Shame: A Major Reason Why Most Medical Doctors Don't Change Their Views

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British Medical Journal 2002;324:623-624 March 16, 2002

 

Shame: A Major Reason Why Most Medical Doctors Don't Change Their Views

 

By Frank Davidoff In the 1960s the results of a large randomized controlled

study by the University Group Diabetes Program showed that tolbutamide,

virtually the only blood sugar lowering agent available at the time in pill

form, was associated with a significant increase in mortality in patients

who developed myocardial infarction. The obvious response from the medical

profession should have been gratitude: here was an important way to improve

the safety of clinical practice. But in fact the response was doubt,

outrage, even legal proceedings against the investigators; the controversy

went on for years.

 

Why?

 

An important clue surfaced at the annual meeting of the American Diabetes

Association soon after the study was published. During the discussion a

practitioner stood up and said he simply could not, and would not, accept

the findings, because admitting to his patients that he had been using an

unsafe treatment would shame him in their eyes. Other examples of such

reactions to improvement efforts are not hard to find.

 

Indeed, it is arguable that shame is the universal dark side of improvement.

 

After all, improvement means that, however good your performance has been,

it is not as good as it could be. As such, the experience of shame helps to

explain why improvement, which ought to be a " no brainer " , is generally such

a slow and difficult process.

 

What is it about shame that makes it so hard to deal with? Along with

embarrassment and guilt, shame is one of the emotions that motivate moral

behavior. Current thinking suggests that shame is so devastating because it

goes right to the core of a person's identity, making them feel exposed,

inferior, degraded; it leads to avoidance, to silence.

 

The enormous power of shame is apparent in the adoption of shaming by many

human rights organizations as their principal lever for social change; on

the flip side lies the obvious social corrosiveness of " shameless " behavior.

 

Despite its potential importance in medical life, shame has received little

attention in the medical literature: a search on the term shame in Medline

in November 2001 yielded only 947 references out of the millions indexed. In

a sense, shame is the " elephant in the room " : something so big and

disturbing that we don't even see it, despite the fact that we keep bumping

into it. An important exception to this blindness to medical shame is a

paper published in 1987 by the psychiatrist Aaron Lazare which reminded us

that patients commonly see their diseases as defects, inadequacies, or

shortcomings, and that visits to doctors' surgeries and hospitals involve

potentially humiliating physical and psychological exposure.

 

Patients respond by avoiding the healthcare system, withholding information,

complaining, and suing. Doctors too can feel shamed in medical encounters,

which Lazare suggests contributes to dissatisfaction with clinical practice.

Indeed, much of the extreme distress of doctors who are sued for malpractice

appears to be attributable to the shame rather than to the financial losses.

Also, who can doubt that a major concern underlying the controversy

currently raging over mandatory reporting of medical errors is the fear of

being shamed? Doctors may, in fact, be particularly vulnerable to shame,

since they are self-selected for perfectionism when they choose to enter the

profession. Moreover, the use of shaming as punishment for shortcomings and

" moral errors " committed by medical students and trainees such as lack of

sufficient dedication, hard work, and a proper reverence for role

obligations probably contributes further to the extreme sensitivity of

doctors to shaming.

 

What are the lessons here for those working to improve the quality and

safety of medical care?

 

Firstly, we should recognize that shame is a powerful force in slowing or

preventing improvement and that unless it is confronted and dealt with

progress in improvement will be slow. Secondly, we should also recognize

that shame is a fundamental human emotion and not about to go away. Once

these ideas are understood, the work of mitigating and managing shame can

flourish.

 

This work has, of course, been under way for some time. The move away from

" cutting off the tail of the performance curve " that is, getting rid of bad

apples towards " shifting the whole curve " as the basic strategy in quality

improvement and the recognition that medical error results as much from

malfunctioning systems as from incompetent practitioners are important

developments in this regard.

 

They have helped to minimize challenges to the integrity of healthcare

workers and support the transformation of medicine from a culture of blame

to a culture of safety.

 

But quality improvement has another powerful tool for managing shame.

Bringing issues of quality and safety out of the shadows can, by itself,

remove some of the sting associated with improvement. After all, how

shameful can these issues be if they are being widely shared and openly

discussed?

 

Here is where reports by public bodies and journals like Quality and Safety

in Health Care come in. More specifically, such a journal supports three

major elements autonomy, mastery, and connectedness that motivate people to

learn and improve, bolstering their competence and their sense of self

worth, and thus serving as antidotes to shame.