In the "Shadow of Shame": A Phenomenological Exploration of the Nature of Shame Experiences in Medical Students

From understanding to embracing: A guide on emotions in medical education research: AMEE Guide No. 184

Emotions refer to conscious and subjectively experienced mental reactions that are often associated with physiological and behavioral changes. In the context of medical education research, emotions have a pervasive influence on how various types of information are perceived and processed, and therefore, can influence how research is designed, conducted, and implemented. While there is considerable research on how emotions affect learning, there is little guidance for researchers on how to recognize and potentially leverage emotions while conducting and disseminating medical education research. Emotions can be potentially beneficial for fostering a stronger connection to research, increasing motivation to conduct sensitive research, and enhancing reflexivity and rigor. In this guide, the authors describe how emotions may influence medical education research while assisting researchers on how to recognize and manage emotions during the research process. This guide builds upon existing research to provide a framework for emotional reflexivity in the context of medical education research.

Does Learner Communication Behavior Change Based on Context? Observations of Surgical Residents Across Clinical Rotations

OBJECTIVE

As surgical residency programs begin developing communication skills-specific training curricula, it is important to understand those skills required of surgeons in the many settings in which they work. It is also useful to observe the skills that residents already demonstrate, as well as those skills that need further development. This study evaluated surgical residents' communication behaviors across different services to understand how the clinical learning environment influences their approach to surgeon-patient interactions.

DESIGN AND SETTING

Our communication coaching program used standardized observation and coding to evaluate residents' communication on pediatric surgery, community general surgery, and trauma/acute care surgery services.

PARTICIPANTS

Twenty-four senior residents were observed interacting with patients and families on morning rounds in each of 3 settings.

RESULTS

A total of 373 patient-resident interactions were observed. Behaviors like introducing the team, showing courtesy and respect, and sharing next steps were consistent across settings. However, different patterns emerged when evaluating 15 skills: effective communication behaviors occurred at the highest rates in pediatrics, followed by community surgery, and lowest in trauma. Most communication behaviors varied significantly between settings, underscoring the need to understand effective communication in each context to support learner development accordingly.

CONCLUSIONS

Communication skills varied significantly among the same surgical residents across different settings. The findings highlight the importance of supporting learners in adapting fundamental aspects of effective communication in various clinical environments. Modern surgical training can benefit from increased focus on communication skills across learning environments, using 1:1 communication coaching that emphasizes existing strengths, and tailoring communication skills to particular settings.

Investigating the determinants of perceived shame in young adults with paternal substance use disorder in Pakistan: A phenomenological study

BACKGROUND

Substance use disorder profoundly affects not only the individuals with the condition but also their family members, particularly children. The impact on children can be long-lasting, influencing their development and well-being throughout their lives. The study explored the determinants of perceived shame in young adults with paternal substance use disorder in Pakistan.

METHOD

Eight young adults aged 20-30 with paternal substance use disorder were selected through a purposive sampling technique for this study. A phenomenological research design, with interpretative phenomenological analysis, was used to gain an in-depth and comprehensive perspective. Semi-structured interviews were conducted with the participants.

RESULT

Two master themes with respective two sub-themes along with 40 codes were identified i.e., personal distress (psychological problems and existential crises) and social and relational issues (social problems and interpersonal turmoil).

CONCLUSION

Shame is the dominant factor that young adults with paternal substance use face. The study highlighted that these young adults face many personal, social, and relational issues that intensify their feelings of shame. This study may assist mental health professionals in developing effective strategies to decrease the feeling of shame in young adults affected by paternal substance use disorder.

Unravelling epistemic injustice in medical education: The case of the underperforming learner

CONTEXT

Epistemic injustice refers to a wrong done to someone in their capacity as a knower. While philosophers have detailed the pervasiveness of this issue within healthcare, it is only beginning to be discussed by medical educators. The purpose of this article is to expand the field's understanding of this concept and to demonstrate how it can be used to reframe complex problems in medical education.

