emotion that regulates social behavior,5 it can be highly distressing and may be particularly prevalent during periods of transition and within environments marked by high stakes, intense competition, and pervasive use of objective performance markers.6 Applying to medical school is one such high-stakes transition period. In the United States, typically after completing 4 years of university education, applicants seek to achieve self-actualization as physicians, but first they must compete with throngs of other premedical students to enter the profession: one of every 2 applicants will be accepted to a U.S. medical school in any given year.7 In this high-stakes situation, shame experiences are likely to be common.6

Second, research into the experiences of medical students and residents—which has revealed the powerful effects of shame, such as impaired well-being, empathy, and learning6,8–12—has pointed to the potential development of factors before medical school matriculation that appear to contribute to shame experiences during medical training. These factors include performance-based self-esteem, past experiences of trauma, and experiences related to being underrepresented in medicine, among others.6,8

Given the damaging potential of shame, the heightened risk of shame during the medical school application process, and the possibility that experiences during this period may influence future shame risk, it is imperative that we examine premedical students’ experiences of shame. In this study, we sought to answer the following question: How do premedical students experience shame as they attempt to gain entrance to medical school and the profession?


Our study used hermeneutic phenomenology, a qualitative methodology that seeks to convey the nature and meaning of a phenomenon and the contextual factors that shape it.13,14 This is accomplished through focused analysis of the essences of the phenomenon that “make [it] what it is and without which the phenomenon could not be what it is.”13 In other words, essences enable the researcher to communicate the deeper meanings of a phenomenon.15


In hermeneutic phenomenology, researchers bring their own experiences into data analysis, recognizing that, in studying deeply personal experiences, their own perspectives shape data collection and analysis. Accordingly, as a research team, we engaged in personal reflexivity and openly discussed how our prior knowledge and past experiences of shame influenced our data analysis.16 We regularly shared and documented our experiences and their relevance to the data analysis during group meetings, in margin notes, and in coding memos.

Methodological reflexivity also informed our research.16 Given the sensitive nature of the research topic, we chose to use individual interviews instead of group data collection (e.g., focus groups) to encourage more candid reflections from participants. Furthermore, this study is part of a program of research, and the findings from previous studies6,8,9 informed data analysis.

Setting and recruitment

We recruited students from a 1-year Master of Biomedical Sciences program at a private institution in the United States. This program enrolls students seeking admission to health professions training programs, including medical school, and helps them strengthen their application credentials. It has historically enrolled a diverse student population, with 30% of prior students identifying as Black/African American, 12% as Hispanic, 3% as American Indian/Alaskan Native, and 1% as Native Hawaiian/Pacific Islander. We publicized the study through in-class announcements and emails, explicitly labeling the investigation as a qualitative exploration of shame experiences. Because our research program focuses on the physician education continuum, we purposively sampled for students who intended to apply to medical school. From September 2020 to March 2021, we recruited and interviewed 12 students, including 7 female students and 5 male students with an average age of 24.1 years (standard deviation = 1.6, range 22–27). With data collection and analysis occurring concurrently, we ceased enrollment after thematic sufficiency was achieved.

Data collection

We collected data during a single, 3-phase, 2-hour session with each participant conducted virtually on Zoom (Zoom Video Communications, San Jose, California). In the first phase of these sessions, one of us (W.E.B.) asked the participant to draw a rich picture17 about an experience of shame during their premedical training. We used rich pictures as an elicitation technique because this approach “encourage[s] holistic rather than reductionist thinking about a situation” and allows participants “to share and express what might [otherwise] be difficult to articulate.”17 The same researcher (W.E.B.) then engaged the participant in a one-on-one, 60-minute, semistructured interview that deeply explored their shame experiences. The rich picture served as a starting point for discussion, and the interview guide—informed by existing theory18 and our previous studies6,8,9 (see Supplemental Digital Appendix 1 at—served as a framework for probing the participant’s shame experiences. After the data collection phase, the same researcher (W.E.B.) led the participant through a debriefing session, during which he assessed for distress from the interview, provided support resources, and situated the participant’s findings within our early, evolving understanding of shame in premedical learners.

