Shame among medical learners: An uncertainty-focused conception

Abstract

Objective:

To analyze the nature and etiology of shame, a common problem that diminishes the well-being of learners and clinicians in medical education and practice, and to explore the relationship between shame and medical uncertainty.

Discussion:

We draw upon various theoretical insights on both shame and uncertainty, and argue that shame is ultimately a product of uncertainty and its transformation by medical learners. We argue that this transformation involves two key processes. The first is a personalization of uncertainty—i.e., a transformation of medical uncertainties focused on clinical care into personal uncertainties focused on one’s self-worth. The second is a resolution of personal uncertainty—i.e., a transformation of personal uncertainties about one’s self-worth into personal certainties about one’s lack of self-worth. These key processes linking medical uncertainty to shame suggest that shame might be prevented or mitigated by targeted interventions aimed at 1) depersonalizing medical uncertainties, 2) helping learners maintain their personal uncertainties, rather than resolving them in self-destructive ways, and 3) making uncertainty and its management a more central, explicit focus of medical training.

Conclusions:

Medical uncertainty has a central, paradoxical relationship to shame among medical learners—representing both a source of the problem and a potential solution. Key processes that lead from uncertainty to shame represent potential targets for interventions to prevent and mitigate shame among medical learners, and fruitful directions for future research.

1. Introduction

Shame is a common, aversive, and debilitating experience of medical learners and practitioners, and an increasing focus of attention in medical education [1]. A growing body of research has documented the extent to which shame arises among physicians and medical learners, and negatively affects their psychological well-being and their professional development and performance [2]. This research has fueled expanding efforts to raise awareness of shame in medical education and practice, to better understand its causes and effects, and to develop interventions that can both prevent and mitigate it [3–5]. These efforts are promising; however, important questions remain about the factors that ultimately give rise to shame and influence its severity and impact.

We view uncertainty as one factor that has received relatively little attention in past research on shame in medical education and practice. Drawing upon various theoretical insights from psychology and other fields, we analyze the relationship between uncertainty and shame, and argue that uncertainty plays a central, paradoxical role—representing both a primary source of shame and a potential solution to the problem. We show how shame arises when medical uncertainties become personalized, or transformed into personal uncertainties about one’s self-worth, which then become resolved, or transformed into personal certainties about one’s lack of self-worth. We argue that these processes represent potential targets for future efforts to prevent and mitigate shame, and outline key directions for future research.

2. Shame and vulnerability

In his seminal work on this topic, Pål Gulbrandsen has drawn attention to the relationship between shame and vulnerability in medical practice, and the need to better understand this relationship in order to improve clinician-patient communication. Drawing on the works of Lazare [6] and Lewis [7, 8], Gulbrandsen has conceptualized shame as an emotional response to the awareness of one’s own vulnerability, which is experienced to some degree by all persons including both clinicians and patients, and shapes all human behavior and interactions [9]. This vulnerability has both an existential and a social nature. The Norwegian philosopher Arne Johan Vetlesen has described vulnerability as a fundamental condition of life, rooted in the basic dependency of human existence and the fragility of personal relationships [10], while vulnerability also represents the central human experience according to Terror Management Theory in psychology [11, 12].

Shame is an emotional response to the awareness of these vulnerabilities, “a powerful, deeply uncomfortable, self-denigrating emotion” that “inheres in the experience of seeing oneself as critically flawed in relation to some internalized ideal, thereby judging oneself as globally deficient or unworthy,” as Whelan and colleagues have asserted [13]. Shame is ultimately social in origin, rooted in the need for belonging; sociologist Viktor Gecas has conceptualized shame as a self-conscious, “reflexive emotion” resulting from a self-evaluation and perceived loss of esteem in the eyes of others [14], and manifesting a fundamental motivation to adhere to prevailing social norms and expectations [15, 16]. The aversiveness of shame reflects the global nature of self-esteem, which pertains to one’s whole self [17]. Shame is psychologically aversive; however, it serves the adaptive social function of encouraging moral conduct consistent with collective interests, and has thus been characterized as a primary or master reflexive emotion [8, 18, 19].

Personal and situational characteristics influence the extent and consequences of shame [20]. Gifted and talented children, for example, are susceptible to shame [21], and personality traits such as perfectionism and achievement orientation are also predisposing factors [20]. Situational factors may also heighten shame by making individuals more or less aware of their vulnerability. For example, high-stakes tasks involving individual actions—e.g., solo musical performances, athletic competitions or advanced medical procedures —may be more shame-inducing than tasks involving collective actions, as may tasks involving significant professional rewards, risks, or responsibilities.

