“Is doctor something I wanted to do or something I wanted to be?” – Emily Silverman
“Shame becomes inevitably bound up with the process of identity formation which underlies man’s striving for self, for valuing, and for meaning. The experience of shame is a fundamental sense of being defective as a person, accompanied by fear of exposure and self-protective rage”. – Gershon Kaufman
Identity is a complex concept – the term originates from the Latin root idem meaning ‘the same’ as in identical. It is used to describe someone’s defining characteristics, combining what makes them unique and, paradoxically, what makes them the same as other members of a group. It is developed by the individual, particularly in young adulthood, but ultimately is recognised or confirmed by others. A doctor’s professional medical identity is formed throughout medical training and is influenced by the values of the medical profession and their personal values.
Experiencing shame leads to a soiling of identity because it arises when we fall short of our values. It can have damaging consequences of anxiety, depression and even self-harm. In medicine, the personal and professional identity can often become dangerously conflated. A doctor is not just a doctor while at work but also when watching their child’s football game or buying wine in the supermarket. They are expected to uphold the values of their profession at all times. The result is that a threat to a doctor’s reputation through workplace error, real or perceived, can have a devastating impact on their sense of self. Instead of feeling guilty that they have done something wrong, they experience shame that they are not good enough, falling short of their own expectations of being a competent doctor, their prized identity.
Shame can conversely play a positive role in identity formation by helping us identify our values or “remind us of promises we keep to ourselves”. This can lead to greater self-awareness and guide us to act morally which are key attributes of a medical professional.
In medical training much emphasis is put on what you do and what you know – much less attention is paid to who you are and what your values are. Values are beliefs that influence your behaviour. Are all doctors supposed to have the same values? Do we want all doctors to be identical? Medical professional values are spelt out as altruism, hard work, discretion, honesty and competence at graduation ceremonies in medical schools worldwide. However, there are other values that are often unspoken and harder to live up to: being infallible, never ill, sacrificing personal needs to those of patients and not appearing vulnerable. Feeling that they are falling short of any of these values is potentially shame-inducing for doctors.
The competency-based system of medical education which is currently in vogue gives the impression that there is a standard way to be a doctor – a model medical identity. If students and trainees deviate from this, for any reason, they will experience shame. Being involved in a medical error or not knowing the answer to a question as a medical student are common sources of shame. Failing to conform to medical group norms of ethnicity, class, sexuality or gender can also be potent shame promoters. Celebrating doctors’ diverse attributes is not a strong suit of the medical profession despite the fact that patients are very diverse and would undoubtedly benefit from being treated by doctors that identify with their needs. Being ill as a doctor is also perceived as shameful. Sick doctors cross the line into patient-hood resulting in being ‘othered’ and ostracised – implicitly or explicitly – from the medical tribe.
We cannot always avoid the painful experience of shame, but we can certainly mitigate its most malign effects. Expressing vulnerability, which is then met with empathy from others, is the most powerful way to build so called ‘shame resilience’. Expressing vulnerability is not however promoted as a core feature of the medical identity. In news clips and documentaries of the COVID-19 pandemic it is not uncommon to see staff weeping and leaning on each other physically for support on wards and intensive care units. Looking more closely it is telling that these staff are always nurses being comforted by each other or by doctors. Tearful, crumpled doctors are not the prevailing image, even though we know from personal accounts that many doctors are in tears before, during and after their shifts. This mirage of invulnerability and infallibility pervades our medical culture and means that the medical identity, while bringing much public pride, is also ripe for bringing personal shame with all its attendant pathologies of depression, addiction, unthinking conformity, rage and bullying.
For more on this topic, see the full article “Addressing shame: what role does shame play in the formation of a modern medical professional identity?” published in BJPsych Bulletin.
Sandy Miles, GP & Medical Educator who teaches on Shame in Medicine