Recognizing and Eliminating Shame Culture in Health Professions Education

Posttraumatic Growth and Second Victim Distress Resulting From Medical Mishaps Among Physicians and Nurses

Medical mishaps are well-known sources of distress. However, some mishaps may give medical professionals an opportunity to experience personal growth. We examined the associations between medical mishaps, second victim distress, and posttraumatic growth. A total of 157 physicians and 139 nurses completed a survey that included questions about mishaps, Second Victim Experience and Support Tool and the Posttraumatic Growth Inventory. Overall, 82.8% of the physicians and 48.9% of the nurses experienced at least one mishap. Lack of training, rumination, and impact of mishaps were associated with distress among nurses, whereas rumination, impact, and stressfulness were associated with distress among physicians. On the other hand, the impact of mishaps is the only factor that was associated with posttraumatic growth among nurses, whereas none with physicians. This study suggests that the posttraumatic growth from medical mishaps is not associated with the theory-driven event-related factors, and highlights the importance of further investigation.

Emotion, ethics, epistemology: What can shame 'do' in medical education?

BACKGROUND

Recent empirical studies have described and theorized a culture of shame within medical education in the Anglo-American context (Bynum). Shame is universal and highly social human emotion characterized by a sense of feeling objectified and judged negatively, in contrast to one's own self-concept. Shame has both an embodied and a relational dimension. Shame is considered especially relevant in healthcare settings (Dolezal and Lyons), and the tenets of patient care within the medical profession include respecting the dignity and upholding the safety of patients. However, shame is frequently deployed as a teaching tool within medical training.

METHOD

Here I ask, what can shame do in medical education (Ahmed)? What epistemic and relational conditions does it construct? I draw from philosophical voices in higher education to illuminate how shaming practices in medical education can undermine dignity safety (Callan), preclude inclusivity, and in the context of the hierarchical and marginalizing medical system, propagate epistemic injustice (Fricker).

DISCUSSION

This argument shows how shame in education can be both phenomenologically and normatively problematic and may act differently upon students who experience marginalization and those who are majoritized. I further suggest that a medical education system which upholds the epistemological and relational frameworks of power, shame, and epistemic injustice, underscores those frameworks in the medical system at large, disserving individual patients who are already at risk of suffering epistemic injustice (Carel), and society at large.

CONCLUSION

This analysis of shame in medical education focuses on the highly relational and interpersonal elements of learning to live and work in the medical system, highlighting the need for respect, trust, and resistance to reorient the relational learning environment toward individual and systemic forms of justice.

Physician Men Leaders in Emergency Medicine Bearing Witness to Gender-Based Discrimination

IMPORTANCE

Approximately 60% of women physicians in emergency medicine (EM) experience gender-based discrimination (GBD). Women physicians are also more likely to experience GBD than men physicians, particularly from patients, other physicians, or nursing staff.

OBJECTIVE

To describe the responses of men who are academic department chairs in EM to GBD directed toward a woman colleague.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was a secondary data analysis drawn from interviews of men EM academic department chairs at 18 sites who participated in a qualitative descriptive study between April 2020 and February 2021 on their perceptions of the influence of gender and leadership in academic medicine. Narrative data related to GBD were extracted and coded using conventional content analysis. Codes were clustered into themes and subthemes and summarized. Data were analyzed from November to December 2021.

EXPOSURE

Semistructured interviews conducted via teleconferencing.

MAIN OUTCOMES AND MEASURES

Qualitative findings identifying experiences witnessing or learning about incidents of GBD against women colleagues, the impact of these observations, and personal or leadership actions taken in response to their observations.

RESULTS

All 18 men participants (mean [SD] age, 52.2 [7.5] years; mean [SD] time as a department chair, 7.2 [5.1] years) discussed witnessing or learning about incidents of GBD against women colleagues. The participant narratives revealed 3 themes: emotional responses to GBD, actions they took to address GBD, and reasons for not taking action to address GBD. When witnessing GBD, participants felt anger, disbelief, guilt, and shame. To take action, they served as upstanders, confronted and reported discrimination, provided faculty development on GBD, or enforced "zero-tolerance" policies. At times they did not take action because they did not believe the GBD warranted a response, perceived a power differential or an unsupportive institutional culture, or sought self-preservation.

CONCLUSIONS AND RELEVANCE

In this qualitative study of men physician leaders, we found all participants reported feeling troubled by GBD against women colleagues and, if possible, took action to address the discrimination. At times they did not take action because of unsupportive workplace cultures. These findings suggest that institutional culture change that supports the interventions of upstanders and does not tolerate GBD is needed.

