| Description |
- Background: Shame is a powerful emotional reaction to a global negative self-evaluation. Prior research has characterized shame’s destructive nature in medical learners and highlighted its potential to catalyze meaningful learning, growth, and identity formation. What is currently unknown, however, is how medical learners respond to a shame experience: the actions, coping strategies, and resources they employ–and how the environment influences this response. Addressing this gap will inform the development of skills, support mechanisms, and environmental conditions that advance learner growth and resilience in the face of shame. In this study, we utilized hermeneutic phenomenology to ask: how do medical learners (i.e., resident physicians and medical students) engage with shame experiences once they have developed, and what factors influence this engagement?
Methods: We employed hermeneutic phenomenology, a qualitative methodology that seeks to convey a rich description of the structures and essences of a lived experience. We utilized data collected during a qualitative research program about shame experiences in residents (n=12) and medical students (n=16). That program employed semi-structured interviews to hermeneutically explore the origins, nature, and impacts of medical learners’ shame experiences; we had not yet examined how they actively engaged with their shame, once present. From the 28 transcripts we previously collected but only partially analyzed, we selected transcripts to achieve a range of levels of training, shame feelings (e.g., acute vs. chronic), individual background factors (e.g., underrepresented vs. majority status), and shame impacts (e.g., constructive vs. destructive). After analyzing 14 transcripts, we possessed significant depth of understanding of the phenomenon and ceased data analysis. We used Ajjawi and Higgs’ six steps of hermeneutic analysis to analyze our data.
Results: Participants’ internal emotional scaffolding—which we conceptualize as comprising one’s identity, self-esteem, and position relative to the world around them (i.e., their self-concept) —was central to their shame engagement and heavily influenced by the surrounding environment. Participants described engaging with shame in complex, nuanced, and highly personal ways. Within these descriptions, we identified two forms of shame engagement: distressing, shame-integrating engagement (SIE) and constructive, shame-disintegrating engagement (SDE). Distressing SIE comprised of actions that drove shame deeper into participants’ sense of self, undermined their self-esteem, and isolated them from others. Constructive SDE comprised actions that helped compartmentalize and detach shame from participants’ sense of self, support broad-based self-esteem, and facilitate connection with others. Supportive environments that exhibited care for learners and their education cultivated more constructive engagement, whereas isolating environmental pressures fostered more distressing engagement.
Conclusions: This study explores the nature of–and processes that shape–medical learners’ engagement with shame. These insights highlight specific ways to address shame’s hidden, stigmatized nature in medical education, including advancing growth mindsets, implementing cognitive restructuring strategies, ensuring accessible support structures, and instilling optimal environmental conditions, including belonging and psychological safety. This study provides a roadmap for development of shame resilience with the goal of creating connected and empathic medical professionals who deliver quality patient care and thrive amidst emotional challenges inherent in medical learning.
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