METHODS

After outlining the basic features of epistemic injustice, we clarify its intended (and unintended) meaning and detail what is required for a perceived harm to be named an epistemic injustice. Using an example from our own work on introversion in undergraduate medical education, we illustrate what epistemic injustice might look like from the perspectives of both educators and students and show how the concept can reorient our perspective on academic underperformance.

RESULTS

Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes. This can lead to one, or both, forms of epistemic injustice: testimonial and hermeneutical. Our worked example demonstrates how medical educators can be unaware of when and how epistemic injustice is happening, yet the effects on students' well-being and sense of selves can be profound. Thinking about academic underperformance with epistemic injustice in mind can reveal an emphasis within current educational practices on diagnosing learning deficiencies, to the detriment of holistically representing its socially constructed and structural nature.

CONCLUSIONS

This article builds upon recent calls to recognise epistemic injustice in medical education by clarifying its terminology and intended use and providing in-depth application and analysis to a particular case: underperformance and the introverted medical student. Equipped with a more sophisticated understanding of the term, medical educators may be able to re-conceptualise long-standing issues including, but also beyond, underperformance.

Embracing Failure: Nurturing Learning and Well-Being in Anesthesiology and Perioperative Medicine

Failure, ubiquitous in life and medical practice, offers myriad opportunities for learning and growth alongside challenges to overall well-being. In this article, we explore the nature of failure, it's sources and impacts in perioperative medicine, and the specific challenges it brings to trainee well-being. With a deeper understanding of the societal, psychological and cognitive determinants and effects of failure, we propose solutions in order to harness the opportunities inherent in failures to create brave and supportive learning environments conducive to both education and well-being.

Development and Initial Validation of the Shame Frequency Questionnaire in Medical Students

PURPOSE

This study presents the steps taken to develop and collect initial validity evidence for the Shame Frequency Questionnaire in Medical Students.

METHOD

The instrument was based on a 7-step survey design; validity evidence was collected from content, response process, internal structure, and relationship to other variables. A literature review and qualitative interviews led to the design of the initial 16-item scale. Expert review and cognitive interviewing led to minor modifications in the original structure. Initial pilot testing was conducted in August 2019 in Uniformed Services University (USU) medical students; reliability assessment and exploratory factor analysis were performed. The revised 12-item scale was tested in January 2022 in Duke University School of Medicine medical students; reliability assessment, exploratory factor analysis, and correlation analysis with depression, burnout, anxiety, emotional thriving, and emotional well-being were performed.

RESULTS

A total of 336 of 678 USU students (50%) and 106 of 522 Duke students (20%) completed the survey. Initial exploratory factor analysis of the USU data revealed 1 factor (shame), and 4 items were dropped from the scale according to predefined rules. Subsequent exploratory factor analysis of the Duke data revealed 1 factor; no further items were removed according to predefined rules. Internal consistent reliability was 0.95, and all interitem correlations were less than 0.85 for USU and Duke samples. As predicted, mean shame scale scores were positively correlated with anxiety ( r = 0.54, P < .001), burnout ( r = 0.50, P < .001), and depression ( r = 0.47, P < .001) and negatively correlated with emotional thriving ( r = -0.46, P < .001) and emotional recovery ( r = -0.46, P < .001).

CONCLUSIONS

The Shame Frequency Questionnaire in Medical Students is a psychometrically sound instrument with strong internal reliability and multisource validity evidence, supporting its use in studying shame in medical students.

Using framework analysis methods for qualitative research: AMEE Guide No. 164

Framework analysis methods (FAMs) are structured approaches to qualitative data analysis that originally stem from large-scale policy research. A defining feature of FAMs is the development and application of a matrix-based analytical framework. These methods can be used across research paradigms and are thus particularly useful tools in the health professions education (HPE) researcher's toolbox. Despite their utility, FAMs are not frequently used in HPE research. In this AMEE Guide, we provide an overview of FAMs and their applications, situating them within specific qualitative research approaches. We also report the specific characteristics, advantages, and disadvantages of FAMs in relation to other popular qualitative analysis methods. Using a specific type of FAM-i.e. the framework method-we illustrate the stages typically involved in doing data analysis with an FAM. Drawing on Sandelowski and Barroso's continuum of data transformation, we argue that FAMs tend to remain close to raw data and be descriptive or exploratory in nature. However, we also illustrate how FAMs can be harnessed for more interpretive analyses. We propose that FAMs are valuable resources for HPE researchers and demonstrate their utility with specific examples from the HPE literature.

