Shame in Medical Practice

by Michael Cussen

“ I remember going into the post office on benefit day and I felt everyone was looking at me”. J.K.Rowling.

The above is a quote from J.K.Rowling, the author of the Harry Potter books, and now reputed to be richer then the Queen of England. Here she is talking about the shame of having to collect her 70 pounds a week dole money and it’s the words “ everyone was looking at me’ that catches the essence of what shame is about. Because it is the eyes that have the power to see and expose and there is often a focus on the eyes of the other as the source of shame.

Shame is a universal human phenomenon and everyone has experienced the feeling of those eyes looking at you. Probably the most intense feelings of shame are experienced in childhood. When I was in primary school in 1960’s Ireland the dean of the school decided to introduce a school uniform. The cost of this uniform was incredibly expensive and you had to buy all the gear in a posh Dublin department store. It was one thing after another –cap, socks, ties, pullovers, shirts pants and blazers. My mother was a widow and the cost of all this stuff was causing her immense stress. And so when the dean decided that we also needed these special indoor shoes she decided that she had had enough. She marched me down to the doctor, made him write me a note that said that I had “flat feet’ and that instead of wearing indoor shoes I could dye my Clarkes sandals black and use them.

When I turned up at school in these dyed sandals masquerading as indoor shoes the dean nearly went ballistic. So at that day’s assembly he got me and Mick O’Connor to come up and stand on the stage. Mick O’Connors mother was some sort of fancy hair dresser and so he was well groomed with neat parted hair, his short pants were ironed and he even had garters to hold up his socks. In contrast I had wild unkempt curly hair, egg on my tie, socks down around my ankles, dirty scabby knees, torn elbows on my jumper and of course a pair of Clarkes sandals masquerading as indoor shoes. And then the dean said, “Now which of these boys would you like to represent our school”.

Shame is considered to be one of the self conscious emotions – the others being guilt, embarrassment, humiliation and pride. These emotions share the following characteristics:

-they result from assessments that people make of themselves.

-they appear spontaneously and are experienced as being out of ones control.

-they result from interactions with others or at least thoughts or imagined interactions with others.

-they can cause extreme discomfort.

-we generally go to great lengths to avoid them.

-They explain much of our interpersonal behavior.

In particular shame can be defined as the unpleasant emotion that people experience when they judge that their thoughts, feelings and behaviors are wrong. It is sometimes described as the intense emotional pain that comes when self esteem and sense of belonging are under attack and from an early age it induces a fear of social rejection.

If one were to use the medical model patients might describe symptoms that made them feel exposed, small, powerless, worthless, incompetent, inadequate and a failure. There is a cognitive sense that everybody knows of this failure or inadequacy and that one may even be mocked or taunted for it. In addition the physical signs of shame are blushing, averting ones gaze, hiding ones face and withdrawing from social contact. Most of these activities serve the purpose of hiding and avoiding the eyes of the other. Common expressions are “I feel like hiding under a rug” or even “ I feel like disappearing from the face of the earth”. Think of the parent who says to the child “I am so ashamed of you. Get out of my sight. I never want to see you again”.

Shame is an emotion whose impact stretches along a continuum from the personal at one end to something that can have professional, national and even international implications. At the international level one can think of the many Germans that came of age after the second world war and who have spoken about the shame they felt because of the part their parents generation played in the Holocaust. In Ireland many felt a profound national shame that was centered around the famine –it was as if it was written out of history in favor of the great battles that were fought against the English. Many in the west felt shame that nothing was done to prevent the Rwanda and Serbian massacres. And the humiliation of Iraqis in the Abu Gharib prison was carried out with the deliberate intention of shaming the prisoners, because as the journalist John Ibbitson said in Toronto’s Globe and Mail; “Shame and humiliation, indignity and loss of face – these emotions have a power in the Middle East that is often compared to that of nuclear weapons”.

At the professional level shame in medical practice was described in a BMJ editorial in 2002 as “The Elephant in The Room”. It is something so big and disturbing that we don’t even see it despite the fact that we keep bumping into it. Patients commonly see their diseases as defects, inadequacies or shortcomings. As a result they may see visits to doctors offices and hospitals as involving potentially humiliating physical and psychological exposure. They may respond by withholding information from their physicians and may lie about their symptoms or treatment and may be ashamed over their type of illness. It is responsible for a lot of negative behavior such as aggression, complaining and even suing. Beneath the surfaces of many of our so called “demanding or difficult” patients you will often find instances of shame. Anything that threatens the dignity of the individual can cause shame. The widespread sexual and physical abuse of children that went on in the past should be a cause of great shame in society. Ironically however it is often the adult survivors of this abuse that feel the most shame.

