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In the 1960’s, a large randomized controlled study was done by the University Group Diabetes program. The results showed that tolbutamide, which was virtually the only pharmaceutical pill at the time to lower blood sugar was associated with a significant increase in mortality in patients who developed myocardial infarction. The obvious response from the medical community should have been gratitude. This was clear evidence that safety in their clinical practices needed to be improved. The response was nothing of the sort. It included doubt, outrage and even legal proceedings against the investigators. The controversy went on for years.
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 and degraded. It leads to avoidance and 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”. It is 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. 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. There is a major concern underlying the controversy over mandatory reporting of medical errors, for 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. The use of shaming as punishment for shortcomings and “moral errors” committed by medical students and trainees contributes further to the extreme sensitivity of doctors. Society is taught to reverence the roles of the medical profession, and a mistake is swept under the rug to avoid shame.
What are the lessons here for those working to improve the quality and safety of medical care?
First recognize that shame is a powerful force in slowing or preventing improvement and unless it is confronted and dealt with, progress in improvement will be slow. Second, recognize that shame is a fundamental human emotion that will not just go away. Once these ideas are understood, the work of mitigating and managing shame can flourish. This work has been under way for some time, but has been resisted over and over. We need a basic strategy in quality improvement and recognize that medical error results as much from malfunctioning systems as much as incompetent practitioners.
We need to support the transformation of medicine from a culture of blame to a culture of safety. Quality improvement is another powerful tool for managing shame. Bringing quality issues and safety out of the shadows can remove some of the sting associated with shame. It is like the stigma of mental health. The more these issues are widely shared and openly discussed, the less shame. Here is where reports by public bodies and journals like Quality and Safety in Health care come in. Such a journal supports three major elements of autonomy, mastery and connectedness. This motivates people to learn and improve, bolstering their competence and their sense of self-worth and thus serving as antidotes to shame.
Frank Davidoff, British Medical Journal 2002; 324:623-624 March 16, 2002 (edited for easier reading)