Shame: A Major Reason Why Most Medical
Doctors Don't Change Their Views
By Frank
Davidoff
In the 1960s the results of a
large randomized 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.
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, degraded; it leads to
avoidance, to 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":
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.
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 trainees such as lack of sufficient dedication, hard work, and a proper
reverence for role obligations probably 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 recognize
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 recognize 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 apples towards "shifting the
whole curve" as the basic strategy in quality improvement and the
recognition that medical error results as much from malfunctioning systems
as from incompetent practitioners are important developments in this regard.
They have helped to minimize
challenges to the integrity of healthcare workers and support the
transformation of medicine from a culture of blame to a culture of safety.
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?
Here is where reports by public
bodies and journals like Quality and Safety in Health Care come in. More
specifically, such a journal supports three major elements autonomy,
mastery, and connectedness that motivate people to learn and improve,
bolstering their competence and their sense of self worth, and thus serving
as antidotes to shame.
British Medical Journal 2002;324:623-624 March 16, 2002
DR. MERCOLA'S COMMENT:
I believe this is a central
issue to the transformation of the medical paradigm.
It never occurred to me that
shame could be a strongly motivating influence preventing many physicians
from changing their previous practice habits.
Shifting them would imply
that they were wrong in the past and that is something that most physicians
seem to have a great deal of problems with and the shaming seems central to
the cause.
Fortunately,
EFT would be a
wonderful tool to heal this wound. The practical challenge, of course, will
be to arrange for the physicians to receive this treatment so they can
progress forward with truthful information that will really serve their
patients well.
Return to Table of Contents #311 |
