Professional identity struggle and ideology: A qualitative study of residents' experiences.

INTRODUCTION: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION: This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Why impaired wellness may be inevitable in medicine, and why that may not be a bad thing.

CONTEXT: A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue-and data suggest-that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve. METHODS: In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a 'disease-focused' approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired. DISCUSSION: Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent-and potentially unavoidable-risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine.

'I'm unworthy of being in this space': The origins of shame in medical students.

OBJECTIVES: Shame results from a negative global self-evaluation and can have devastating effects. Shame research has focused primarily on graduate medical education, yet medical students are also susceptible to its occurrence and negative effects. This study explores the development of shame in medical students by asking: how does shame originate in medical students? and what events trigger and factors influence the development of shame in medical students? METHODS: The study was conducted using hermeneutic phenomenology, which seeks to describe a phenomenon, convey its meaning and examine the contextual factors that influence it. Data were collected via a written reflection, semi-structured interview and debriefing session. It was analysed in accordance with Ajjawi and Higgs' six steps of hermeneutic analysis: immersion, understanding, abstraction, synthesis, illumination and integration. RESULTS: Data analysis yielded structural elements of students' shame experiences that were conceptualised through the metaphor of fire. Shame triggers were the specific events that sparked shame reactions, including interpersonal interactions (eg, receiving mistreatment) and learning (eg, low test scores). Shame promoters were the factors and characteristics that fuelled shame reactions, including those related to the individual (eg, underrepresentation), environment (eg, institutional expectations) and person-environment interaction (eg, comparisons to others). The authors present three illustrative narratives to depict how these elements can interact to lead to shame in medical students. CONCLUSIONS: This qualitative examination of shame in medical students reveals complex, deep-seated aspects of medical students' emotional reactions as they navigate the learning environment. The authors posit that medical training environments may be combustible, or possessing inherent risk, for shame. Educators, leaders and institutions can mitigate this risk and contain damaging shame reactions by (a) instilling a true sense of belonging and inclusivity in medical learning environments, (b) facilitating growth mindsets in medical trainees and (c) eliminating intentional shaming in medical education.

Shame, guilt, and the medical learner: ignored connections and why we should care.

CONTEXT: Shame and guilt are subjective emotional responses that occur in response to negative events such as the making of mistakes or an experience of mistreatment, and have been studied extensively in the field of psychology. Despite their potentially damaging effects and ubiquitous presence in everyday life, very little has been written about the impact of shame and guilt in medical education. METHODS: The authors reference the psychology literature to define shame and guilt and then focus on one area in medical education in which they manifest: the response of the learner and teacher to medical errors. Evidence is provided from the psychology literature to show associations between shame and negative coping mechanisms, decreased empathy and impaired self-forgiveness following a transgression. The authors link this evidence to existing findings in the medical literature that may be related to unrecognised shame and guilt, and propose novel ways of thinking about a learner's ability to cope, remain empathetic and forgive him or herself following an error. RESULTS: The authors combine the discussion of shame, guilt and learner error with findings from the medical education literature and outline three specific ways in which teachers might lead learners to a shame-free response to errors: by acknowledging the presence of shame and guilt in the learner; by avoiding humiliation, and by leveraging effective feedback. CONCLUSIONS: The authors conclude with recommendations for research on shame and guilt and their influence on the experience of the medical learner. This critical research plus enhanced recognition of shame and guilt will allow teachers and institutions to further cultivate the engaged, empathetic and shame-resilient learners they strive to create.

Development and Initial Validation of the Shame Frequency Questionnaire in Medical Students.

PURPOSE: This study presents the steps taken to develop and collect initial validity evidence for the Shame Frequency Questionnaire in Medical Students. METHOD: The instrument was based on a 7-step survey design; validity evidence was collected from content, response process, internal structure, and relationship to other variables. A literature review and qualitative interviews led to the design of the initial 16-item scale. Expert review and cognitive interviewing led to minor modifications in the original structure. Initial pilot testing was conducted in August 2019 in Uniformed Services University (USU) medical students; reliability assessment and exploratory factor analysis were performed. The revised 12-item scale was tested in January 2022 in Duke University School of Medicine medical students; reliability assessment, exploratory factor analysis, and correlation analysis with depression, burnout, anxiety, emotional thriving, and emotional well-being were performed. RESULTS: A total of 336 of 678 USU students (50%) and 106 of 522 Duke students (20%) completed the survey. Initial exploratory factor analysis of the USU data revealed 1 factor (shame), and 4 items were dropped from the scale according to predefined rules. Subsequent exploratory factor analysis of the Duke data revealed 1 factor; no further items were removed according to predefined rules. Internal consistent reliability was 0.95, and all interitem correlations were less than 0.85 for USU and Duke samples. As predicted, mean shame scale scores were positively correlated with anxiety ( r = 0.54, P < .001), burnout ( r = 0.50, P < .001), and depression ( r = 0.47, P < .001) and negatively correlated with emotional thriving ( r = -0.46, P < .001) and emotional recovery ( r = -0.46, P < .001). CONCLUSIONS: The Shame Frequency Questionnaire in Medical Students is a psychometrically sound instrument with strong internal reliability and multisource validity evidence, supporting its use in studying shame in medical students.