Storylines of Trauma in Health Professions Education: A Critical Metanarrative Review

PHENOMENON

Learners in medical education are often exposed to content and situations that might be experienced as traumatic, which in turn has both professional and personal implications. The purpose of this study was to synthesize the literature on how trauma has been conceptualized and approached within medical education, and the implications thereof.

APPROACH

A metanarrative approach was adopted following the RAMESES guidelines. Searches of 7 databases conducted in January 2022 with no date limitations yielded 7,280 articles, of which 50 were identified for inclusion through purposive and theoretical sampling. An additional 5 articles were added from manual searches of reference lists. Iterative readings, interpretive and reflexive analysis, and research team discussions were performed to identify and refine metanarratives.

FINDINGS

Five metanarratives were identified, including the concept of trauma, the trauma event, the person with trauma, the impact of trauma, and addressing trauma, with each metanarrative encompassing multiple dimensions. A biomedical concept of trauma predominated, with lack of conceptual clarity. Theory was not integrated or developed in the majority of articles reviewed, and context was often ambiguous. Trauma was described in myriad ways among studies. Why certain events were experienced as trauma and the context in which they took place were not well characterized. The impact of trauma was largely concentrated on harmful effects, and manifestations beyond symptoms of post-traumatic stress were often not considered. Furthermore, the dominant focus was on the individual, yet often in a circumscribed way that did not seek to understand the individual experience. In addressing trauma, recommendations were often generic, and earlier research emphasized individually-focused interventions while more recent studies have considered systemic issues.

INSIGHTS

Multiple dimensions of trauma have been discussed in the medical education literature and from many conceptual standpoints, with biomedical, epidemiologic, and individualized perspectives predominating. Greater precision and clarity in defining and understanding trauma is needed to advance research and theory around trauma in medical education and the associated implications for practice. Exploring trauma from intersectional and collective experiences and impacts of trauma and adapting responses to individual needs offers ways to deepen our understanding of how to better support learners impacted by trauma.

Breaking the Silence: A Workshop for Medical Students on Dealing With Failure in Medicine

PROBLEM

Failure is a powerful teacher but an emotionally stressful experience. Before residency, when failure in clinical training is inevitable, medical students should learn to talk about and cope with failure. However, medical school curricula rarely include this topic, and physicians seldom share their mistakes and failures with trainees. This report describes and evaluates a workshop on dealing with failure in medicine.

APPROACH

Two attending surgical consultants and a life coach facilitated the workshop between February 2021 and February 2022, which consisted of different educational approaches, such as presentations, small group discussions, and journal clubs. The sessions aimed to enable medical learners to identify and analyze actual and potential failure events in everyday clinical practice and learn from them, disclose and communicate medical failures and "speak up," reflect on failure and develop coping strategies, and understand the moderating role of fear of failure.

OUTCOMES

Thirty medical students participated in the workshop. Dealing with failure in a productive manner was the medical learners' key learning objective and anticipated takeaway from the workshop. After the workshop, 19 of the 30 participants anonymously completed the standard university evaluation form. The medical students gave the workshop a mean (SD) rating of 8.59 (0.98) on a Likert scale ranging from 1 to 10. They felt better prepared to approach future challenges in a constructive manner after being equipped with strategies to deal with failure. Listening to the failure experiences of faculty and peers in a safe environment helped them accept that failure is inevitable.

NEXT STEPS

The findings suggest that medical students appreciated a safe environment to discuss failure. By promoting a safe learning environment early in the medical career, medical schools could make an important contribution to reducing the stigma of failure and eliminating the shame and blame culture, thus contributing to students' well-being.

Professional identity struggle and ideology: A qualitative study of residents' experiences

INTRODUCTION

To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency.

METHODS

We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings.

RESULTS

We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals.

CONCLUSION

This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

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.