3. The vulnerability of medical uncertainty

In the setting of medical practice and education, numerous shortcomings can engender the sense of vulnerability that leads to shame; however, uncertainty—the conscious, metacognitive awareness or perception of ignorance [22]—is particularly important given the paramount value of knowledge in medicine. This valued knowledge is both theoretical (regarding the nature, etiology, and natural history of medical conditions) and practical (regarding the diagnosis, prognosis, and management of these conditions). Medical knowledge is a primary source of professional reward and personal pride for physicians and learners; conversely, lack of medical knowledge—that is, medical ignorance—is a primary source of professional censure and personal shame [23].

Yet to the extent that shame is a self-conscious response to vulnerability, ignorance alone is not a sufficient cause. Shame requires not only ignorance but the conscious awareness of it—that is, uncertainty [22]. Physicians and learners achieve this awareness whenever new information, experiences, or ways of thinking or acting make them aware of what they do not know, or otherwise challenge their preconceptions. This resulting awareness of ignorance is what allows physicians and learners to view themselves as vulnerable and experience the self-conscious emotion of shame; without it, there would be nothing to be ashamed about.

Uncertainties pertaining to numerous specific issues can be a source of shame for medical learners [22]. Most are scientific in nature, pertaining to data-centered issues such as the diagnosis, causes, prognosis, or treatment of health conditions, while others are practical, pertaining to system-centered issues such as the structures and processes of healthcare, and learners’ role in these processes (Fig. 1). Still others are personal, pertaining to learner-centered issues such as the existential or moral implications of a health condition (Fig. 2). These various uncertainties ultimately arise from distinct sources, including the fundamental indeterminacy or randomness of health phenomena, limitations in scientific evidence, and the fundamental complexity of health problems and their management.

Fig. 1.

Uncertainties experienced by medical learners: scientific and practical issues. Adapted from Han et al. [22].

Fig. 2.

Uncertainties experienced by medical learners: personal issues. Adapted from Han et al. [22].

The source of uncertainty may also determine the extent to which different uncertainties are perceived as shameful by medical practitioners and learners. In her groundbreaking ethnographic studies of uncertainties experienced by medical students in clinical training [24], sociologist Reńee Fox classified students’ uncertainties as arising from three main sources: (1) limitations in their own knowledge, (2) limitations in the knowledge of the medical profession at large, and (3) the inability to distinguish between these sources. We view these three sources of uncertainty as pertaining to three different kinds of ignorance, respectively: personal ignorance, scientific ignorance, and meta-ignorance (ignorance about the sources of one’s ignorance). Fox did not specifically examine the relationship between uncertainty and shame; however, she observed that the uncertainties students found most aversive and motivating were those arising from personal ignorance or meta-ignorance, given that these uncertainties could be attributable to individual shortcomings of students themselves. It thus threatened their self-concept and sense of competence. These—not just any—uncertainties were the ones that students experienced as personal vulnerabilities.

4. From medical to personal uncertainty, vulnerability to shame

Fox’s seminal study suggested that the personal significance of medical uncertainty—its relationship to learners’ self-concept and sense of personal competence—determines its psychological aversiveness and influence, and a large body of psychological theory and empirical research supports this possibility. Uncertainty-Identity Theory, put forth by Michael Hogg, holds that “some uncertainties we simply do not care about,” and that the uncertainties that matter most to us are those that involve the self and our self-conceptions. For any given uncertainty to be important, Hogg argues, it must possess “self-relevance”—that is, it must reflect and relate to one’s self, to questions about one’s identity and social relationships and standing [25]. Hogg uses the term “self--uncertainty” to describe this type of uncertainty, which can apply to three different domains—the individual self, relational self, and collective self—reflecting the extent to which self-identity is determined by knowledge derived not only from one’s individual experiences but from social comparison [26]. Self-uncertainty in these domains has been shown to motivate a variety of different actions, including meaning-making (creation of understandings), defense of worldviews, and identification with particular social groups.

