Shame followed me throughout my medical career, although it is only now that I am able to see it and name it. At 19, I was overwhelmed by the thought of the cadaver in front of me as a man who had previously been living and breathing. Crying down the phone to my mother that if I was too emotional at the very start of medical school, how could I ever be a doctor? On call for the first time and handing over a list of jobs – feeling I wasn’t good enough despite working flat out for 12 hours. As a senior registrar, I could not acknowledge my deteriorating mental health and seek help. And throughout it all, the hot, flushed, sinking feeling I had when I was asked a question I didn’t know the answer to. Shame can be thought of as an emotion we experience when we compare ourselves to an ideal self, and feel we are not living up to this ideal. So what were the ideals I was trying to live up to as a doctor?
The most pervasive ideal for me was that I should always have all the answers, which was particularly difficult in a specialty that is full of uncertainty. Working in the emergency department, you never know what might happen, or who might walk through your door. I felt it most when questioned by doctors from other specialties, who perhaps forget that you have to know a little bit about a lot in emergency medicine. I wondered – would I have the knowledge to answer all their questions when I complete my training and became a consultant? As I became closer to this point, the more I realised that this wasn’t going to happen. This one of the things that led me to research how new consultants in emergency medicine experience uncertainty. The consultants I spoke to described how others (patients and colleagues) expected certainty from them. There were tensions between this ideal of certainty and their knowledge of the messy uncertainties of clinical practice. It is worrying that not knowing is seen as shameful, as being honest about uncertainties is important for the safety of our patients.
What about my other experiences? My tears over the cadaver came from a sense of empathy, imagining a life for this man and the feelings of those he left behind when he died. Empathy is something we value in doctors, and being a caring, empathetic doctor was certainly an ideal of mine. I felt I had to tread a fine line between ‘professional’ detachment and feeling (and showing) empathy. The acceptability of emotion, in my experience, was cultural. In some departments, space was created to help us make sense of difficult situations and normalise our emotional responses to them. In others, I can remember the relief of climbing into my car finally letting out my tears. Bound up in my identity as a medical student, and then a doctor, was the idea that I help others. This made it very difficult to see when I needed help for my mental health. Others have also written about the difficulties of reconciling the reality of being unwell and a patient with the ideal of a doctor being strong, healthy, productive, and not letting others down.
After 13 years working as a doctor, I decided to give up my licence to practice. I had changed since I made the decision, aged 17, to study medicine and it was no longer the right fit. A career in medical education has allowed me to flourish in a way I had been unable to as a doctor. My next project is to research the professional ideals of medical students, and to consider the role of personal identities. Until relatively recently, the medical profession has been dominated by men, and I wonder how my gender influenced my experiences. Gender may play a role in how acceptable it is to express uncertainty, and there are obvious gendered stereotypes around how people express emotions.
The interaction between personal identities and the ideals doctors have as they form a professional identity is an area that is surprisingly lacking in research. This fits in to the wider conversation around diversity in medicine. While we talk about the benefits of diversity, it appears that those who have identities that aren’t traditionally associated with ‘doctor’ still feel they have to conform to a standardised ideal created by the dominant groups in society. I hope that the work I do in this area can contribute to challenging some of the unhelpful and unrealistic ideals we have, and make medicine a more inclusive and less shameful place.
Dr Anna Collini MBBS MA AFHEA, Lecturer in Medical Education, King’s College London
24th July 2023