‘Shame competence’ aims to break the cycle of blame in medicine : NPR

During the pandemic, an elderly doctor is very tired from work, he sits at his desk in the resident’s office and holds his head.

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The distress that Will Bynum later recognized as shame overcame him almost immediately.

Bynum, then in his second year of family medicine residency, was finishing a long shift when he was called for an emergency delivery. To save the baby’s life, he used a vacuum device that applies suction to facilitate rapid delivery.

The baby escaped unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon after, Bynum retreated to an empty hospital room, trying to process his feelings about this unexpected complication.

“I didn’t want to see anyone. I didn’t want anyone to find me,” said Bynum, now an associate professor of family medicine at Duke University School of Medicine in North Carolina. “That was a really primitive response.”

Shame is a common and very uncomfortable human emotion. In the years since, Bynum has become a leading voice among clinicians and researchers who say the intense crucible of medical training can amplify shame in future doctors.

He’s now part of an emerging effort to teach what he describes as a “shaming skill” to medical students and practicing doctors. Although shame cannot be eliminated, Bynum and her fellow researchers argue that related skills and practices can reduce shame culture and promote a healthier way of engaging in it.

Without this approach, they argue, tomorrow’s doctors will not recognize and treat emotions in themselves and others. And so, they risk transmitting it to their patients, even inadvertently, which could worsen their health. Shaming patients can backfire, Bynum said, making them defensive and leading to isolation and sometimes substance use.

Blame it on the patients

America’s political environment poses an additional barrier to changing shame culture. Health and Human Services Secretary Robert F. Kennedy Jr. and other top health officials in the Trump administration have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder and other chronic problems on the lifestyle choices of people with these conditions — or their parents.

For example, FDA Commissioner Marty Makary suggested in a Fox News interview that more diabetes could be treated with cooking classes instead of “just throwing insulin at people.”

Even before the political change, this attitude was also reflected in medical practices. A 2023 study found that a third of doctors reported feeling pushed aside when treating patients with type 2 diabetes, sometimes linked to obesity. About 44% considered these patients to lack motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like to feel shame. We want to avoid it. It’s very uncomfortable,” said Michael Jaeb, a nurse at the University of Wisconsin-Madison who led a review of related studies, published in 2024. And if the source of the shame comes from the clinician, the patient may wonder, “Why should I go back?” In some cases, this patient can generalize this to the entire healthcare system. »

Indeed, some patients, like Christa Reed, have avoided doctors because of it. Reed abandoned regular medical care for two decades, tired of lectures about weight. “When I was pregnant, I was told that my morning sickness was because I was a plus-size and overweight woman,” she said.

Except for a few urgent medical issues, like an infected cut, Reed avoided health care providers. “Because seeing a doctor for an annual visit would be pointless,” said the Minneapolis-area wedding photographer, now 45. “They were just telling me to lose weight.”

Then, last year, severe jaw pain led Reed to see a specialist. A routine blood pressure check showed a sky-high value, sending him to the emergency room. “They said, ‘We don’t know how you normally get around,'” she said.

Since then, Reed has found supportive doctors with expertise in nutrition. His blood pressure remains under control thanks to medication. She’s also nearly 100 pounds below her heaviest, and she hikes, bikes, and lifts weights to build muscle.

A “masochistic” work ethic

Savannah Woodward, a California psychiatrist, is part of a group of doctors trying to draw attention to the harmful effects of shame and develop strategies to prevent and alleviate it. Although this effort is in its early stages, she co-led a session on the shame spiral at the American Psychiatric Association’s annual meeting in May.

If doctors don’t recognize shame in themselves, they can risk depression, burnout, sleep difficulties and other ripple effects that erode patient care, she said.

“Often we don’t talk about the importance of human connection in medicine,” Woodward said. “But if your doctor is burned out or feels like they don’t deserve to be your doctor, patients feel it. They can tell.”

In a survey this year, 37 percent of graduating students reported feeling publicly embarrassed at some point during medical school, and nearly 20 percent described public humiliation, according to an annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, as well as an almost “masochistic” work ethic, as Woodward described it. Then they undergo a series of exams and years of training, under constant surveillance and with patients’ lives at stake.

During training, physicians work in teams and make presentations to faculty about a patient’s medical problems and the recommended treatment approach. “You stumble over your words. You miss things. You put things out of order. You become empty,” Bynum said. And then shame sets in, he says, leading to other debilitating thoughts, such as “‘I’m not good at this. I’m an idiot. Everyone around me would have done so much better.'”

Still, shame remains “a chink in your armor that you don’t want to show,” said Karly Pippitt, a family physician at the University of Utah who has taught medical students about the potential of shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “God forbid you act like you’re not capable or show fear.”

Stop the Shame Cycle

When teaching students about shame, the goal is to help future doctors recognize the emotion in themselves and others, so as not to perpetuate the cycle, Pippitt said. “If you’ve felt shame throughout medical school, this normalizes that experience,” she said.

Importantly, doctors-in-training can work to reframe their mindset when they receive a bad grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they have failed as a doctor, they can focus on their mistakes and ways to improve.

Last year, Bynum began teaching Duke doctors about shaming skills, starting with about 20 obstetrics-gynecology residents. This year, he launched a larger initiative with The Shame Lab, a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people in Duke’s department of family medicine and community health, including faculty and resident physicians.

This type of training is rare among Duke OB-GYN resident Canice Dancel’s peers in other programs. Dancel, who completed the training, now works to help students learn skills such as suturing. She hopes they will follow this approach in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would after giving birth. “I was too afraid of how she was going to react to me,” he said.

“It was a little devastating,” he said when a colleague later told him the mother would have liked him to come see her. “She had sent me a message to thank me for saving her baby’s life. If I had given myself a chance to hear that, it would have really helped me to recover, to be forgiven.”

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