A high proportion of our doctors are distressed – are shame and Imposter Syndrome contributing?
Shame has been identified as a risk factor for physician suicide, and that is but the tip of the iceberg of the relationship between doctors and shame.
How can we describe the feeling of shame? It is a ubiquitous emotion that makes us so uncomfortable that we will go to great lengths to avoid it, including avoiding acknowledging its existence and its impact on our lives and the lives of those around us. It can lead us to believe that we are flawed in some way, making us feel different from others, unable to fit in, unwanted. Shame makes us feel isolated and vulnerable. (1)
It is a powerful emotion, insidious, pervasive, pernicious, so often unspoken, yet potentially very dangerous. It creates fear of exclusion, fear of loss of safety. As a self-directed emotion, it tells us we are inadequate, unworthy, dishonourable. Unspoken, it stays hidden, driving us to hide or to find ways of not feeling shame – ‘shame avoidance’ – through alcohol or drug use, through isolation, through over-working, through transferring our shame to others by bullying or shaming them, and this in turn can lead to further feelings of shame.
It is self-perpetuating – feeling ashamed of being ashamed or ashamed of the numbing and avoidance behaviours that shame leads to, and ashamed of their consequences.
Shame can impact so heavily on our mental health and even our physical wellbeing that some consider it should be classed as a determinant of health.
The degree of shame covers a spectrum from mild to very severe, debilitating and even incapacitating. All of us will feel a degree of shame at some point in our lives. Indeed, some consider it a natural part of a child’s learning, learning to tell right from wrong. Self-observation that is prompted by shame, and felt as regret, provides an opportunity to learn, change, or do something differently the next time around. Shame in this context may not be so damaging but chronic shame may become toxic and very harmful, both to mental and physical health.
Shame is often confused with guilt – an emotion we might experience as a result of a wrongdoing or mistake about which we might feel remorseful and wish to make amends. Where we will likely have an urge to admit guilt, or talk with others about a situation that left us with guilty feelings, it is much less likely that we will share our shame. In fact, we’ll most likely conceal what we feel, because shame does not make a distinction between an action and the self. With guilt, we identify a “bad” behaviour that is separate from us, but with shame, we feel like a “bad” person.
How does this pertain to Medicine?
Unfortunately, although it is becoming more aware of its limitations, the culture of Medicine remains tough. Shaming has been in the past an unfortunate and integral part of medical training, yet as Professor Deborah Bowman (2) points out:
“shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health.”
It creates chronic anxiety in students striving to compete, to succeed and to avoid being publically shamed. This does not necessarily improve once they are qualified. Shame holds us back from seeking support when we need support, it isolates us, it threatens our sense of self-worth and our very sense of self. In the case of mental health, it contributes to doctors leaving untreated their own illness which may desperately need treatment. Leaving unloved and unsupported a self that deserves love and support.
The very characteristics that we value in a caring physician are those which may lead to the development of shame when things do not go as planned. People drawn into Medicine as a career tend to be compassionate and sensitive to others, but also highly intelligent, very high achievers, perfectionists, competitive and driven. Then there is the fact that Medicine is an inexact science – human bodies do not always work in prescribed ways, do not seem to have read medical text books, do not always behave as they are supposed to. Medical environments are at times hectic, highly technical, highly pressurised and highly emotional. Add to this that today’s Medicine, at least in the public sector, demands the physician works too quickly, leaving little room for rest or reflection, and thus more likely to make mistakes.
The consequences of things not going to plan may be severe. What does that do to a doctor who cares deeply and who demands self-perfection, when their greatest fear is met?
As in the general community, shame has many sources: personal illness, relationship breakdowns, substance abuse, financial worries – it is as common in physicians as in the rest of the population. Medicine brings more – failure to pass exams, to be accepted into training programs, to keep up heavy work-loads, to be unwell and need others to cover, to cope with the human pain and losses witnessed. Worse still is when something goes wrong and we feel we are to blame. That is a lonely and isolating place to be. Being struck off the register, being sued or being publically shamed is every doctor’s nightmare and brings with it intolerable shame.
Doctors who experience mental illness in any form often feel ashamed and marginalised, having a not unjustified sense that their colleagues feel mental illness in doctors is a weakness, that as the doctor they cannot themselves be sick, that as the healer they themselves cannot need healing, that doctors should always be strong.