Doctors also experience shame at an early stage and many medical students and residents will avoid teaching experiences because of the fear of being shamed. I recently spoke with a medical resident who told me about a friend of hers who had been called to the emergency room to assess a young man with a headache. She examined him, found everything to be normal and then discharged him. Four hours later the man had a stroke. The family sued. The resident then got in contact with her medical defense insurers and they told her not to talk to anybody. When she tried to speak with her supervisor about the incident he refused to talk to her and also warned her not to talk to anybody else about the case. Of course she had to talk to somebody and so when she spoke to her friend, the resident who was telling me this story, all she could talk about was the shame that she was feeling. If residents and young doctors feel that they are going to be singled out and shamed then something is wrong with a system that treats its younger members in such a fashion.

Older doctors too can feel shamed in medical encounters which can lead to dissatisfaction with clinical practice. Doctors generally see themselves as perfectionists and judge both themselves and their colleagues by very high standards. They feel they should try and know everything, never make mistakes, work very hard and be polite and available at all times. But when something goes wrong they are devastated and research has shown that much of the extreme distress that doctors who are sued feel is attributable to shame rather the to financial losses.

There are many ways in which people respond to shame. The most common are avoidance or hiding, becoming hostile or aggressive and attempting to pursue a quest for perfection or mastery over that which was considered a failure.

Hiding is perhaps the most common response to shame. The shamed person most does this by avoiding the person who shamed him. Lying may be considered a form of hiding and many people will lie when they feel shamed. The most extreme form of hiding is suicide, which is in effect disappearing from the face of the earth- the term “mortified” means being shamed to death.

Perhaps the most bizarre example of lying and its relationship to shame and medicine that I have come across is in the book called “The Adversary” 1. This is the true story of a man called Jean-Claude Romand. He, along with a group of friends, entered medical school in France. At the end of the first year he failed to turn up for the exams. But when the results came out he told his friends that he had passed the exams. They do not post the results in France. Then every year after that he reregistered for first year but took the classes with his friends as they advanced through medical school. He spent as much time and energy pretending to become a doctor as he would have in becoming one in reality.

While they took Intern jobs he pretended to get an intern job in an obscure hospital. Then after that he took an important position at the WHO in Geneva. He married, had two children and drove to work each day. Except he had no work to go to and instead walked in the woods around Geneva or sat in his car reading books and magazines. He told his wife never to phone him at work. For 18 years he played this role and he never told anyone the truth because he said was ashamed of what he had done. He felt his life was a complete lie. He embezzled his parents, his wife’s parents and is mistress. Finally when things started to unravel he killed his parents and set fire to his house killing his wife and children.

Of course shame can be a repressive force and it may mean that people will avoid visiting doctors and other health care professionals for fear of being exposed both physically and psychologically. But on the other hand it is a mark of our humanity because to feel shame is not to be bad or a failure but to know that there is a better side to ourselves to which we aspire. In fact one of the greatest insults is not to accuse a person of being ashamed but to say “you are shameless”- it speaks to ones lack of humanity. In fact many people believe that we as a society are in trouble because we have lost our sense of shame and that there is a lack of leadership in public life of people knowing and doing what is right.

On a personal level people can lessen the effects of shame by developing supportive relationships or by surmounting the apparent deficits. But it appears that the only way to overcome shame is to accept responsibility. And accepting responsibility goes beyond the current fashion for meaningless apologies- started of course by Bill Clintons famous apology when he said that “mistakes were made” and thus took no personal responsibility.

An example of how someone can take responsibility was an article published in the literary magazine Granta called “I gave the names”2. The author was a member of an anti apartheid resistance movement in South Africa. In 1964 he was arrested. He was interrogated by the South African police and under pressure gave up the names of his comrades. As a result 10 of these comrades were tortured and spent up to 19 years in jail while he was let go and moved to England. He came to believe that his behavior was shameful and wrong. His life for the next 20 years was a mess and he went through a series of relationships. In the article he describes how he came to think that the answer to his problems at various times was to change jobs, To take a new name or to just keep on moving from place to place.

However he eventually had a type of epiphany after talking to a friend who was a psychotherapist. And this is what he says; “I learned what was, for me, a simple lesson of immense importance: to take responsibility for what I had done. Not why I had done it, or the circumstances of my doing it, but that I had done it. That I had betrayed my colleagues. Whatever the circumstances I was nonetheless an agent, not a victim. I had chosen, I had acted. I had behaved disgracefully. There are still times when waves of self disgust and shame well up uncontrollably and I feel they will drown me. The sense of hopelessness returns and I want to run and hide. But I have come to believe that there is simply no other way to be: to remember and take responsibility for the past in order to live in the present and contribute to the future”.

Michael Cussen is the 2005 Nova Scotia Family Physician of the year and sits on the Council on Health Care and Promotion of the Canadian Medical Association. He rides a Klein Carbon Fibre road bike and a Gary Fisher mountain bike.

References:

Carrere Emmanuel. (2000) The Adversary: a true story of murder and deception; New York: Bloomsbury.

Leftwich Adrian (2002) ‘I gave the names’. Granta (Issue 78). Bad Company.