Abstract
Background
Physician mental health is an increasingly discussed topic. Despite the progress made
regarding the discussion of physician mental health, these issues remain concerning.
In particular, the discussion as to why these issues are so problematic remains limited.
Contributors can include bullying, the “hidden curriculum” of medicine, how the medical
culture handles errors, and importantly, shame.
Objective
This narrative review evaluates the literature on bullying and abuse in medicine,
how abuse can exacerbate shame, how the handling of medical errors can exacerbate
shame, how shame can negatively affect mental health, and how the medical community
and leaders can mitigate these issues.
Discussion
Physician mental health remains an important issue. Job-related stressors, bullying,
medicine's hidden curriculum, medical error, traumatic patient encounters, and perfectionism
can contribute to physician depression and burnout. Shame may underlie these factors.
Shame is a universal emotion that leads to poor self-esteem, depression, eating disorders,
abuse, and addiction. However, shame can be addressed and overcome, especially via
acknowledgment, vulnerability, and empathy. The medical community can provide some
of these techniques by encouraging environments of kindness and respect, giving constructive
rather than destructive feedback, providing empathy and support after a medical error,
and encouraging mutual learning environments where questions are asked with respect
in order to enhance learning. This is opposed to hierarchies and “pimping,” where
questions are asked with intimidation and disrespect.
Conclusions
Shame is likely a contributor to physician mental health issues. For shame resilience
to occur, it must not be kept secret and mutual support should be provided. By addressing
the possible causes behind physician mental health concerns, including shame, more
solutions can be proposed.
Keywords
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References
- Medical students and medical school.JAMA. 1982; 247: 309-310
- A longitudinal study of students' depression at one medical school.Acad Med. 1997; 72: 542-546
- Embarking upon a medical career: psychological morbidity in first year medical students.Med Educ. 1995; 29: 337-341
- Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey.Med Educ. 2001; 35: 12-17
- The health status and life satisfaction of first-year medical students.Acad Med. 1990; 65: 586-588
- Life satisfaction and resilience in medical school—a six-year longitudinal, nationwide and comparative study.BMC Med Educ. 2006; 6: 48
- Low self-esteem in GP registrars.BMJ. 2006; 332: gp239-gp240
- Why so many doctors lack self-confidence, and how to get it back.(Available at:)
- The relationship between verbal abuse of medical students and their confidence in their clinical abilities.Acad Med. 1998; 73: 907-909
- Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.JAMA. 2011; 306: 952-960
- Depression, stigma, and suicidal ideation in medical students.JAMA. 2010; 304: 1181-1190
- Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors.J Affect Disord. 2001; 64: 69-79
- Details on suicide among US physicians: data from the National Violent Death Reporting System.Gen Hosp Psychiatry. 2013; 35: 45-49
- Suicide risk among physicians: a multivariate analysis.Arch Suicide Res. 2004; 8: 287-292
- Doctors’ suicide rate highest of any profession.(Available at:)https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession#1Date: 2018Date accessed: May 12, 2019
- Physician suicide: a fleeting moment of despair.Psychiatry (Edgmont). 2009; 6: 18-22
- Suicide in physicians and veterinarians: risk factors and theories.Curr Opin Psychol. 2018; 22: 23-26
- Physician suicide.Medscape Drugs Dis. 2015;
- Physician depression and suicide: a shared responsibility.Teach Learn Med. 2015; 27: 341-345