Shame at the Gates of Medicine: A Hermeneutic Exploration of Premedical Students' Experiences of Shame.

PURPOSE: Little is known about the nature of shame in students attempting to enter medical school, despite its potential to impact well-being and professional identity formation during training. In this study, the authors used hermeneutic phenomenology to ask: How do premedical students experience shame as they apply to medical school? METHOD: From September 2020 to March 2021, the authors recruited 12 students from a U.S. Master of Biomedical Sciences program who intended to apply to medical school. Data collection consisted of each participant creating a "rich picture" depicting a shame experience during their premedical training, a semistructured interview that deeply explored this and other shame experiences, and a debriefing session. Data were analyzed using Ajjawi and Higgs's 6 steps of hermeneutic analysis. RESULTS: Self-concept, composed of an individual's identities and contingencies of self-esteem, was central to participants' shame experiences. Through a confluence of past and future self-concepts and under the influence of external factors and the weight of expectations, shame often destabilized participants' present self-concepts. This destabilization occurred because of events related to application processes (repeat Medical College Admission Test attempts), interpersonal interactions (prehealth advisor meetings), and objective performance measures (grades, test scores). Participants' efforts to restabilize their self-concept catalyzed specific identity processes and self-concept formation. CONCLUSIONS: Shame provided a window into the emotional experiences, identity processes, and ideologies that shape students' attempts to enter medical school. The authors discuss the central role of contingencies of self-esteem, the potential origins of performance-based self-esteem in trainees, and the identity negotiation and identity work involved in shame reactions. They call for the adoption of contingencies of self-esteem within current conceptualizations of professional identity formation; training for faculty and prehealth advisors about the nature of shame in premedical learners; and consideration of the consequential validity of standardized tests, which may trigger damaging shame.

Development of a Community Hospital Medicine Affiliated Inpatient Rotation for Family Medicine Residents-A Collaborative Success.

Background: Hospitalists perform key roles as inpatient educators for family medicine residents. For the past decade, Duke University Family Medicine Residency Program had its inpatient family medicine resident rotation at non-Duke facilities. Objective: The authors describe the steps taken in 2020 to develop an inpatient Duke family medicine rotation at a North Carolina community hospital, Duke Regional Hospital, and provide outcomes data. Methods: Duke Family Medicine Residency and Duke Regional Hospital Medicine collaborated in addressing key issues to develop an inpatient rotation for family medicine residents. Performance metrics of patients cared for by both the family medicine inpatient resident team and internal medicine teams were compared. Resident satisfaction survey results were reviewed. Results: Retrospective cohort evaluation comparing the two inpatient services (internal medicine and family medicine) revealed the family medicine resident inpatient service performed comparatively in length of stay and 30-day readmission rates. Resident evaluation surveys of the family medicine inpatient rotation showed overall satisfaction with learning objectives. Conclusions: This new family medicine inpatient rotation has benefitted all parties. Key quality performance metrics such as LOS and readmissions are comparable to internal medicine, hospitalists have more teaching opportunities, and Duke family medicine has its residents training in a Duke-affiliated community hospital for their core inpatient rotation.

Perfectionism, Power, and Process: What We Must Address to Dismantle Mental Health Stigma in Medical Education.

In this commentary, the authors draw on 2 personal accounts of mental illness published by Kirk J. Brower, MD, and Darrell G. Kirch, MD, in this issue to consider how and why mental health stigma is maintained in medical education. In particular, they explore how perfectionism, power differentials, and structural forces drive mental illness stigma in medical education. They argue that mental health stigma in medical education, while deeply embedded in the physician archetype and medical culture, is not inevitable and that dismantling it will require individual courage, interpersonal acceptance, and institutional action.

