Shame Competent Response to Medical Error

DW is a colleague who joined my practice 2 years ago after residency. A few days ago, after DW placed an intrauterine device (IUD), the patient's uterus perforated, leading to emergency surgery. Later that day, I saw a departmental email that listed the case for presentation at an upcoming morbidity and mortality (M&M) conference. Today, I found DW after clinic to see how he was feeling and handling the situation. He shared that he felt like a failure and was worried that people were judging him as being incompetent. He had not talked with anyone about what happened because he was afraid of the effect it would have on his reputation. He said he has been feeling isolated at work and has experienced anxiety and self-doubt over his clinical decisions, even referring another patient needing an IUD to a colleague rather than attempting the procedure again. He continued to share that he was not sleeping well, has been defensive with his spouse, and even snapped at one of the nurses over a minor miscommunication, all of which, he expressed, were out of character for him. He said he was struggling and did not know what to do. Other than listening intently and validating his feelings, what more can I do to support my colleague?

Medical error leading to procedural complications is a challenging reality of practicing medicine. The term “second victim effect” describes the significant distress experienced by health care workers after unexpected adverse patient outcomes.¹ Evidence supports the second victim effect, with recent medical error being linked to depression, anxiety, diminished empathy, and maladaptive coping among physicians and medical learners.^2–4

Self-conscious emotions are a critical but underrecognized component of the second victim effect. Self-conscious emotions directly address how we feel about ourselves, arising from a self-evaluation that is often precipitated by falling short of a socially valued standard or internalized ideal.⁵ Shame occurs when we blame this shortcoming on a globally flawed or deficient self as opposed to specific actions, behaviors, or circumstances (eg, “I am bad” vs “I did a bad thing”). By implicating the global self, shame tends to prompt feelings of negative self-judgment, significant distress, and self-protective behaviors, ranging from hiding and disengagement to defensiveness and attacking others.⁵

Although a medical error that leads to a procedural complication is not inherently shameful in and of itself, it brings with it a high risk of shame because the error is a clear shortcoming of the standard to first do no harm. Colleagues have an opportunity to provide shame competent support to help a peer process the deeper self-conscious emotions triggered by this event. Shame competence is a set of specific skills, principles, and practices that facilitate constructive engagement with shame, including (1) maintaining ongoing awareness of shame, (2) recognizing the presence of shame, (3) identifying unhelpful strategies to avoid shaming, and (4) seeking or providing proactive support.⁶

Shame is a taboo, veiled emotion that is infrequently acknowledged or discussed. Thus, it is critical to maintain active awareness of its potential presence, both in oneself and in others, following events that may trigger damaging self-evaluation. In the context of peer support, being shame competent requires recognizing a colleague's potential for damaging self-evaluation in response to events including, but not limited to, medical error and procedural complications. This understanding is a form of enhanced empathy, whereby physicians place themselves in the shoes of another and consider more than just how their colleague is feeling but also how they are feeling about their innermost self.