Editorials

Shame: the elephant in the room

Managing shame is important for improving health care

In the 1960s the results of a large randomised 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.¹ 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 improvementwhich ought to be a "no brainer"is generally such a slow and difficult process.²

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 behaviour. 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.³ The enormous power of shame is apparent in the adoption of shaming by many human rights organisations as their principal lever for social change⁴; on the flip side lies the obvious social corrosiveness of "shameless" behaviour.

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.⁵ 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 traineessuch as lack of sufficient dedication, hard work, and a proper reverence for role obligations⁶probably 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 recognise 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 recognise 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 applestowards "shifting the whole curve" as the basic strategy in quality improvement⁷ and the recognition that medical error results as much from malfunctioning systems as from incompetent practitioners⁸ are important developments in this regard. They have helped to minimise challenges to the integrity of healthcare workers and support the transformation of medicine from a culture of blame to a culture of safety.⁹

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?¹⁰ Here is where reports by public bodies ^{8 9} and journals like Quality and Safety in Health Care come in. More specifically, such a journal supports three major elementsautonomy, mastery, and connectednessthat motivate people to learn and improve, bolstering their competence and their sense of self worth, and thus serving as antidotes to shame.¹¹

Frank Davidoff, executive editor, Institute for Healthcare Improvement. 

143 Garden Street, Wethersfield, CT 06109, USA (fdavidoff{at}mail.acponline.org)

Footnotes

   This editorial is a shorter version of one that appears in the March issue of Quality and Safety in Health Care, relaunched this month with an expanded scope (2002;11:2-3. http://qhc.bmjjournals.com/cgi/content/full/11/1/2)