Scoping Review of Restorative Justice in Academics and Medicine: A Powerful Tool for Justice Equity Diversity and Inclusion

Purpose

Restorative Justice (RJ) as a practice and mindset is growing within academic medicine and health care. The authors aim to categorize the extent to which RJ training and practices have been researched, explored, and applied within health care, medicine, and academic contexts.

Methods

In July 2021, the authors conducted a scoping literature review, searching four databases for peer-reviewed articles and book chapters discussing RJ. Authors also used bibliography searches and personal knowledge to add relevant work. Reviewers independently screened article titles and abstracts, assessing the full texts of potentially eligible articles with inclusion and exclusion criteria. From each included article, authors extracted the publication year, first author's country of origin, specific screening criteria met, and the depth with which it discussed RJ.

Results

From 599 articles screened, 39 articles, and books were included (published 2001-2021). Twenty-five (64%) articles discussed RJ theory with few describing application practices with substantial depth. Ten (26%) articles only referenced the term "restorative justice" and seven (18%) discussed legal applications in health care. Fifty-four percent were from outside the United States. Articles tended to describe RJ uses to address harm and often missed the opportunity to explore RJ's capacity to proactively build community and culture that helps prevent harm.

Conclusions

RJ in health care is a rapidly expanding field that offers a framework capable of building stronger communities, authentically preventing and responding to harm, inviting radical inclusion of diverse participants to build shared understanding and culture, and ameliorate some of the most toxic and unproductive hierarchical practices in academics and medicine. Most literature calls to RJ for help to respond to harm, although there are very few well-designed and evaluated implementations. Investment in RJ practices holds significant promise to steer our historically hierarchical, "othering" and imperfect systems to align with values of justice (vs. punishment), equity, diversity, and inclusion.

How Does TIMELESS Training Impact Resident Motivation for Learning, Assessment, and Feedback? Evaluating a Competency-Based Time-Variable Training Pilot

PURPOSE

As competency-based medical education has become the predominant graduate medical education training model, interest in time-variable training has grown. Despite multiple competency-based time-variable training (CBTVT) pilots ongoing in the United States, little is known about how this training approach impacts learners. The authors aim to explore how their CBTVT pilot program impacted resident motivation for learning, assessment, and feedback.

METHOD

The authors performed a qualitative educational case study on the Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS) program at the University of Cincinnati from October 2020 through March 2022. Semistructured interviews were conducted with TIMELESS residents (n = 9) approximately every 6 months to capture experiences over time. The authors used inductive thematic analysis to develop themes and compared their findings with existing theories of learner motivation.

RESULTS

The authors developed 2 themes: TIMELESS had variable effects on residents' motivation for learning and TIMELESS increased resident engagement with and awareness of the program of assessment. Participants reported increased motivation to learn and seek assessment, though some felt a tension between performance (e.g., advancement through the residency program) and growth (e.g., improvement as a physician). Participants became more aware of the quality of assessments they received, in part due to TIMELESS increasing the perceived stakes of assessment, and reported being more deliberate when assessing other residents.

CONCLUSIONS

Resident motivation for learning, assessment, and feedback was impacted in ways that the authors contextualize using current theories of learner motivation (i.e., goal orientation theory and attribution theory). Future research should investigate how interventions, such as coaching, guided learner reflection, or various CBTVT implementation strategies, can help keep learners oriented toward mastery learning rather than toward performance.

Using Trainee Failures to Enhance Learning: A Qualitative Study of Pediatric Hospitalists on Allowing Failure

INTRODUCTION

Attendings allow trainee failure when perceived educational benefits outweigh potential patient harm. This strategy has not been explored in pediatrics, where it may be shaped by unique factors. Our objectives were to understand if, when, and how pediatric hospitalists allow trainees to fail during clinical encounters.

METHODS

Using constructivist grounded theory, we conducted semistructured interviews with 21 pediatric hospitalists from a children's hospital in the United States. Iterative, constant comparative analysis took place concurrent with data collection. During regular team meetings, we refined and grouped codes into larger themes.