In the "Shadow of Shame": A Phenomenological Exploration of the Nature of Shame Experiences in Medical Students.

PURPOSE: Shame occurs when an individual blames a globally flawed self for a negative outcome. Much of the focus on shame in medical education has been directed toward graduate medical education with less recognition paid to shame occurring in medical school. In particular, while research has explored the triggers of medical students' shame, little is known about what shame feels like, what it makes an individual want to do, and what perceived effects it causes. Thus, this study asks: After shame has been triggered in medical students, how is it experienced? METHOD: The authors selected hermeneutic phenomenology to provide a rich description of the structures and meaning of medical students' lived experiences of shame. Sixteen medical students from a private medical school in the United States were recruited for the study. Data were collected using one-on-one semistructured interviews and analyzed in accordance with Ajjawi and Higgs' 6 steps of hermeneutic analysis. RESULTS: Data analysis yielded component parts of participants' shame experiences, including affective feelings, physical manifestations, cognitive processes, action tendencies, and effects. Analysis of the relationships among these component parts yielded specific phenomenological structures, including patterns of shame (e.g., chronic shame, flashbacks), self-evaluative processes (e.g., battling voices, skewed frames of reference), and perceived effects of shame (e.g., isolation, psychological distress). An overarching theme of shame as a destabilizing emotion emerged across the dataset. CONCLUSIONS: Shame is a complex emotion in medical students that, through its destabilizing effects, can lead to withdrawal, isolation, psychological distress, altered professional identity formation, and identity dissonance. The authors highlight the possibility that shame may be occurring as a response to educational trauma, present a metaphor of dominoes to conceptualize the destabilizing nature of shame, and outline the implications for individuals and institutions in medical education.

Mutual Rewards: Engaging the Field and Creating a Path Toward Academic Journal Editorship.

In this commentary, the inaugural cohort of Academic Medicine assistant editors shares their experiences in this role and the value of creating a path toward academic journal editorship for early- and mid-career scholars. They are a group with diverse backgrounds and a common commitment to advance scholarship in medical education. They collectively describe how they have contributed to the journal in multiple ways, reflect on how they navigated onboarding challenges in the midst of a pandemic, and, most important, share why this role matters for the medical education scholarship community. They express how the assistant editor role has been mutually rewarding, allowing the assistant editors to gain entry to academic journal editorship while also serving the journal and its community.

The Psychology of Shame: A Resilience Seminar for Medical Students.

Introduction: Shame is a powerful emotion that can cause emotional distress, impaired empathy, social isolation, and unprofessional behavior in medical learners. However, interventions to help learners constructively engage with shame are rare. This module educated medical students about shame, guided them through an exploration of their shame experiences, and facilitated development of shame resilience. Methods: In this 2-hour workshop, clinical-year medical students were guided through the psychology of shame through didactic slides. Next, a small panel of volunteer students, recruited and coached prior to the workshop, shared reflections on the content, including their shame experiences during medical school. This was followed by didactic slides outlining strategies to promote shame resilience. Participants then broke into faculty-led small groups to discuss session content. The module included a small-group facilitator guide for leading discussions on shame, didactic slides, discussion prompts, an evaluation tool, and a film entitled The Shame Conversation that was created after the initial workshop. Results: A retrospective pre/postsurvey revealed statistically significant increases in: (1) importance ascribed to identifying shame in one's self or colleagues, (2) confidence in one's ability to recover from a shame reaction, and (3) comfort in reaching out to others when shame occurs. Analysis of open-ended questions showed that students felt the seminar would enhance future resilience by helping them identify and normalize shame, distinguish shame from guilt, and reach out to others for help. Discussion: This workshop appears to prepare students to more constructively engage with shame when it occurs in medical training.

When will I get my paper back? A replication study of publication timelines for health professions education research.

INTRODUCTION: Biomedical researchers have lamented the lengthy timelines from manuscript submission to publication and highlighted potential detrimental effects on scientific progress and scientists' careers. In 2015, Himmelstein identified the mean time from manuscript submission to acceptance in biomedicine as approximately 100 days. The length of publication timelines in health professions education (HPE) is currently unknown. METHODS: This study replicates Himmelstein's work with a sample of 14 HPE journals published between 2008-2018. Using PubMed, 19,182 article citations were retrieved. Open metadata for each were downloaded, including the date the article was received by the journal, date the authors resubmitted revisions, date the journal accepted the article, and date of entry into PubMed. Journals without publication history metadata were excluded. RESULTS: Publication history data were available for 55% (n = 8) of the journals sampled. The publication histories of 4,735 (25%) articles were analyzed. Mean time from: (1) author submission to journal acceptance was 180.93 days (SD = 103.89), (2) author submission to posting on PubMed was 263.55 days (SD = 157.61), and (3) journal acceptance to posting on PubMed was 83.15 days (SD = 135.72). DISCUSSION: This study presents publication metadata for journals that openly provide it-a first step towards understanding publication timelines in HPE. Findings confirm the replicability of the original study, and the limited data suggest that, in comparison to biomedical scientists broadly, medical educators may experience longer wait times for article acceptance and publication. Reasons for these delays are currently unknown and deserve further study; such work would be facilitated by increased public access to journal metadata.