Professor Michael Myers (3), a psychiatrist who has spent his working life caring for the health of physicians, believes:
“If you’re a physician, fallen low with a mental illness, you can struggle with a lot of shame. If we expect broken physicians to forgive themselves as part of their recovery, we will have to change the culture of medicine. Judge less, forgive more.”
We know that the incidence of suicide amongst female doctors is higher than that of the general population, and higher than that of men in Medicine. It is a tragedy to be losing even one of our beautiful young doctors and it is imperative that we find compassionate solutions. Is it possible that a chronic sense of the shame of not being good enough is contributing towards this?
You could ask: why should such successful high achieving women feel such a degree of shame? One answer could lie in the so called “Imposter Phenomenon”. First described in 1985 by Dr Pauline Clance (4), it is a concept that describes:
“very high achieving individuals who are marked by an inability to internalize their accomplishments and a persistent fear of being exposed as a fraud.”
Perfectionism is a risk factor and women doctors are thought to be particularly at risk. Contributing to this could be those same personality traits that define the “good” doctor and the pressure of competing in a male dominated domain, which has been slow to change, despite the rising numbers of women graduating from medical school.
Consider the student who enters medical school after stellar achievements in high school, always topping the class, often excelling in many other fields in sports and the arts, an already established pattern of a need to be seen as excellent. Entering medical school, they meet dozens of other students each of whom has had the same experience, has the same need to achieve and the pressure is on.
Medical school is a highly competitive environment requiring absolute dedication and the ability to maintain a demanding or punishing study schedule which causes significant and lasting anxiety. (5)
While this is imposed by our medical schools on the students, it is also imposed by the students on themselves. Students and their families have often made financial and personal sacrifices to study Medicine and much is expected of them. This can lead to an intolerable level of self-doubt and anxiety, anxiety about failure, anxiety about making mistakes, anxiety about being shamed, anxiety about shame and simply anxiety about anxiety, all while working in highly demanding roles.
A recent study of American medical students (6) found that around half the women and just under a quarter of the men suffered from Impostor Syndrome, which is characterised by chronic feelings of self-doubt and fear of being discovered as an intellectual fraud. Far from improving as the students progressed from year to year, their symptoms actually got worse. The study also found that there was a negative impact on the students’ mental health demonstrated in a strong correlation between Impostor Syndrome and some of the components of burnout (7) such as emotional and physical exhaustion, cynicism and depersonalisation.
Poor outcomes happen in Medicine and when confronted by errors or results for which they may or may not have been responsible, clinicians may doubt themselves and feel guilty and ashamed. A doctor with a strong sense of their own capabilities can be supported to work through these emotions. A doctor already plagued by self-doubt, who already assesses themselves in some way as flawed, and for whom the outcome confirms this, will be less able to accept feedback on how to cope with such emotions, as the feedback does not fit in with their internal view of themselves. This self-blame may further perpetuate shame. The authors of an article on Imposter Syndrome (8) note that the medical profession
“neither sufficiently prepares physicians to grapple with mistakes nor adequately supports them to share their insecurities”.
It feels, somehow, that although the term ‘Imposter Syndrome’ sounds derogatory, it is something many of us can identify with to a greater or lesser extent, and perhaps even laugh about. As a young doctor, I frequently had dreams where I had to re-sit that dreaded physics exam I needed high grades in to enter medical school. When I passed my post-graduate exams I thought they had made a horrible mistake and that another letter would be arriving.
At the severe end of the spectrum, Imposter Syndrome is no joke, but rather a chronic form of self-doubt that leads to chronic anxiety and shame. To counteract this the doctor is driven to work harder, be more thorough, to constantly endeavour to cover their bases. It drives them to avoid taking on more senior positions of which they would be very capable and to choose the least threatening of career paths. Could it be that at the most extreme end of the spectrum, this could also lead to suicidality?
We need to develop a deeper understanding of the psychology behind burnout and depression in our physicians. We need to be able to identify students and young doctors at risk of developing Imposter Syndrome, chronic self-doubt and shame, and fully support them to access the care they need. It is time for us to be more compassionate towards one another and more compassionate towards ourselves. In caring for others, we need first to deeply care for ourselves. In healing others, we too may need healing. It starts with self-love, self-compassion, with challenging the need to be perfect or superhuman. It starts with being kind to ourselves, developing a deeper understanding of ourselves. It starts with honouring and respecting one another and reaching out when we become aware all is not well.
Feeling we need to hide our shame, fears and misgivings only buries them deeper, perpetuating our problems. We need to work towards creating a medical workforce which allows us to express vulnerability in order to develop our true strength.