- Suicide risk in patients with major depressive disorder.J Clin Psychiatry. 1999; 60 (discussion 75–6, 113–6)
- Risk factors for suicide in psychiatric outpatients: a 20-year prospective study.J Consult Clin Psychol. 2000; 68: 371-377
- Psychological autopsy studies of suicide: a systematic review.Psychol Med. 2003; 33: 395-405
- Confronting depression and suicide in physicians: a consensus statement.JAMA. 2003; 289: 3161-3166
- Physician wellness: a missing quality indicator.Lancet. 2009; 374: 1714-1721
- Abuse of residents: it's time to take action.CMAJ. 1996; 154: 1705-1708
- Improving physician well-being, restoring meaning in medicine.(Available at:)https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-BeingDate accessed: May 21, 2019
- National physician suicide awareness day.(Available at:)
- Gender differences in depression.Curr Dir Psychol Sci. 2001; 10: 173-176
- Prevalence of and risk factors for depressive symptoms among young adolescents.Arch Pediatr Adolesc Med. 2004; 158: 760-765
- Risk factors for depression in older adults in Beijing.Can J Psychiatry. 2011; 56: 466-473
- Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts: evaluation of suicide risk in a time of managed care.Psychosomatics. 1999; 40: 18-27
- Harassment and discrimination in medical training: a systematic review and meta-analysis.Acad Med. 2014; 89: 817-827
- A report on student abuse during medical training.Med Teach. 2003; 25: 497-501
- The prevalence of medical student mistreatment and its association with burnout.Acad Med. 2014; 89: 749-754
- Eradicating medical student mistreatment: a longitudinal study of one institution’s efforts.Acad Med. 2012; 87: 1191-1198
- Impact of a program to diminish gender insensitivity and sexual harassment at a medical school.Acad Med. 2000; 75: 464-469
- Residents' and medical students' reports of sexual harassment and discrimination.Acad Med. 1996; 71: S25-S27
- Prevalence and characteristics of bullying of trainees in palliative medicine.Palliat Med. 2005; 19: 84-86
- Resident experience of abuse and harassment in emergency medicine: ten years later.J Emerg Med. 2010; 38: 248-252
- Bullying and harassment of trainees: an unspoken emergency?.Emerg Med Australas. 2015; 27: 464-467
- Altering workplace attitudes for resident education (AWARE): discovering solutions for medical resident bullying through literature review.BMC Med Educ. 2016; 16: 127
- Sexual harassment of female doctors by patients.N Engl J Med. 1993; 329: 1936-1939
- Patient assaults on psychiatric residents: the Canadian experience.Can J Psychiatry. 1991; 36: 107-111
- TRUST: the 5 rights of the second victim.J Pat Saf. 2007; 3: 107-119
- Do house officers learn from their mistakes?.BMJ Qual Saf. 2003; 12: 221-226
- Dealing with failure: the aftermath of errors and adverse events.Ann Emerg Med. 2002; 39: 344-346
- Posttraumatic shame and guilt.Trauma Violence Abuse. 2006; 7: 122-141
- When doctors struggle with suicide, their profession often fails them.(Available at:)https://www.npr.org/sections/health-shots/2018/07/31/634217947/to-prevent-doctor-suicides-medical-industry-rethinks-how-doctors-workDate: 2018Date accessed: May 12, 2019
- Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey.BMJ. 2006; 333: 682
- Traumatic deidealization and the future of medicine.JAMA. 1990; 263: 572-573
- Predicting depressive symptoms with a new measure of shame: the Experience of Shame Scale.Br J Clin Psychol. 2002; 41: 29-42
- Self-conscious emotions and depression: rumination explains why shame but not guilt is maladaptive.Pers Soc Psychol Bull. 2006; 32: 1608-1619
- An exploration of shame, social rank and rumination in relation to depression.J Individ Differ. 2004; 36: 1143-1153
- Assessment of shame and guilt and their relationships to psychopathology.J Pers Assess. 1992; 59: 584-604
- Proneness to shame, proneness to guilt, and psychopathology.J Abnorm Psychol. 1992; 101: 469-478
- Suicide Explained.Melbourne University Press, Victoria1995