Sentinel Emotional Events: The Nature, Triggers, and Effects of Shame Experiences in Medical Residents.

PURPOSE: 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. METHOD: In this hermeneutic phenomenology study, the authors recruited 12 (self-nominated) residents from an internal medicine residency at a large teaching hospital in the United States. Data collection from each participant in 2016-2017 included (1) a written reflection about an experience during medical training in which the participant felt "flawed, deficient, or unworthy," and (2) a semi-structured interview that explored the participant's shame experience(s) in depth. The data were analyzed according to hermeneutic traditions, producing rich descriptions about participants' shame experiences. RESULTS: Participants' shame experiences ranged from debilitating emotional and physical reactions to more insidious, fleeting reactions. Participants reported shame triggers relating to patient care, learning processes, and personal goals; numerous factors contributed to their shame experiences. The effects of shame reactions included social isolation, disengagement from learning, impaired wellness, unprofessional behavior, and impaired empathy. Positive effects of shame reactions included enhanced learning, increased willingness to reach out for help, and improved relationships. CONCLUSIONS: Shame reactions can be sentinel emotional events with significant physical and/or psychological effects in medical learners. This study has implications for learners, educators, and patients, and it may pave the way toward open, honest conversations about the role shame plays in medical education.

Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students.

PROBLEM: Medical schools face the challenge of developing efficacious resources to promote well-being and foster resilience in students. The authors developed, implemented, and evaluated a shame resilience seminar for second-year clerkship medical students. APPROACH: In February 2018, the authors conducted a 2.5-hour seminar (part of a longitudinal series) about shame, a common and potentially damaging emotion. The seminar consisted of a large-group session to introduce the psychology of shame, during which speakers shared their personal experiences with the emotion. Next, a small-group session allowed students to discuss their reactions to the large-group content in a safe and familiar environment. Before the seminar, faculty development was provided to small-group leaders (upper-level medical students and faculty) to increase their comfort leading discussions about shame. Students completed a pre/post retrospective survey immediately following the seminar. OUTCOMES: The authors found statistically significant increases in students' confidence in identifying shame and differentiating it from guilt; in their attitudes regarding the importance of identifying shame reactions in themselves and others; and in their willingness to reach out to others during a shame reaction. Surveys of group leaders revealed no reports of significant student distress during or after the seminar. NEXT STEPS: This seminar represents a reproducible means of promoting shame resilience in medical students. The speakers' personal shame experiences and the safety of the small groups for discussions about shame were central to the seminar's apparent success. Next steps include developing an empirically derived, longitudinal shame resilience curriculum spanning the medical school years.

Who Am I, and Who Do I Strive to Be? Applying a Theory of Self-Conscious Emotions to Medical Education.

The self-conscious emotions of shame, guilt, and pride are a distinct set of cognitively complex, powerful, and ubiquitous emotions that arise when an individual engages in self-evaluation. Currently, little is known about the influence or outcomes of self-conscious emotions in medical learners. In this article, the authors present a leading theory of self-conscious emotions that outlines the appraisals and attributions that give rise to and differentiate shame, guilt, and two forms of pride. The authors then apply the theory to three relevant topics in medical education: perfectionism, professional identity formation, and motivation. In doing so, the authors present novel ways of viewing these topics through the lens of self-conscious emotion, suggest areas of future research, and outline a framework for emotional resilience training. Ultimately, the goal of this article is to highlight the fundamental nature of shame, guilt, and pride, which the authors believe are underappreciated and understudied in medical education, and to inform future empirical study on the role that these emotions might play in medical education. Additionally, from a practical standpoint, this article aims to encourage educators and learners to recognize self-conscious emotions in themselves and their colleagues, and to begin developing more resilient approaches to learning-approaches that acknowledge and confront shame, guilt, and pride in medical education.