In a similar vein, the Causal Uncertainty Model developed by Weary and Edwards highlights the social, relational nature of self-uncertainty, which they term “personal uncertainty.” This model is concerned with “causal knowledge” not of the physical but the social world—comprising “social events for which the self or others are possible causal agents,” and pertaining to “one’s own and others’ motives and intentions” [27]. The model construes causal uncertainty as “meta-cognitive feelings” that indicate inadequacies in individuals’ current state of knowledge that individuals find unpleasant and continually strive to resolve. In academic settings causal uncertainty has been correlated with a number of negative outcomes among learners, including low academic confidence and self-esteem, greater use of avoidant coping strategies such as self-handicapping, imposter syndrome, high fear of negative evaluation, and global uncertainty about one’s self-esteem [27]. Psychologist Kees van den Bos defines personal uncertainty as an uncomfortable, behaviorally motivating “subjective sense of doubt or instability in self-views, worldviews, or the interrelation between the two” [28]. He argues that personal uncertainty is a “hot-cold cognitive social psychological process” that “involves the implicit and explicit feelings and other subjective reactions people experience as a result of being uncertain about themselves” [29]. It threatens an individual’s sense of self and elicits negative emotions and actions aimed at getting rid of it.

These insights from psychological theory shed light on how different kinds of uncertainty lead to the experience of shame among medical learners and practitioners. They suggest that a critical part of this process is a personalization of uncertainty: a transformation of medical uncertainties (pertaining to scientific or practical issues in healthcare) into personal uncertainties (pertaining to one’s self-concept and worth). For medical uncertainties to cause shame among medical learners, they must first be taken personally—i.e., perceived as uniquely threatening to one’s self-esteem, which encompasses perceptions of self-worth and self-efficacy [17, 30]. Uncertainties about what is wrong with one’s patient, how one should respond, and what will happen must somehow become uncertainties about who one is, what is meaningful to one as a person, and whether one belongs in their peer group or profession. Scientific and practical questions must take on existential and social significance; domain-localized professional doubts must become global personal self-doubts about one’s worth as a human being. Personalization is thus a key mediating process between medical uncertainty and the experience of shame.

5. The paradox of self-doubt: personal uncertainty or certainty?

The personal uncertainty—or profound self-doubt—that leads to shame can be provoked by any uncertainty that challenges medical learners’ or practitioners’ conceptions of themselves as competent, worthy individuals and reduces their metacognitive confidence regarding these positive self-conceptions [31]. Paradoxically, however, this self-doubt reflects not personal uncertainty, but certainty. Individuals who experience shame are not simply raising questions about their self-esteem or self-worth; they are posing negative, self-defeating answers to these questions. They are attaining at least some maladaptive degree or level of certainty—even if only fleeting—about their answers, which is that they are flawed. Shame is thus arguably a problem of personal certainty rather than uncertainty—of inordinate faith rather than doubt about one’s self-concept.

Supporting this view, psychiatrist and psychologist Ron Wright has argued that one’s self-concept is itself an object of certainty and uncertainty—a cognitive representation that can be held with greater or lesser conviction [32]. Certainty about a negative self-concept diminishes self-esteem, whereas uncertainty can heighten it [18]. Wright has further noted how self-critical certainties play a key role in the pathogenesis of mood disorders such as depression: “it is other beliefs held with notable certainty that are causing the problem here, more than the ‘missing’ belief in one’s competence…these negative beliefs are held with great certainty, sometimes nearly impenetrable to evidence” [32]. A therapeutic goal of cognitive therapies for these conditions is thus to increase self-uncertainty: to help patients see their negative self-judgments not as indisputable facts but beliefs that can and should be questioned. In a similar vein, Brinol and colleagues have noted how some individuals with chronic self-doubts and low self-esteem have excessive metacognitive confidence (certainty) about their own insecurity, and that “undermining doubt by making people doubt their doubts”—in effect, increasing personal uncertainty by inducing a “state of double doubt”—may enhance self-esteem [31]. Both the adaptive nature of personal uncertainty and the maladaptive nature of personal certainty have been acknowledged in other situations involving threats to one’s self-concept [33].

These insights shed additional light on how medical uncertainty may contribute to shame among medical learners. They suggest that although the personalization of medical uncertainty is a critical step that incites personal uncertainty, an equally critical next step is a resolution of this uncertainty to some important extent. In order to experience shame, uncertainties about who one is, what is meaningful to one personally, and whether one belongs in one’s peer group or profession must somehow be transformed into some minimal level and duration of negative, self-critical certainties. One’s global personal doubts about one’s life and self must be validated, one’s greatest fears confirmed: one must somehow come to conclude—with at least some psychologically impactful degree of certainty, and for at least some psychologically impactful amount of time—that one lacks identity, meaning, and belonging. This uncertainty resolution process is the final step in the path from medical uncertainty to shame, culminating in a conviction about one’s unworthiness and powerlessness as a human being. Although born of uncertainty, shame lives on through certainty.