Guilt and Burnout in Medical Students

THEORY

Burnout is prevalent among medical students and is correlated with negative feelings, behaviors, and outcomes. Empathy is a desired trait for medical students that has been correlated with reduced burnout. The concept of guilt is closely related to concern about the well-being of others; therefore, feelings of guilt may be associated with empathy. Excessive guilt poses an increased risk for internalized distress, symptoms such as anhedonia, and may be related to burnout. The relationship between pathogenic guilt and burnout in medical students is unknown.

HYPOTHESIS

We hypothesize that pathogenic guilt is present and related to both burnout and empathy in medical students.

METHODS

We conducted a cross-sectional survey study of all students in one medical school. Data were collected in February 2020. The Oldenburg Burnout Inventory (OBLI), Toronto Empathy Questionnaire (TEQ), and Interpersonal Guilt Questionaire-67 (IGQ-67) were used. A modified version of IGQ-67 was used to measure four subscales of pathogenic guilt: survival guilt, separation guilt, omnipotence guilt, and self-hate guilt. Data analyses for this study including screening, evaluation of assumptions, descriptive statistics, reliabilities, one-way ANOVA, and correlation coefficients, were conducted using SPSS version 26.

RESULTS

Of 300, 168 (56.0%) students participated in the study. Survival, omnipotence, and self-hate classes of pathogenic guilt were positively correlated with burnout. Empathy was correlated with two classes of pathogenic guilt: survival and omnipotence. Empathy was inversely related to burnout (disengagement).

CONCLUSIONS

Pathogenic guilt may be a contributor to burnout in medical students. Guilt should be a target of prevention and treatment in burnout in medical students.

Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1891544.

Living life in limbo: experiences of healthcare professionals during the HCPC fitness to practice investigation process in the UK

BACKGROUND

It is the responsibility of healthcare regulators to ensure healthcare professionals remain fit for practice in healthcare settings. If there are concerns about an individual healthcare professional they may undergo a fitness to practice investigation. This process is known to be hugely stressful for doctors and social workers, but little is known about the impact of this experience on other professions. This study explores the experiences of registrants going through the process of being reported to the UK's Health and Care Professions Council (HCPC) and attending fitness to practice (FTP) hearings. We discuss the implications of this process on registrants' wellbeing and, from our findings, present recommendations based on registrants experiences. In doing so we articulate the structural processes of the HCPC FTP process and the impact this has on individuals.

METHODS

This study uses semi-structured interviews and framework analysis to explore the experiences of 15 registrants who had completed the FTP process. Participants were sampled for maximum variation and were selected to reflect the range of possible processes and outcomes through the FTP process.

RESULTS

The psychological impact of undergoing a FTP process was significant for the majority of participants. Their stories described influences on their wellbeing at both a macro (institutional/organisational) and micro (individual) level. A lack of information, long length of time for the process and poor support avenues were macro factors impacting on the ability of registrants to cope with their experiences (theme 1). These macro factors led to feelings of powerlessness, vulnerability and threat of ruin for many registrants (theme 2). Suggested improvements (theme 3) included better psychological support (e.g. signposting or provision); proportional processes to the incident (e.g. mediation instead of hearings); and taking context into account.

CONCLUSIONS

Findings suggest that improvements to both the structure and conduct of the FTP process are warranted. Implementation of better signposting for support both during and after a FTP process may improve psychological wellbeing. There may also be value in considering alternative ways of organising the FTP process to enable greater consideration of and flexibility for registrants' context and how they are investigated.

Medical Training and Errors: Competence, Culture, Caring, and Character

Medical trainees will inevitably make errors as they learn. Errors should be minimized by a stronger focus on competence through better supervision and increased opportunities for simulation, as well as by reinforcing a culture that supports open identification of errors, disclosing errors to patients and families, and that focuses on prevention through quality improvement. Yet, errors are also opportunities for education and remediation. Medicine's duty of care includes care for those harmed through errors and should also include care for those who have made the error. Errors that cause harm to patients challenge trainees to engage the character traits of honesty, humility, trustworthiness, and compassion and to strengthen the practical wisdom to know when and how to exercise these character traits. The moral core of medicine-care of the patient in circumstances that may be uncertain and imperfect-as well as the duties of honesty, disclosure, repair, and redress may make equanimity (the calmness, composure, and evenness of temper needed in difficult and challenging situations) one of the most important character traits medical educators should identify, nurture, and encourage in trainees.