AAMC Reporter, June 2015
Making errors is an inherent part of learning, even in medicine. Shame and guilt about errors, though, can have a major impact on the progress of resident physicians and how they interact with peers, colleagues, students, and patients. William E. Bynum, MD, an attending physician at Fort Belvoir Community Hospital and immediate past chair of the AAMC Organization of Resident Representatives, writes about and presents on how these two emotions differ in the context of learner errors.
Bynum is the co-author of “Shame, Guilt and the Medical Learner: Ignored Communications and Why we Should Care,” which appeared in the November issue of Medical Education. The article explores what separates the concepts of shame and guilt and suggests ways that academic medicine can foster shame-free reactions to errors. Being able to forgive oneself and others is a crucial component of recovering from a medical error, Bynum believes.
Reporter: What is the difference between shame and guilt, and why is understanding these emotions important in educating physicians?
Bynum: Shame and guilt are emotions that relate to how one evaluates oneself in relation to an undesirable event. When someone experiences shame, the object of negative evaluation is directed at his or her personal identity; the message is “I am a bad person.” With guilt, the object of evaluation is the action, not the person; the message is “The thing I did was bad.”
Psychology differentiates between shame and guilt; shame leads to avoidance, whereas guilt stimulates reparative action and a desire to improve. This means shame and guilt have potentially profound and different implications for learners. Shame inhibits engagement, while guilt, though uncomfortable, promotes formative learning.
The goal is not to deny or ignore the feeling of shame, but to recognize a shame response and process it in a way that moves the evaluation from one’s self to an assessment of the mistake or event. This is the first step towards self-forgiveness and learning.
Another response to shame is impairment of empathy. How does your work fit with the expanding field of medical curricula designed to teach empathy?
One of the most startling findings of the past few years is the decline of empathy in medical learners during the course of their education. I believe shame has something to do with this because when you see yourself as a deficient person, let’s say as the result of an error, you don’t want others to see you that way as well. Studies indicate that shame, through this negative internal evaluation, increases personal distress empathy, a response that occurs when empathizing with someone else triggers negative emotional associations. In turn, the associated distress impairs healthy, other-oriented empathy.
How can a better understanding of shame in medical learners move us closer to the broad goal of patient centered care?
Focusing on patient-centered goals is important and worthwhile, but sometimes we focus so much on the patient outcomes that we miss the many steps between the medical provider’s emotions and the patient’s experience. The first step is asking what is happening at a human level. I believe that most patients want a doctor who is willing to be vulnerable, who is willing to admit his or her mistakes, and who approaches the practice of medicine with a certain degree of resilience. Shame-resilient physicians are willing to embrace empathy and learn from errors. This is an approach that can lead to improved patientcentered care with better outcomes and patient satisfaction.
How do shame and guilt factor into changing notions of success in medical education, especially in the clinical setting?
We all need to be asking ourselves, what kind of doctors do we want to be? Do we want to be perfectionists who strive to know everything but are terrified to make the inevitable first, second, or third error? Or do we want to be doctors who strive to improve every day but can admit and accept our errors or lack of knowledge in a constructive and forgiving way? Maybe in this sense success is measured not by how much we know or which capabilities we possess, but rather how we respond when these things fall short.
The people who most have to recognize the need to humanize doctors are doctors themselves. In the medical community, as in academic medicine, we propagate perfection as much as or more than the public. As a result, our collective tolerance for error is low, even the kind that comes during the natural course of learning. But that really flies in the face of what learning is all about. You stumble and practice for a while before you get better at things. So how do you find a way to make necessary mistakes, but continue to feel adequate? That’s at the heart of shame resilience.
Your research centers on the issue of medical errors. Why is this important and what is the takeaway for medical schools and teaching hospitals?
Making errors is a normal part of learning and practicing medicine. However, shame impairs our ability to learn from mistakes, maintain a positive view of ourselves, forgive ourselves, and effectively empathize with others.
Being vulnerable requires the willingness to brush yourself off and get back out there, knowing the same thing could happen again. Medical learners and their teachers should strive to foster and model vulnerability, develop resilience at the earliest stages of medical training, and understand the emotions associated with making mistakes so they can constructively manage the aftermath. I think we have come to a point in medical education where we’re willing to be open and honest with ourselves about the emotional issues inherent in medical training and learning. As a community of learners and teachers, I feel we’re moving the dial in a positive, and much needed, direction.
Association of American Medical Colleges. Reproduced and distributed with permission.