All participants vividly remembered shame experiences across a range of clinical contexts, including rounds, clinical skills, patient visits, and assistance during surgeries and had rarely, if ever, shared these stories. As participants heard others’ examples of shame experiences, they disclosed their own narratives, expressing relief that such occurrences were common, and not a sign of personal inadequacy.
Manifestations of shame
Students described shame as a threatened sense of self, characterized by perceptions of being fundamentally flawed, inadequate, unworthy, or deficient as a person. One participant said: “You often feel like dirt under someone’s shoe” (G3/P3).
The students highlighted a range of negative emotions associated with shame and embarrassment, including feeling angry, confused, desperate, frustrated, humiliated, insecure, intimidated, nervous, or sad. Shame reactions involved physical manifestations, such as moist hands, flushing face, pounding heart, queasy stomach, sweating, trembling voice, crying, or fainting. The somatic and emotional manifestations of shame were accompanied by negative cognitions. “Every time I experience something (shameful), it goes on in my head forever” (G1/P3).
Social interactions contributing to shame reactions
The social situations that elicited shame fell into three main categories: clinician behaviour, suboptimal supervision, and disturbing interactions with patients and families.
Clinician behaviour
The participants described being newcomers in the clinical environments where they encountered personnel who were unprepared for, or hostile to, the presence of medical students, and whose avoidant or dismissive behaviour triggered shame when the students felt unacknowledged: “There were constantly little hints that you’re insignificant, that you’re in the way and they don’t want you to be there” (G1/P3).
Clinicians’ shame-inducing social behaviour consisted of breaches of social norms for respectful conduct, e.g., not acknowledging students’ presence, not making eye contact, not using their names or not shaking hands when meeting for the first time. Interactions that caused shame could be transient or more long-lasting and involve clinicians in larger groups, e.g., rounds. One student entered a physicians’ office at the start of a two-week hospital rotation:
I said, “Hi I’m a medical student.” This doctor turned around and looked at me and said “Congratulations!” Then he continued working. My heart was in my head, it was pounding, I was sweaty, and I thought “Sorry for existing”. (G2/P4)
Students felt devalued when doctors did not show up for teaching, were unaware that students were supposed to be with them at specified times, or avoided interactions all together. A female student who had identified her mentor, but not been greeted or acknowledged by him, shared the following experience:
He opened the door to this room, and it was a restroom. I was standing outside waiting for him to finish his business and he didn’t even bother to tell me that he was going to the restroom. I said, “fuck this, I’m going home.” I was like I have to go back tomorrow, and this is shameful. (G2/P4)
Students felt powerless and unable to voice protest regarding such shame experiences. The hierarchy of the clinic was frequently mentioned as a barrier to resistance.
A common theme in the groups was the shame caused by not being greeted:
If you haven’t said hi to the doctor and you haven’t said hi to the patient, then you are no one. You’re just a student, or a guy in a white coat. (G3/P2)
Students were often not addressed as a person, but as a generic “student”. They described this as a source of embarrassment, especially when patients were involved. “Can the student leave the room” (G1/P2).
Suboptimal supervision
The need to learn could become a source of bewilderment and shame when students were criticized or humiliated for lacking medical knowledge, for being inexperienced, or for being of little use in patient treatment.
Criticism without pedagogic support caused shame and loss of confidence: “She commented on my performance in a very negative manner. I rarely feel ashamed or embarrassed, but I felt more and more insecure after that” (G3/P4).
Disturbing interactions with patients and families
Meeting patients was not a source of shame, but the student-clinician-patient triad was consistently mentioned as a potentially shame-inducing configuration. Shame arose in students who witnessed unethical behaviour and felt they were unable to protest or protect the patient. In other examples, shame resulted from being linked with impolite or abusive clinicians:
I was in the emergency with this man with a mental disability. The doctor came to drain his abscess, he didn’t speak to me, he didn’t say hello, and didn’t speak to the patient. He just started to use the syringe, the patient was very afraid and was trying to get away from the doctor. I felt so ashamed about being associated with the doctor. (G1/P3)
Often shame emerged when supervisors involved students in patient interactions without providing introductions to the people who were present:
We walked into the room and they knew the doctor, but they didn’t know me. I hoped the family didn’t think “who is she, why is she here when our father has died”. I wished I had my Harry Potter invisibility coat. (G2/P3)
Effects of shame on learning and professional development
Shame experiences had immediate or prolonged consequences that could impact negatively on students’ learning, career choice, or professional identity formation. Such effects included inability to focus on the task at hand, loss of motivation to learn or to practice, reluctance to request assistance, avoidance of certain situations or medical specialties, and loss of confidence in one’s ability to learn. Participants saw shaming as unhelpful for learning: “It’s interesting, does shame make us better, or does it just kind of weigh us down? It made me practice more, but I still felt kind of useless” (G3/P4).
Inability to focus on learning
Feelings of shame and attempts to defend against shame filled students’ awareness and made learning virtually impossible. “In other situations when I feel shame I become really stressed and my mind is constantly trying to defend myself from feeling like nothing and then I’m not able to learn” (G1/P3).
Loss of motivation
As a result of shaming experiences, students stated that they “stopped engaging, listening and asking questions”. In the following event, students are trying to understand the function of auscultation versus ultrasound in clinical assessment:
We said, “so what you’re saying is look at the whole picture and see all the pieces of the puzzle and see the whole patient”. And he said “no, no, you should just know what you’re doing”. He basically just said a big fuck you to all of us. For the rest of the hour, we did not ask any questions and we were just annoyed. (G3/P2)
Impact on career choice
Memories of a shameful interaction with a particular physician could deter students from pursuing a medical specialty. “I think he was an internal medicine doctor and now he’s a geriatrician and I still take a mental two steps back every time I think about geriatrics and internal medicine” (G1/P2).
Loss of confidence
Participants saw confidence as crucial for workplace learning to occur and reported that shame experiences typically impacted their ability to take initiative, to try things for the first time, and interact with patients in their role as medical student.
My professionalism and my ability to be a good med student and a good doctor are connected to confidence. This whole process gets thrown off if someone comes in and shakes that little confidence that you have. It’s much harder to launch yourself into something new if you don’t know if anyone is there to catch you. (G3/P4)
Influence on professional identity formation
Shame and loss of confidence threatened students’ integrity and professional identity development. The participants identified the medical hierarchy, and the need to belong and be like others in one’s social group, as potent mechanisms for change:
Should I respect my personality, who I want to be, or should I respect the hierarchy? And sometimes the struggle takes so much time and I miss the opportunity to be that good person I think I am. (G1/P3)