Data analysis

Interviews were recorded, transcribed verbatim, anonymized, and loaded into NVivo software (QSR International, Doncaster, Australia). The whole team engaged in data analysis, which included analyzing the transcripts and rich pictures using Ajjawi and Higgs’s 6 steps of hermeneutic analysis: immersion, understanding, abstraction, synthesis, illumination, and integration.15 We list our specific activities in each stage in Table 1. Throughout the data analysis, we engaged in iterative cycles of writing and rewriting,13 attended to the relationships between the parts (i.e., triggers) of a shame experience and the whole (i.e., impacts of shame on self-concept),19 and focused our analysis on the essences of participants’ shame experiences. This study was approved by the participating institution’s institutional review board.

Table 1:
Specific Steps in a Hermeneutic Analysis of Data from a Qualitative Study of Premedical Students’ Shame Experiences, 2022a


A key, overarching essence of our participants’ experiences of shame was its occurrence at the gateway of medicine. Participants provided varying descriptions—including in rich pictures (see Supplemental Digital Appendix 2 and 3 at—of a similar phenomenon: feelings of shame during efforts to make themselves competitive and/or prove themselves worthy, to others and themselves, to pass through the gates of medical school. Struggling or failing to do so played a central role in participants’ experiences of shame:

I felt like I was outside of that gate, the last person on the hierarchy. I was very much in a vulnerable situation trying to reach my goals to go onto this journey. (P9)

The impact of shame on participants’ self-concept

A second essence to emerge in our analysis was the significant impact that shame could have on an individual’s self-concept. Self-concept, as defined in psychology, comprises individuals’ self-esteem (i.e., one’s overall sense of personal value and self-worth) and identities (i.e., the qualities that make a person different from others),20 and it can be defined as “the subjective interpretations of who [individuals] are—based on socio-demographic characteristics, roles, personal attributes, and group memberships.”20 In other words, “self-concepts are semantic, but also visual and affective representations of who we were, who we are, and who we can become.”21

Shame presented fundamental challenges to participants’ self-concepts. Importantly, these challenges were not events isolated in time: shame experiences occurring at the gateway of medicine appeared to manifest within a confluence of present, past, and future self-concepts and under the influence of powerful external forces. Figure 1 depicts the relationships we observed among these constructs in a shame reaction.

Figure 1:
A depiction of how shame experiences in premedical students can occur within a complex confluence (indicated by the jumbled lines) of present, past, and future self-concepts and under the influence of external forces, ultimately yielding a destabilized current self-concept, from a qualitative study of premedical students’ experiences of shame, 2022.

The impact of shame on participants’ present self-concept.

Shame experiences could significantly destabilize participants’ present-day self-concepts. This destabilization was characterized by loss of self-esteem, identity dissonance, and globally negative self-evaluations; it was triggered by events related to participants’ efforts to pass through the gates of medicine. For example, not being invited for a medical school interview caused one participant to “feel very self-conscious, start to compare myself, and doubt myself in ways I hadn’t before” (P12). Upon receiving a C (average grade) in undergraduate organic chemistry, another participant questioned, “Who am I? What do I do if I don’t do well in my studies?” (P2). Being belittled by peers about testing accommodations for a disability caused another participant to feel shame and view herself as “not as capable or competent as others” (P10). Still other participants—in response to events such as low Medical College Admission Test (MCAT) scores (P3), mistreatment from classmates (P8), and struggling to keep up with the premedical workload (P4)—assessed themselves as “not smart or good enough” (P3); “socially inept, emotionally incompetent, and unworthy of friendship” (P8); and having “a me problem” (P4). List 1 includes the shame triggers reported by participants.

Among the most destabilizing shame triggers were interactions with premedical advisors during which a participant’s scores and/or personal demographics were the focus. One participant recalled a meeting during which an advisor inquired only about his grades and coursework, concluding that “you’re wasting your time” applying to U.S. medical schools (P9). Another participant from an underrepresented background recalled a meeting during which an advisor identified the participant’s family background as an inhibitor, advising “that I wouldn’t make it…that I shouldn’t do medicine because I’m a first-generation student, and nobody who’s first generation makes it this far” (P10). The shame induced by these interactions could lead to a relatively fixed and profoundly destabilized self-concept:

[The shame] was like I’m having a dream…and watching down on myself. It was like lacking an anchor and things were just floating away. I was seeing myself as truly not good enough…and I was pretty definitive in the way that things around me were reflecting who I was. (P5)

List 1 Shame Triggers Reported in a Qualitative Study of Premedical Students’ Experiences of Shame, 2022

Objective scores

  • Low test scores and/or grades in undergraduate and/or graduate studies
  • Low Medical College Admission Test score

Application processes

  • Compiling and reviewing an application
  • Attending an open house
  • Taking the Medical College Admission Test multiple times
  • Prehealth advisor meetings
  • Being rejected by a medical school

Interpersonal interactions

  • Mistreatment from peers (i.e., derogation, microaggressions)
  • Competition with peers
  • Mistreatment from supervisors (e.g., harsh treatment, being singled out)

The impact of participants’ past experiences on present self-concept and shame.

