That morning, the shouting pertained to a scan that the senior registrar said was needed for the very poorly elderly lady in Bed 7, whom the young doctor had been looking after for several days […] The senior registrar had flown into a rage at the patient’s bedside. At the top of her lungs she castigated the young doctor for her stupidity, her ineptitude, her pathetic time-wasting. What was wrong with her? How would she ever succeed as a doctor if she couldn’t complete a task that any fool could accomplish with their eyes closed? On and on it went. The young doctor did not move, her shame overflowing. Tears welled and began to fall, one by one, onto the blue linoleum at her feet (Morland 72).
In this scene from Polly Morland’s 2022 non-fiction work, A Fortunate Woman: A Country Doctor’s Story, we are confronted with the public shaming of a medical learner. A registrar, entrusted with the task of training junior colleagues, who “appear[s] to believe that a jolly good beasting [is] essential to the induction of a young doctor” (Morland 71), rounds on one such colleague, when the results of a scan are not forthcoming. She challenges the doctor’s mental acuity, technical ability, and time management. Forced to endure this public tongue lashing, the humiliated junior is overwhelmed. As if materialising her “overflowing” shame, she begins to weep.
Unfortunately, accounts of such humiliations are not unusual, even if changes in medical culture have made them less acceptable. Studies of such mistreatment date back to the 1960s, with one 1991 survey reporting mistreatment in 96% of its respondents. In a 1998 article for Academic Medicine, Kassebaum and Cutler observed that the abuse of students was “ingrained in medical education”, which often manifested as “public belittlement and humiliation” in “misguided efforts to reinforce learning.” By all accounts, it remains an enduring problem, as shown by the personal testimonies of Danielle Ofri and Brian R. Smith, and further studies and commentaries by Hu et al and Markman et al. In their phenomenological analyses of shame in medical education, Will Bynum et al. have identified such instances of supervisor mistreatment as a particularly potent trigger for shame, which arises as an overwhelming negative evaluation of the self.
Morland’s description of the subsequent fallout echoes the language and actions that Ofri and Bynum et al. have observed in shamed doctors. The junior doctor finds the experience “scalding”, a “mortification” exacerbated by her sense of responsibility for the witnessing patient. Only previous and subsequent experiences of “happy months” where she feels “valued” prevent her from “quit[ting] medicine there and then” and “rehabilitate her love for the job” (72). The incident does teach her lessons, but only in the negative: that doctors should comfort patients, not the other way round; that bullying is damaging for doctors and patients; that her relationships with her patients are paramount; and that people, like the very poorly elderly lady, who, in the midst of her dressing down, held her hand, “are amazing” (73).
Morland’s vignette is a useful illustration of the association between medical learner mistreatment, pedagogy and shame. Unlike the testimonies written by Ofri and Smith, or discussed by Bynum et al, however, it is written in the third person by someone else. In this regard, it implicitly responds to a narrative challenge: how does one report on another’s shame? Shame is deeply personal experience that can have a devastating effect on the subject’s sense of self. Such devastation is deeply isolating, as much because the intensity of the experience for the individual far exceeds any effects it might have on those around them. This is why shame research gives primacy to first-person testimony. Third-person accounts of shame are usually evaluations or summaries of these testimonies, or interpretations of signs, like bowed heads, sunken shoulders, hidden faces and blushes, by bystanders. Direct, third-person access to shame seems restricted to fictional representations, where omniscient narrators can assume an unparalleled access to their characters inner lives. Since this is patently a work of nonfiction, we might then be tempted to identify this passage as simply summarising Morland’s interview with the junior doctor and move on.
This would overlook the role that literary technique plays in bringing us proximate to the doctor’s experience. The indirect reproduction of her registrar’s questions, the agentless emergence of tears – these little gestures insist on the disarming humiliation of the encounter and its visible impact. The questions, given in the third person, without quote marks or attribution, are an instance of Free Indirect Speech: a technique that merges the voices of narrator and character to deliver the registrar’s castigation more directly, while maintaining the narrative’s tense and person. Written in this way, however, the questions carry a certain ambiguity. Instead of speech, they might well be taken as the products of the junior doctor’s chronic rumination, or the repetitive thinking of negative thoughts, feelings or phrases. In this interpretation, which subtly directs us to the doctor’s interiority by taking the questions as instances of Free Indirect Thought, the questions have become internalised, posed silently by the doctor to herself. Taking these questions as instances of Free Indirect Thought is implausible, simply because they are bracketed by phrases that emphasise the orality of the occasion. Not only are they introduced by a verbal act, “castigated”, but this public question endures for some time: “on and on it went”. By pointing this out as an instance of Free Indirect Discourse, an umbrella term which incorporates representations of both speech and thought, I mean to stress the productive ambiguity of the device, which treads the line between remembering what was said and reactivating those words in an internal process of self-chastisement. Rather than simply hearing the questions from the outside, the subject interpolates them into her self-talk, turning harsh words into intrusive thoughts, without marking a strict division between the two.
The value in such an approach is, I think, clear. It creates a narrative space where inferences of shame in others can be explored, without presuming either an unfettered access to that other’s interiority or that such experiences simply cannot be shared or communicated. It reminds us that, as Denise Riley once wrote, “the worst words revivify themselves within us, vampirically” (46), whose “echoes” may continue to shame long after their original speaker has forgotten them. Most importantly, it creates a continuity between what is said, what is heard, and what we come to obsess over: words whose shameful force may only intensify over time.
Dr Arthur Rose – Postdoctoral Research Fellow, University of Exeter
7th October 2024
