Research

The encounter between a patient and a practitioner is recognized to be an important site where medical shame arises. For patients, fear of judgement and uncomfortable exposure is strongly correlated to nondisclosure of medically relevant information and clinical avoidance. This means that understanding how to manage shame may directly impact on the effectiveness of the delivery of healthcare. In WS1 we will investigate shame experiences in clinical encounters with a focus on patient experience. Philosophical approaches will be used to examine the phenomenology of shame in interpersonal encounters and related to the experience of health-related stigma, illness and physical exposure, while providing conceptual resources to investigate varieties of shame that may be most prevalent in such encounters and as a result of particular power relations. A cultural analysis will provide insights into representations of clinical encounters in literature, memoirs and illness narratives, while also investigating television, film and social media depictions of clinical encounters, with interest in the shame spectacles that are commonplace on ‘medicalized’ reality television. Empirical research will ask patients of healthcare services to write about their experiences of shame during clinical encounters in a semi-structured format. These context-specific narratives of shame will be analysed qualitatively.

The workplace for healthcare professionals provides the context, structure, and processes that not only organises their work but can also influence their thoughts, feelings, and actions. The workplace provides and reinforces certain standards for practice, can impose certain expectations, and can respond to practitioners in positive or negative ways. Furthermore, the workplace supports particular cultures, promoting some individuals and practices while dismissing others. The workplace, therefore, not only provides the context for negative self-conscious experiences, but can come to be a significant feature in practitioner shame, particularly through institutional structures which might foster bullying, excessive accountability, naming and blaming, etc. In WS2 we will investigate healthcare professionals’ shame experiences in the context of their workplace. Philosophical approaches will investigate shame and power in institutional hierarchies and organizational culture. Critical discourse analysis will be used to analyse documents from the General Medical Council’s (GMC) Archive, with particular focus on political discourse (speeches, writing, and media commentary) in respect of legislative change, and individual cases, in order to assess the role of shame and negative self-conscious emotions in accountability, regulation, and disciplinary processes. A cultural analysis will investigate literature, including memoirs, and visual media, including television, film and social media, that represent or recount professional shame experiences in the medical workplace. An empirical investigation will also be undertaken into how and why medical practitioners experience shame, what contexts and conditions facilitate and evoke such experiences, what influence these experiences have, and how professionals navigate such experiences in practice.

Recent studies indicate that medical students and trainees frequently experience shame in pedagogical contexts, and are affected by these experiences in both negative and positive manners. WS3 specifically seeks to identify when and why medical students feel shame in the context of medical education, and, ultimately, what influence these experiences have on medical students’ motivation, wellbeing, and their developing sense of  professional identity. A particular emphasis will be on investigating the political dimensions of shame experiences, looking at how shame might be experienced differentially by students as a result of race, ethnicity, class, gender or disability. WS3 will also be concerned with informing medical curricula with regards to addressing shame in education. A series of workshops will be organized throughout the project with medical educators, students, relevant advisory board members and collaborators to develop recommendations for medical schools and educators. In WS3, philosophical approaches will research shame in interpersonal interactions, along with: questions surrounding shame and power in institutional hierarchies; shame/blame dynamics; and pedagogical theories regarding the use of shame in education. A cultural analysis will consider literature, television and film depictions of shame experiences in medical training and education. Empirically, shame in medical education will be researched, using a Constructionist Grounded Theory approach, through a case study of one medical programme. We will recruit 10 medical students from each year of the medical programme at the University of Exeter (n=50). The students will complete a critical incident log of an experience of shame at least once a month for one academic year. This will generate data for ~600 experiences of shame. In the course of the on-going analysis, some students will be interviewed to gain more detail about their experiences. Together this will provide a deep dive into shame experiences of some students on one medical programme that will facilitate wider understanding and learning about shame in the medical context (See Appendix 1 for more information).

A philosophical analysis of shame, along with its variants and varieties, will form the conceptual foundation of the project, informing, and entangling with, the cultural and empirical research approaches. We are concerned with investigating the ‘shame’ concept, along with its varieties and variants, alongside the experiential basis of shame, as enframed in particular contexts and power relations. In doing so, a set of conceptual tools and frameworks will be developed which will be utilized and refined for the analysis of cultural texts and empirical findings. Philosophical research will proceed through three primary methodologies: (a) conceptual analysis, (b) feminist phenomenology, and (c) critical discourse analysis.

Cultural analyses help to understand structural aspects of experience that may not be easily captured in empirical investigations. This is particularly relevant for an experience like shame that is often anticipated, concealed or bypassed – represented as structurally present but experientially absent. The focus for the cultural studies research will be contemporary (post-1980), and there will be an explicit emphasis on feminist and post-colonial analyses, seeking to uncover differential experiences of shame among patients, medical students and clinicians based on gender, class, ethnicity, race and disability, while remaining alert to other intersectional factors such as sexuality and ability. The proliferation of illness narratives and medical memoirs since 1980, many written by women and ethnic minorities, makes this period most fruitful for considering lived experiences in medicine. The cultural studies investigation will incorporate a range of methodological practices (e.g., affect theory, feminist theory, critical race studies, deconstruction, post-colonial theory, narratology and iconography) and will proceed through two primary fields of study: (a) literary analysis, and (b) visual culture studies.

A sociological investigation will provide an analysis of real-world, context-specific experiences of shame in medicine and healthcare practice. This will focus on the physical, cultural, social, institutional and psychological components of the experience, and how these interrelate and come to define an experience as shame in that context. A Constructivist Grounded Theory (CGT) approach will be used to collect and analyse the data. Data will be generated from practising doctors, medical students, and patients using two primary methodologies: (a) the Critical Incident Technique (CIT) combined with the ‘Diary Diary–Interview’ Method, and (b) qualitative interviews. The findings from this research will be informed by, at the same time as informing, the findings from the philosophy and cultural studies research.