Assessing for Learner Shame Should Be a Routine Part of Remediation for Unprofessional Behavior

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In the September 2016 edition of Academic Medicine, Mak-van der Vossen et al1 use latent class analysis to distinguish three classes of unprofessional behavior from one another. They conclude that certain classes of unprofessional behavior may be more difficult to remediate than others. This conclusion and numerous items on their master list of unprofessional behaviors (Table 1 in their article) may be further understood by considering the unrecognized presence of shame in the learners studied.
Shame is a self-conscious emotion that results from a negative self-evaluation and is characterized by feelings of being internally flawed, deficient, or unworthy.2 The phenomenology of shame includes feeling small, inferior, worthless, and exposed; the resulting action tendencies include hiding, withdrawing, avoiding, escaping, and wanting to disappear.2 Shame is a normal human emotion, but an enduring shame response may lead to self-doubt, impaired empathy, impaired relationships, defensiveness, and a tendency to project blame outwards, among other outcomes.3 In medical learners, shame may lead to disengagement in critical learning processes, declines in empathy, self-critical responses to error and feedback, and perceived mistreatment.4
Many of the categories of unprofessional behavior in the article mirror the phenomenology, action tendencies, and outcomes of shame, including “insecurity,” “avoiding [feedback],” “hiding [behind the student role],” “inability to work independently,” “ inadequate relationships,” “poor collaboration,” “failure to incorporate feedback,” and “argumentative communication.”
The possibility thus exists that unprofessional behavior in medical learners is driven, in part, by shame. This has profound implications on remediation efforts. Shame is a painful and isolating emotion that is not easily shared, spoken about, or identified. Failure to assess for shame in the midst of unprofessional behavior will not only hamper remediation efforts, but may actually worsen learner distress, especially if punitive approaches are used. Indeed, remediation itself—even when done in a constructive manner—may be shaming to many.
The authors rightfully point out that psychological treatment may be necessary in some cases of unprofessional behavior. I would argue that supervisors should assess for underlying psychological distress in all cases of unprofessional behavior, particularly when shame is likely involved. Furthermore, remediation for unprofessional behavior should begin with supportive, fair, and nonpunitive efforts to help learners address shame and other forms of emotional suffering. The success of the entire remediation process likely depends on this critical first step.
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