RESULTS

Nineteen of the 21 participants shared that they intentionally allowed failure as a teaching strategy, acknowledging this strategy's emotional power and weighing the educational benefits against harms to current and future patients, caregivers, and trainees. Participants described a multistep process for allowing failure: 1) initiate an orientation to signal that they prioritize a psychologically safe learning environment; 2) consider factors which influence their decision to allow failure; and 3) debrief with trainees. However, participants did not explicitly alert trainees to this teaching strategy. They also avoided using the word "failure" during debriefs to protect trainees from psychological harm.

CONCLUSIONS

Most pediatric hospitalists in this study allowed failure for educational purposes. However, they did so cautiously, weighing the educational value of the failure against the safety of both current and future patients, the relationship with the caregivers, and the trainees' well-being. Future research should involve trainees to more comprehensively understand the experience and effectiveness of this teaching strategy.

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.

Trends in medical students' health over 5 years: Does a wellbeing curriculum make a difference?

BACKGROUND

Trends in New Zealand (NZ) medical students' health and the influence of a wellbeing curricula are unknown.

METHODS

The author's collected self-report data from NZ medical students on 'Graduation Day' from 2014 to 2018, using a serial cross-sectional survey design with validated scales assessing psychological health, stigma, coping, and lifestyle. Comparisons were made with NZ general population same-age peers. Analyses examined trends, differences between 'cohorts' of students receiving different exposures to a wellbeing curriculum, and correlations between students' own lifestyle practices and their frequency of talking with patients about those topics.

RESULTS

Of 1,062 students, 886 participated. The authors found statistically significant self-reported increases from 2014 to 2018 for negative psychological indices, including scores for distress and burnout, suicidal thoughts in the preceding year, and the likelihood of being diagnosed with an anxiety disorder. There was a significant increase in numbers of students reporting having their own doctor as well as increased healthy coping strategies and a significant decrease in stigma scores. Academic cohorts of students who had completed a wellbeing curriculum were more likely to report high distress levels, having been diagnosed with a mood disorder, and being non-drinkers than students without wellbeing training. When compared to NZ peers, medical students smoked less, exercised more, and were less likely to have diagnosed mood and anxiety disorders, but reported more distress. The authors found a significant correlation between the amount of exercise students undertook and their likelihood to discuss exercise with patients.

CONCLUSIONS

NZ medical students have better physical health than general population peers and are more likely to discuss exercise with patients if exercising themselves. However, cohorts of graduating students report increasing distress despite the implementation of a wellbeing curriculum. Research is needed into mechanisms between students' self-awareness, willingness to report distress, stigma, mind-set, coping, and psychological outcomes, to inform curriculum developers.

A Framework for Antiracist Curriculum Changes in Nephrology Education

Addressing persistent racial health disparities in cases of kidney disease will first require significant investment in examining how structural racism has influenced our clinical practice and medical education. Improving how we understand and articulate race is critical for achieving this goal. This work begins with ensuring that race's mention within nephrology literature and curricular materials for medical trainees is thoroughly rooted in evidence-based rationale-not to serve as a proxy for polygenic contributions, social determinants of health, or systemic health care barriers. While many institutions are increasingly recognizing the importance of instituting such changes on behalf of the systematically marginalized patient populations who are most affected by these disparities, there is a paucity of guidance on how to critically appraise and revise decades of pathophysiological and epidemiological findings through an antiracist lens. In this article, we propose an inquiry-based framework with case-study examples to help readers recognize improper use of race within nephrology, assess personal and institutional readiness to introduce changes to said content, and generate materials that center evidence-based findings and reject harmful misinterpretations of race.

Disruption and Dissonance: Exploring Constructive Tensions Within Research in Medical Education

The academic medicine community has experienced an unprecedented level of disruption in recent years. In this context, the authors consider how the disruptions have impacted the state of research in medical education (RIME). The articles in this year's RIME supplement reflect several constructive tensions that provide insight on future for the field. In this commentary, the authors discuss themes and propose a framework for the future. Recommendations include: normalizing help seeking during times of disruption and uncertainty, contextualizing the application of complex approaches to assessment, advancing and problematizing innovation, and recognizing the deeply embedded and systemic nature of inequities.