Shame: A Major Reason Why Most Medical Doctors Don't Change Their Views
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
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
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. These motivate people to learn and
improve, bolstering their competence and their sense of self worth,
thus serving as antidotes to shame.
British Medical Journal
2002;324:623-624 March 16, 2002
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