6. Shame and uncertainty in medical education and practice: future directions

We have briefly explored the problem of shame and its relationship to uncertainty in medical education and practice. Drawing upon insights from existing literature, we have argued that shame is an aversive, reflexive emotion rooted in a profound sense of vulnerability that is both existential and social in nature, and that shame in medicine arises primarily from medical uncertainties that are first personalized, or transformed into personal uncertainties about one’s self-worth, and then resolved, further transformed into at least some impactful degree of personal certainty about one’s lack of self-worth.

This uncertainty-focused conception of shame provides only a limited account of this highly complex and consequential problem; however, we believe it can help advance efforts to understand shame in medical education and practice. An uncertainty-focused conception treats shame as an epistemic as well as an emotional problem, and identifies two critical causal processes—the personalization and resolution of uncertainty—that can engender shame among medical learners and practitioners. More research is needed to elucidate these processes and the potential moderating and mediating factors in the path from medical uncertainty to shame. Potential moderating factors include characteristics of both individual learners (e.g., personality traits, life experiences [34–37]) and the learning environment (e.g., performance standards, feedback processes, interprofessional relationships [4]) that may affect the extent to which medical uncertainties are personalized and resolved in a negative, self-critical manner. Potential mediating factors include self-related cognitions including perceptions of self-efficacy and self-worth, and individuals’ subjective uncertainty or certainty about these perceptions. Various individual- and system-level factors may reinforce unrealistic expectations of knowledge and foster a culture of “shame and blame” [5, 38, 39] that makes medical uncertainty personally threatening.

We believe that an uncertainty-focused conception can advance efforts not only to understand but to address the problem of shame in medical education and practice. Each key process in this conception—the personalization of medical uncertainties and the negative resolution of personal uncertainties—represents a potential target for interventions to prevent and mitigate shame, and we conclude our analysis by identifying some promising directions for future work.

6.1. Depersonalizing medical uncertainty

If the critical initial step in the development of shame is the personalization of medical uncertainty, then one way to mitigate shame is to depersonalize medical uncertainty—to diminish the transformation of domain-specific medical uncertainties into global, personal uncertainties about one’s self-worth or self-efficacy. A key focus for future research is to develop interventions that can help medical learners to treat medical uncertainties as strictly medical—to uncouple them from personal uncertainties.

Some interventions could target medical learners. Although personality traits and many other factors that predispose individual learners to personalize medical uncertainties may be fixed and unalterable [36], their influence might conceivably be diminished through interventions aimed at normalizing medical uncertainty and uncoupling it from personal uncertainties that arise during medical training [4]. Examples include peer support programs that raise health professionals’ awareness of shame and encourage open discussion and sharing of personal stories. Promising examples include the Shame Space (https://www.theshamespace.com/) and other efforts to build “shame resilience” [40], as well as strategies to promote “intellectual candor”—the admission of doubts, thoughts and problems by educators, with the goal of “inviting reciprocal vulnerability” with learners [41]. A key function of such programs is to normalize uncertainty as unavoidable, acceptable experiences that do not reflect on their individual character or self-worth.

System-level interventions to normalize and thereby depersonalize medical uncertainty could target the medical learning and practice environment. Examples include shared decision making interventions in clinical care, which acknowledge limitations in the scientific evidence supporting various medical services. Other clinical care processes such as team rounds may serve a similar uncertainty-normalizing function by providing safe spaces for not only medical learners but teachers and other medical professionals to ask questions and to openly acknowledge medical uncertainty and error, and promote collective solidarity in managing these problems [42, 43]. Integrating the medical humanities within medical education may also help learners accept and manage uncertainty in medicine [44].

Some educators and clinicians may worry that normalizing medical uncertainty will diminish learners’ motivation to pursue the medical knowledge necessary for high-quality healthcare. We acknowledge this concern but believe that normalizing uncertainty and pursuing knowledge are complementary goals that can and should be simultaneously pursued. Thus the task of depersonalizing medical uncertainty raises a larger, cultural need: to somehow promote a culture of uncertainty tolerance in medicine. This may be the most important intervention for mitigating shame.

6.2. Maintaining personal uncertainty

If the final critical step in the development of shame is the resolution of personal uncertainty, resulting in personal certainty about one’s lack of self-worth, then another way to mitigate shame is to maintain personal uncertainty—to prevent or diminish the transformation of personal uncertainty into personal certainty. A key focus for future research is to develop interventions that can help medical learners achieve and sustain a healthy level of skepticism about their self-concept—to view their self-worth and efficacy as provisional works-in-progress.