- Burned by bullying in the American workplace: prevalence, perception, degree and impact.J Manage Studies. 2007; 44: 837-862
- Bullying at work: the impact of shame among university and college lecturers.Br J Guid Counc. 2004; 32: 281-299
- Shame resilience theory: a grounded theory study on women and shame.Fam Soc. 2006; 87: 43-52
- The association of shame and guilt with suicidality.J Soc Psychol. 1998; 138: 535-536
- Situational determinants of shame and guilt in young adulthood.Pers Soc Psychol Bull. 1992; 18: 199-206
- Five components of a basic suicide syndrome.Suicide Life Threat Behav. 1972; 2: 3-18
- Perfectionism, shame, and depressive symptoms.J Couns Dev. 2006; 84: 148-156
- Shame, guilt and suicide.in: Joiner T.E. Rudd M.D. Suicide Science. Springer, Boston, MA2002: 67-79
- Helping physicians cope with their own chronic illnesses.West J Med. 2001; 175: 336-338
- Positive and negative perfectionism and the shame/guilt distinction: adaptive and maladaptive characteristics.Pers Individ Diff. 2005; 38: 1609-1619
- Shame, guilt, symptoms of depression, and reported history of psychological maltreatment.Child Abuse Negl. 2007; 31: 1143-1153
- The relationship of shame, social anxiety and depression: the role of the evaluation of social rank.Clin Psychol Psychother. 2000; 7: 174-189
- A system of medical error disclosure.BMJ Qual Saf. 2002; 11: 64-68
- Error in medicine.JAMA. 1994; 272: 1851-1857
- From shame to guilt to love.JAMA. 2015; 314: 2507-2508
- The shame of failure: examining the link between fear of failure and shame.Pers Soc Psychol Bull. 2005; 31: 218-231
- Professional development of medical students: problems and promises.Acad Med. 1997; 72: 1056-1062
- Workplace bullying among healthcare workers.Int J Environ Res Public Health. 2013; 10: 3121-3139
- Position Statement: Workplace Bullying & Harassment 2009.Australian Medical Association, Canberra2009
- A summary review of literature relating to workplace bullying.J Community Appl Soc Psychol. 1997; 7: 181-191
- Workplace bullying in junior doctors: questionnaire survey.BMJ. 2002; 324: 878-879
- Residents' experiences of abuse, discrimination and sexual harassment during residency training. McMaster University Residency Training Programs.CMAJ. 1996; 154: 1657-1665
- I wasn’t surprised by Four Corners. Bullying in medicine is as old as the profession.(Available at:)https://www.theguardian.com/commentisfree/2015/may/26/i-wasnt-surprised-by-four-corners-bullying-in-medicine-is-as-old-as-the-professionDate: 2015Date accessed: December 1, 2018
- ‘You learn better under the gun’: intimidation and harassment in surgical education.Med Educ. 2005; 39: 926-934
- Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.JAMA. 1998; 279: 1194-1199
- Perspective: a culture of respect, part 1 the nature and causes of disrespectful behavior by physicians.Acad Med. 2012; 87: 845-852
- ‘It would not be tolerated in any other profession except medicine’: survey reporting on undergraduates’ exposure to bullying and harassment in their first placement year.BMJ Open. 2014; 4: e005140
- How doctors treat doctors may be medicine’s secret shame.(Available at:)https://www.theguardian.com/commentisfree/2015/feb/06/how-doctors-treat-doctors-may-be-medicines-secret-shameDate: 2015Date accessed: December 2, 2018
- Prevalence of abusive encounters in the workplace of family physicians: a minor, major, or severe problem?.Can Fam Physician. 2010; 56: e101-e108
- Women physicians and stress.J Womens Health Gend Based Med. 2000; 9: 185-190
- Michigan College of Emergency Physicians Workplace Violence Task Force. Workplace violence: a survey of emergency physicians in the state of Michigan.Ann Emerg Med. 2005; 46: 142-147
- Sexual harassment and discrimination experiences of academic medical faculty.JAMA. 2016; 315: 2120-2121
- Sexual harassment during medical training: the perceptions of medical students at a university medical school in Australia.Med Educ. 2000; 34: 980-986
