'I'm unworthy of being in this space': The origins of shame in medical students

Med Educ. 2020 Aug 13. doi: 10.1111/medu.14354. Online ahead of print.

Abstract

Objectives: Shame results from a negative global self-evaluation and can have devastating effects. Shame research has focused primarily on graduate medical education, yet medical students are also susceptible to its occurrence and negative effects. This study explores the development of shame in medical students by asking: how does shame originate in medical students? and what events trigger and factors influence the development of shame in medical students?

Methods: The study was conducted using hermeneutic phenomenology, which seeks to describe a phenomenon, convey its meaning and examine the contextual factors that influence it. Data were collected via a written reflection, semi-structured interview and debriefing session. It was analysed in accordance with Ajjawi and Higgs' six steps of hermeneutic analysis: immersion, understanding, abstraction, synthesis, illumination and integration.

Results: Data analysis yielded structural elements of students' shame experiences that were conceptualised through the metaphor of fire. Shame triggers were the specific events that sparked shame reactions, including interpersonal interactions (eg, receiving mistreatment) and learning (eg, low test scores). Shame promoters were the factors and characteristics that fuelled shame reactions, including those related to the individual (eg, underrepresentation), environment (eg, institutional expectations) and person-environment interaction (eg, comparisons to others). The authors present three illustrative narratives to depict how these elements can interact to lead to shame in medical students.

Conclusions: This qualitative examination of shame in medical students reveals complex, deep-seated aspects of medical students' emotional reactions as they navigate the learning environment. The authors posit that medical training environments may be combustible, or possessing inherent risk, for shame. Educators, leaders and institutions can mitigate this risk and contain damaging shame reactions by (a) instilling a true sense of belonging and inclusivity in medical learning environments, (b) facilitating growth mindsets in medical trainees and (c) eliminating intentional shaming in medical education.