#KeyLIMEPodcast 212: We Should be Ashamed.

The KeyLIME hosts get serious and explore the topic of shame among residents. The study in this week’s paper explores the experiences, contributing factors and effects of shame among 12 medical residents. If you’re curious about the  manifestations of shame or are struggling with personal shame related to your professional training, you won’t want to miss this one – listen in here.


KeyLIME Session 212

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Bynum et al,. Sentinel Emotional Events: The Nature, Triggers, and Effects of Shame Experiences in Medical Residents Acad Med. 2019;94:85–93.


Jon Sherbino (@sherbino)


I don’t have anything funny or pithy to say on this topic.  (I guess it’s a judgement call if my previous episodes are either funny or pithy.)  This paper was flagged for me by an uproar on Twitter. The attention, conversation and endorsement of the experience of shame in #meded reminds me that the good ol’ days perhaps weren’t that good.  Equally worrisome, is that the current days may actually be structured in a way that is harmful to the psychological wellbeing of health professions trainees.

The crowdsourcing of this paper allows us to overrule our (informal) principle of not reviewing our own papers.  So, in this case, Lara, you get to bend the rules.

If you are curious about the manifestations of shame or are struggling with personal shame related to your professional training, read on.  You may gain insights that are helpful to you.  For a broader discussion of shame, I would direct you to Brene Brown.  Her books have been particularly enlightening for me.


“This study explores an under-investigated topic, how medical residents experience shame within clinical learning environments, by asking residents to reflect on (1) the nature of their shame experiences; (2) the events that triggered, and factors that contributed to, those shame experiences; and (3) the perceived effects of those shame experiences.”

Key Points on the Methods

Different from guilt (which is related to a specific, changeable behaviour) shame is described as: “when an individual engages in self-evaluation in response to a negative event, such as a perceived transgression or failure to reach an expectation. Shamed individuals attribute a triggering event to something global and unchanging about themselves, such as their intellect or overall capability, and fail to distinguish the self from the behavior. Thus, shame is associated with negative evaluations about the entire self, and the shamed individual struggles with feeling defective, deficient, unworthy, and/or damaged.”

Internal medicine residents from a single teaching hospital in the USA were voluntarily recruited. A written reflective exercise (‘write about a specific situation during your medical training that caused you to feel deficient, flawed, and/or unworthy”) was followed by a semi-structured interview.  Post interview same day or routine referral for counselling was offered.

A hermeneutic phenomenology approach was used.  Phenomenology typically describes in deep, rich detail the lived experience.  Hermeneutic (from the Greek ‘translate’) provides an exegesis (I couldn’t resist I’m a preachers kid) or interpretation of meaning.  So, hermeneutic phenomenology moves from description to interpretation or explanation.  Assumed and addressed within this approach is the influence of the researcher’s own shame experiences.

A process of immersion and understanding of the text led to abstraction and synthesis of themes to illuminate and integrate key findings.

Key Outcomes

Three women and nine men, average age 32, distributed from PGY1 to 3 participated.

Shame reactions  included:

  • Physical (sympathomimetic response)
  • Emotional (‘feeling betrayed’)

Shame reactions could last minutes to months.  Less intense shame reactions could coalesce into larger responses if experienced in an additive way (frequency, close in time etc.)

Triggers were often specific events related to:

  • Patient care (medical errors)
  • Learning (harsh treatment from a supervisor)
  • Failing to achieve a personal goal (not being selected for an academic position)

Triggers were potentiated by:

  • Comparing oneself to others
  • Failure to achieve a high level of performance
  • Perfectionism
  • Fear of judgement
  • Skewed frames of personal reference
  • Influence (positive or negative) of a supervisor

Shame resulted in:

  • Social isolation
  • Disengagement from learning
  • Burnout and depression
  • Unprofessional behaviour
  • Impaired empathy
  • . counter intuitively,
    • Resilience
    • Desire to help others
    • Increased learning

Key Conclusions

The authors conclude…

“Shame reactions can be sentinel emotional events with significant physical and/or psychological effects in medical learners.” 

“By revealing our experiences with shame in medical education, we may begin to overcome the taboo and stigmatized nature of the emotion and confront it in a way that builds connection, community, and healing.”

Spare Keys – other take home points for clinician educators

Shout out to Duke School of Medicine for tackling big issues relevant to #wellnes in #meded.  Check out the WISER (Web-based Implementation for the Science of Enhanced Resilience) resources.

Access KeyLIME podcast archives here