Participants seem to have arrived at the gateway of medicine with self-concepts shaped by influences from their past that involved family expectations, extracurricular activities, demographic factors (e.g., race, gender), and previous academic achievement. In recounting past experiences, participants recalled “being the kid who was picked on and left out” (P8), having “success be a way of love being affirmed” (P4), and “being a Black male [who is told] you’ll never be anything more than an athlete” (P2).

Certain events could invoke these historically rooted self-concepts, trigger shame, and destabilize present self-concept. Upon not receiving an interview for a top medical school, a participant whose prior self-concept included feeling intellectually exceptional (i.e., “a feeling that I was different, special…and maybe really smart” [P12]), suddenly felt like “one of a million other people trying to get into [a competitive school] who overestimated their abilities or themselves” (P12). When another participant striving to make her immigrant parents proud had to retake the MCAT exam 3 times, she felt “lonely and inadequate to be a medical student” (P6), a self-concept that she tried desperately to hide from others.

The impact of shame on participants’ future self-concepts.

Shame reactions also shaped—and were shaped by—imagined, hoped for, future self-concepts. Participants envisioned their futures as physicians as “dreams” (P5, P7) that provided “hopeful opportunity” (P7), the ability to support family members (P2), the chance to live up to parental expectations (P6, P11, P12), and the chance to be a caregiver (P4). One participant who viewed medicine as offering “instant credibility in all walks of life” pondered a question voiced by numerous participants: whether his performance at the gateway of medicine would deem him worthy of achieving the self-concept toward which he was striving:

Questioning my ability to succeed in the field that gets me that respect inherently forces the question of whether I deserve that respect, or I’m capable of earning that respect. (P1)

The influence of expectations as drivers of ideal self-concept and catalysts of shame.

Future self-concepts relate to who a participant is striving to be in the future; ideal self-concepts relate to who a participant is striving to be, or think they should be, now. In recounting the origins of their shame experiences, participants frequently alluded to expectations that informed these ideal self-concepts, provided benchmarks for self-assessment, and could trigger feelings of shame. These expectations cued participants to who they should be (“I have to be perfect to get admitted” [P2]) and what they should value (“grades are everything…the rest of your life is grades” [P5]); how they should act (“it is seen as weak if you don’t fight through adversity” [P2]) and how they should not act (“it is professional to be deferential to someone’s position and not open up during a difficult time” [P5]); and what they should do (“you have to sit at your computer screen for 19 hours a day and make sure that you know everything” [P2]) and what they should not do (“you’re not supposed to have [multiple] MCAT attempts” [P6]).

While some expectations appeared to have been implicitly internalized, many were explicitly communicated to participants by specific sources including: premedical advisors, letter of recommendation writers, faculty and small-group leaders, friends, parents, online forums (i.e., Student Doctor Network), and rank lists (i.e., U.S. News and World Report rankings). Upon receiving messages from these sources, participants could experience shame and a challenge to their present self-concept. For example, a participant recalled encountering an “unwritten rule” in “online forums such as Student Doctor Network and Reddit” that one should not take the MCAT exam multiple times, a discovery that amplified the shame she felt for needing to retake the exam (P6). Another participant, upon being told by a premedical advisor that his grades would never allow him admission to medical school, “immediately internalized it” and began conceptualizing himself as a “barcode…viewed by some as a single metric…and not my story, my empathy, and everything I’ve brought to the table” (P9).