- Sexual harassment in medical training.N Engl J Med. 1993; 328: 322-326
- Perfectionism, fear of failure, and affective responses to success and failure: the central role of fear of experiencing shame and embarrassment.J Sport Exerc Psychol. 2009; 31: 602-627
- Reported sexual abuse and bulimic psychopathology among nonclinical women: the mediating role of shame.Int J Eat Disord. 2002; 32: 186-191
- Mental health consequences and correlates of reported medical student abuse.JAMA. 1992; 267: 692-694
- Shame and suicide: a case study.Death Stud. 2000; 24: 157-162
- Changed women and changed organizations: consequences of and coping with sexual harassment.J Vocat Behav. 1993; 42: 28-48
- Emotional reactions during and after trauma: a comparison of trauma types.J Aggress Maltreat Trauma. 2008; 16: 391-408
- Daring Greatly: How The Courage to Be Vulnerable Transforms the Way We Live, Love, Parent and Lead.Penguin Random House, New York2012
- Health consequences of workplace bullying: experiences from the perspective of employees in the public service sector.Int J Qual Stud Health Well Being. 2006; 1: 109-119
- Psychopathological features of a patient population of targets of workplace bullying.Occup Med. 2008; 58: 122-128
- Workplace bullying and mental distress—a prospective study of Norwegian employees.Scand J Work Environ Health. 2011; 7: 276-287
- Longitudinal relationships between workplace bullying and psychological distress.Scand J Work Environ Health. 2012; 38: 38-46
- Psychologically controlling teaching: examining outcomes, antecedents, and mediators.J Educ Psychol. 2012; 104: 108
- Power day: addressing the use and abuse of power in medical training.J Bioeth Inq. 2016; 13: 203-213
- Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC).Jt Comm J Qual Improv. 2001; 27: 93-100
- Shame, guilt, and the medical learner: ignored connections and why we should care.Med Educ. 2014; 48: 1045-1054
- Shame: the elephant in the room.BMJ Qual Saf. 2002; 11: 2-3
- Medical students' professionalism narratives: a window on the informal and hidden curriculum.Acad Med. 2010; 5: 124-133
- The hidden curriculum: what can we learn from third-year medical student narrative reflections?.Acad Med. 2010; 85: 1709-1716
- The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching.BMJ. 2004; 329: 770-773
- Learning professionalism: a view from the trenches.Acad Med. 2007; 82: 1010-1014
- Kohut's tragic man: an example from “death of a salesman”.Clin Soc Work J. 1993; 21: 213-225
- Resilience as an underexplored outcome of workplace bullying.Qual Health Res. 2013; 23: 291-301
- A concept analysis of empathy.J Adv Nurs. 1996; 23: 62-1167
- Brené Brown encourages educators to normalize the discomfort of learning and reframe failure as learning.About Campus. 2016; 20: 3-7
- The effects of feedback interventions on performance: a historical review, a meta-analysis, and a preliminary feedback intervention theory.Psychol Bull. 1996; 119: 254
- Self-efficacy: toward a unifying theory of behavioral change.Psychol Rev. 1977; 84: 191-215
- Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance.J Appl Psychol. 1988; 73: 199-207
- Are shame, guilt, and embarrassment distinct emotions?.J Pers Soc Psychol. 1996; 70: 1256-1269
- Complaints, shame and defensive medicine.BMJ Qual Saf. 2011; 20: 449-452
- The emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability.Swiss Med Wkly. 2009; 139: 9
- Vulnerability is power in leadership and relationships.JSD. 2011; 32: 61-62
- Vulnerable leadership.Lond J Prim Care. 2016; 8: 37-38
- What bosses gain by being vulnerable.(Available at:)
- Forgiveness in organizations.Posit Organ Behav. 2007; 2: 129-142
Article info
Publication history
Published online: August 17, 2019
Accepted:
June 22,
2019
Received in revised form:
June 18,
2019
Received:
January 14,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