Importantly, the goal of such interventions is not to simply turn negative personal certainties into positive certainties—i.e., to simply bolster self-esteem. Excessive self-esteem can lead individuals to over-value their roles or accomplishments, overestimate their control over situations, or lose motivation to learn and improve themselves. Greater positive personal certainty—i.e., metacognitive confidence regarding one’s self-worth or self-efficacy—may exacerbate these undesirable effects. A more adaptive goal is to reduce excessive self-concept certainty of either kind (negative or positive) and help learners achieve a middle-ground epistemic state of self-concept uncertainty—that is, a meta-cognitive position of indeterminacy, flexibility, and openness regarding one’s self-concept. This is the aim of some cognitive therapy approaches to mood disorders [32], and it may be an appropriate focus for efforts to mitigate shame among medical learners. This goal would be to induce a state of “double doubt” [31] that challenges learners’ certainty about a negative self-concept, and helps replace feelings of worthlessness or lack of self-efficacy with healthy skepticism of one’s self-concept—to help learners critique their own negative thoughts and feelings and acknowledge their unjustifiably one-sided nature. The challenge is to help learners embrace—rather than avoid—uncertainty about themselves, and to accept that being human means being simultaneously worthy and unworthy, powerful and powerless in facing the uncertainties of medicine and life.

We are not aware of interventions that focus on embracing and maintaining uncertainty as a means of addressing shame among medical learners; however, strategies developed for related purposes in other settings could help achieve this goal. Cognitive therapy techniques employed in the treatment of mood disorders—e.g., cognitive restructuring and reframing to normalize uncertainty, problem-solving training to cultivate skills in recognizing and mitigating negative uncertainty beliefs [45]—could be used to counsel and coach individual learners. Educational interventions designed to promote “professional identity formation”—understood as “the integration of the knowledge, skills, values, and behaviors of a profession with one’s preexisting identity and values” [46]—are also promising given that cultivating learners’ capacity to embrace uncertainty has been identified as an integral goal of such interventions [47–49]. Negotiating and maintaining an optimal level of personal uncertainty in medical training is a key type of “identity work” that medical learners struggle with [50, 51]. Potentially valuable professional formation interventions include interactive reflective writing activities [52], which create a psychologically safe space and narrative form for learners to share and make sense of their responses to personal uncertainties. Other professional formation interventions that may serve similar functions include training on mindful clinical practice and resilient responses to difficult interactions, and faculty development focused on reflective coaching skills [48]. Such interventions, however, reinforce an individualistic conception of professional formation [46]. Interventions to help learners embrace and maintain uncertainty should ideally target cultural, social, and other contextual factors that affect professional identity formation and restrict learners’ capacity to embrace uncertainty.

6.3. Tolerating the ambiguity of uncertainty

An uncertainty-focused conception of shame reveals the ambiguous nature of uncertainty: It is both a problem and a solution. It engenders shame by raising doubts about one’s self-worth, but also mitigates shame by calling those self-doubts themselves into question. Uncertainty is thus both aversive and attractive, constraining and liberating. Managing shame in medical education and practice requires medical learners, teachers, and practitioners to understand these ambiguities in the nature of uncertainty and its relationship to shame. As we have attempted to show, it also requires them to enact ambiguous responses: both increasing and decreasing, maintaining and eliminating different uncertainties (medical, personal) at different times. Managing shame is thus a matter of managing uncertainty, a fundamental task that requires a higher-order presence of mind—a metacognitive capacity to achieve an adaptive, optimal balance of responses to one’s uncertainties. This capacity is the hallmark of uncertainty tolerance in a normative sense [53, 54], and preventing and mitigating shame among medical learners ultimately requires creating a medical education and practice environment that fosters this capacity. Making uncertainty and its management a more central, explicit focus of medical training—beginning from pre-medical studies to both undergraduate and graduate medical education—may be a critical part of this effort.

In the Norwegian language, the concept of “uncertainty” can be expressed using two different words: usikkerhet, which signifies the more cognitive experience of doubt, and utrygghet, which signifies the more emotional experience of insecurity. Our colleague Pål Gulbrandsen has wisely pointed out that the goal of medical education and practice is to foster usikkerhet without utrygghet, doubt without insecurity, among clinicians. This key insight captures both the meaning and the challenge of tolerating uncertainty and mitigating shame in medical education and practice, and points the way forward for future work.