Shame recovery and self-concept stabilization

In analyzing how shame experiences destabilize self-concept, we also identified how restabilization of self-concept could occur through participants’ efforts to recover from shame. Central to these efforts were active negotiations among current, past, and future self-concepts within a set of powerful environmental influences. For example, participants who believed, or were told by the system, that their grades or MCAT scores would disqualify them from admission to medical school engaged in intensive efforts to improve those metrics. For many participants, this required extreme sacrifice that could lead to additional changes in self-concept—vis a vis alignment with ideal self-concepts—through the integration of scores into their self-concept:

I canceled [my extracurriculars] and laser focused on my studies and made them my entire life.…I bounced back academically but there was a lot that suffered as a result.…It wasn’t necessarily the person I wanted to be. (P7)

Another participant described the intensive study required to improve his grades as making him “hyperfocused on getting out of the box [of seeing myself only through my scores]” (P9). Like other participants, this required sacrificing hobbies, relationships, and other extracurricular activities. However, unlike some participants, he maintained awareness of how this hyper-focus was changing his self-concept and took active steps to control it:

I realized, wow, I’m becoming very tunnel vision here. It’s working out, but that’s not the only thing that’s valuable. Let’s try and expand other aspects of my life. I had to actively do that. (P9)

The confluence of—and negotiation among—past, present, and future self-concepts in a shame reaction

To illustrate how shame experiences can occur among a convergence of past, present, and future self-concepts, we present an extended excerpt from our data (see Box 1). We made modifications to protect participant anonymity but focused on ensuring that we did not change the participant’s narrative. We chose this example to highlight the intersectionality, tension, and negotiation occurring among self-concept trajectories as well as the significant role that trauma can play in shame experiences.


In this study, we found shame to be a salient, potent, and revealing emotional experience at the gateway of medicine, where premedical students’ past, present, and future self-concepts collided with the structural norms that govern passage into the profession. Our analysis revealed the roots of present-day shame in students’ past experiences, such as childhood trauma, immigration, and underrepresentation. It also illuminated influential ideologies, embedded within medical school admissions structures, that allow shame to flourish. Below, we relate our results to theories of self-concept, performance-based self-esteem, and identity processes to support analytic generalizability of our findings.22 We explore the significance and implications of the central role of self-concept in premedical students’ shame experiences and the specific identity processes, catalyzed by shame, that shape its formation.

The central role of self-concept

In a previous study of medical students’ experiences, we identified the destabilizing nature of shame and how this destabilization can occur, namely through affective upswells, battling self-talk, and spiraling, negative self-evaluation.9 In our current study, our attention was drawn to what appears to be destabilized in a shame reaction: an individual’s self-concept. As a psychological construct, self-concept encompasses both an individual’s identity and contingencies of self-esteem,20 that is, the sources from which they derive value and self-worth. As such, the notion of self-concept incorporates who I am (identity) as well as what makes—or does not make—me feel worthy to be the person I am (self-esteem).

Data from our current study and from our prior studies6,8 suggest that (1) self-concept formation in medical learners is highly dynamic and forms trajectories that connect past, present, and future selves, and (2) contingencies of self-esteem—or the sources from which self-esteem is derived, such as grades, family, and peers—are salient in medical learners’ experiences of shame and play a critical, active role in their self-concept development.

In highlighting the presence of self-concept trajectories and particularly the role of self-esteem, we expand upon workplace learning theories describing the formation of identity trajectories. Through his evaluation of how individuals define themselves across and within communities of practice, Étienne Wenger asserts that identity formation is a process of “constant becoming” that occurs through successive forms of participation and “with a coherence through time that connects the past, the present, and the future.”23 As individuals traverse this participation arc, he argues, their identities form trajectories and become defined relative to the convergence and divergence of these trajectories, all within a field of external influences.23

Performance-based self-esteem

Whereas Wenger focuses on who an individual is becoming, our data reveal a closely linked trajectory composed of how premedical students feel about who they are becoming and the self-esteem contingencies that shape this self-evaluation. Our participants reported notable shifts in their contingencies of self-esteem as they navigated the premedical landscape and its heavy emphasis on scores. In essence, to enhance the competitiveness of their applications through improved scores, many participants felt compelled to shed existing self-esteem contingencies, such as being social, engaging in hobbies, and living their personal values, to make room for intensive study. The products of this intensive study (i.e., scores, grades, grade point average), in turn, became more potent contributors to students’ self-worth. This suggests the development of performance-based self-esteem, a contingency of self-esteem in which self-worth becomes dependent upon one’s sense of accomplishment and perceived level of performance.24

Having previously identified performance-based self-esteem as a powerful contributor to shame in medical students,6 we now call attention to its apparent origins before medical school matriculation and its potential projection into medical training. The higher performance (i.e., enhanced scores) that results from shedding other contingencies of self-esteem may establish a feedback loop that is reinforced in medical school where objective performance features prominently in learner assessment, during high-stakes residency admissions processes, and throughout future career paths.6,25 Indeed, the predominant role of scores from early childhood education to the gateway of medicine appears to fuel an axiom central to medical school admissions and beyond: How I objectively perform governs how I know myself, how I feel about myself, and who I can become. Critically, premedical students who have operationalized this axiom are likely to carry it into the profession where it can fuel damaging shame and destabilized self-concept when students are faced with inevitable learning struggles (e.g., related to the rigor of medical training), when objective performance markers fade (e.g., the transition to workplace-based learning in graduate medical education), and/or when bad things happen (e.g., a medical error or the death of a patient).6,8

Identity processes

In analyzing the nature of premedical students’ shame—and the cycles of self-concept destabilization and restabilization it prompted—we identified specific identity processes active at the gates of medicine. These processes include identity negotiation—defined broadly as “those activities through which people establish, maintain, and change their identities”26—and identity work or the range of activities individuals undertake in “forming, repairing, maintaining, or strengthening”27 their self-concepts. Our study suggests that premedical students, especially those from underrepresented or marginalized backgrounds, may struggle to negotiate their identities within the context of rigid admissions processes and formal structures that impart—explicitly or implicitly—information about who they should be, how they should act, and what they should value. The nature and effects of shame itself—including intrusive feelings of self-doubt and inadequacy, diminished self-worth, and social isolation—appear to further weaken students’ negotiating power, demanding significant identity work and rendering them more susceptible to the influence of assimilation forces within their environments.


Our study of shame experiences in premedical students has implications for learners, admissions officers, educators, and institutional leaders in medicine.

First, given the central role of both identity and contingencies of self-esteem in this study, we posit that self-concept formation may be the more descriptive, inclusive term for complex processes currently characterized within the narrower label of professional identity formation in medicine. Furthermore, our data reveal self-concept formation to be active before formal entry into the medical profession, a finding contrary to conceptualizations of professional identity formation that largely depict these processes as beginning upon admission to medical school or occurring primarily thereafter.28–31

Second, our study highlights the incredible influence that power brokers in admissions processes—particularly premedical advisors—hold over premedical students’ emotional states, self-concepts, and future paths in medicine. We call on all premedical advisors to (1) recognize their potential to uphold powerful ideologies governing admission into the medical profession and (2) acknowledge their potential to trigger damaging shame and destabilize self-concept, particularly in students whose scores may not reflect their potential for success in medicine. To achieve these goals, premedical advisors might receive formal training about the presence and nature of shame in premedical students and the factors that may drive it, including competition, performance-based self-esteem, childhood trauma, and underrepresentation.

Third, stakeholders from across the continuum of medical education should work to align and integrate a set of shared values—ultimately derived from what is required for competent, empathic, and humanistic medical practice—across all admissions thresholds in medical education. Our study reveals a potential incongruence between the high value placed on scores in admissions and what is actually needed for success in the profession (namely humanistic traits, empathy, and perseverance well beyond academic prowess and test-taking ability). If, as suggested by one of our participants, the preeminent use of scores in medical education does indeed transform multidimensional students into unidimensional “barcodes” (P9), how many diverse, resilient, well-rounded, and humanistic future physicians are shut out of the profession because their barcodes will not open the gates? In students for whom the gates do open, what contingencies of self-esteem, behaviors, and self-concepts—shaped by the processes they endured to open them—do they carry into the profession?

Fourth, the potential for standardized exams, such as the MCAT exam, NBME shelf exams, and Step exams of the United States Medical Licensing Exam, to trigger shame6,8 may affect the consequential validity—or the “intended or unintended consequences of score interpretation and use in the short- and long-term”32—of their use in high-stakes admissions decisions. Indeed, the profound shame that students may experience in preparing for and taking these exams signals significant and underrecognized consequences of their use in medical admissions processes. Further research is needed to gather more evidence of the consequential validity of these instruments, the findings of which should be weighed against other forms of validity evidence to determine whether their current use is appropriate or should be discontinued or reimagined.

Finally, our study has implications for leaders, educators, and clinical supervisors who work inside medicine’s gates and assume responsibility for the education and well-being of the students who enter the profession. Given the role of past trauma in present-day shame experiences, which can be traumatic events in and of themselves,9 educators and leaders need training in the principles of trauma-informed care and trauma-informed medical education.33,34 Indeed, creating safe environments will require becoming attuned to the potential for new or retriggered trauma to occur within the medical education setting. Likewise, efforts are needed to advance equitable, inclusive, and antiracist approaches to medical education that enable recognition of the harm that medicine as an institution has inflicted and may continue to inflict (e.g., through shame induced by medical admissions processes) on marginalized communities.35 Finally, stakeholders should help students retain broad-based sources of self-esteem and mitigate the damaging effects of performance-based self-esteem. This will require the creation of learning environments that facilitate authentic self-expression and a willingness to see students as dynamic, diverse, and multifaceted individuals who will be the future physicians our society needs.


The findings from this single-institution, qualitative investigation of shame are not generalizable to all premedical students or settings nor are they intended to be. While our study provides deep insights into the emotional experiences and self-concept processes occurring at the gateway of medicine, key aspects of students’ experiences of shame and the environmental influences that shape them remain beneath the surface. Additionally, the present study, through its focus on the nature of shame and its impacts, did not deeply investigate how premedical learners recover from and constructively engage with shame experiences. This analysis, which will be the focus of future study, will yield greater information about the ways in which shame contributes to resilience development and constructive self-concept formation.


In this study, we used hermeneutic phenomenology to analyze shame experiences occurring when premedical students seek admission into the medical profession. Perhaps the foremost essence of shame in premedical students is the window it provides into the self-concept processes and institutional structures that shape the journey to becoming a physician. By partnering with medical learners to pull back the curtain and peer through that window, we might leverage the power of shame to facilitate engaged, inclusive, and resilient passage through the gates of medicine and beyond.

Box 1

A Vignette Depicting the Confluence of Past, Present, and Future Selves—and Subsequent Self-Concept Destabilization—in a Shame Reaction, from a Qualitative Study of Premedical Students’ Experiences of Shame, 2022a

Hanna is a student in a pre-doctoral graduate program and applicant for medical school. Hanna describes repeated feelings of shame triggered by negative interactions with classmates in her team-based learning small group, including receiving microaggressions, being deliberately ignored, and being reported to an advisor as overly direct and “unable to read social cues.” This treatment made her feel “socially inept, unworthy of friendship or communication, and like I shouldn’t be a part of [this program].”

Germane to this shame reaction were past experiences that had shaped her self-concept prior to graduate school. Hanna grew up in a household in which she was traumatized by a father who frequently “gaslit” her, kept her from socializing with others, and could be emotionally, verbally, and physically abusive:

He would punch a wall and say “You see what you did? This is your fault.”…I had no friends, and I was never allowed to have friends, have sleepovers. I was never allowed to spend time with people.…I was his f****** punching bag emotionally.

This led to an earlier self-concept characterized by feelings of social ineptitude, a need to perform at a high level—academically and athletically—to feel worthy, and deep-seated confusion over whether the abuse by her father was deserved. Upon being mistreated by classmates in a team-based learning group, Hanna experienced significant re-traumatization and shame. This emotional experience was characterized by reinforcement of an earlier self-concept that, in a new environment away from her father, she had worked to change. This, in turn, led to dissonance between her present self-concept—influenced by her past experiences and the recent mistreatment from peers—and the future self-concept towards which she was striving:

I know I’m smart. I want to work hard and do my part and want to be involved.…I generally don’t think I’m socially inept or incapable of emotional intelligence. But [my classmates] definitely made me feel like that.

At the crux of this intersection of self-concepts was shame, the effects of which led to emotional distress, impaired belonging, and learning struggle. In small group settings, for example, Hanna recalls being intensely distracted by ruminating thoughts and efforts to manage others’ perceptions of her, leaving less capacity for learning and prompting her to study in isolation.

Hanna ultimately navigates her shame and negotiates her self-concept dissonance by relying on trusted peers and taking agency over her self-evaluation. She does this by reaching out to friends who treat her with respect, detaching her self-worth from the treatment of her small group members (“who is [my classmate] to say I’m less worthy?”), and engaging in active, validating self-talk:

I can talk myself into this loop of “No. You are socially capable. It’s okay. These people, what they think of you isn’t going to matter in a year.” And I can talk myself out of it. (P8)

aThis vignette is an extended excerpt from the data collected during the participant interviews. We made modifications to protect participant anonymity but focused on ensuring that we did not change the participant’s narrative.


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