Shame in Medical Education: A Randomized Study of the Acquisition of Intimate Examination Skills and Its Effect on Subsequent Performance

ABSTRACT

Theory: Although medical students are exposed to a variety of emotions, the impact of emotions on learning has received little attention so far. Shame-provoking intimate examinations are among the most memorable events for students. Their emotions, however, are rarely addressed during training, potentially leading to withdrawal and avoidance and, consequently, performance deficits. However, emotions of negative valance such as shame may be particularly valuable for learning, as they might prompt mental rehearsal. We investigated the effect of shame on learning from the perspective of cognitive load theory. Hypotheses: We hypothesized that (a) training modality determines state shame, (b) state shame directly affects the quality of a clinical breast examination as one example of a shame-provoking exam, and (c) students who experience shame during training outperform those who just discuss the emotion during subsequent performance assessments. Method: Forty-nine advanced medical students participated in a randomized controlled, single-blinded study. After a basic, low-fidelity breast examination training, students were randomized to further practice either on a high-fidelity mannequin including a discussion of their emotions or by examining a standardized patient's real breasts. Last, all students conducted a breast examination in a simulated doctor's office. Dependent variables were measures of outcome and process quality and of situational shame. Results: Students training with a standardized patient experienced more shame during training (p < .001, d = 2.19), spent more time with the patient (p = .005, d = 0.89), and documented more breast lumps (p = .026, d = 0.65) than those training on a mannequin. Shame interacted with training modality, F(1, 45) = 21.484, p < .001, η² = 0.323, and differences in performance positively correlated to decline in state shame (r = .335, p = .022). Conclusions: Students experiencing state shame during training do reenact their training and process germane load—in other words, learn. Furthermore, altering simulation modality offers a possibility for educators to adjust the affective component of training to their objectives.

keywords:

• Shame
• emotion
• medical education
• manual skills

Acknowledgments

Preliminary results of the study were presented in 2013 during the annual meeting of the Association for Medical Education in Europe, Prague, Czech Republic. Wolf E. Hautz and Therese Schröder contributed equally. All authors were responsible for the study conception and design. Katja A. Dannenberg and Wolf E. Hautz performed the data collection. Wolf E. Hautz analyzed the data. Therese Schröder, Wolf E. Hautz, and Katja A. Dannenberg drafted the manuscript, all authors made critical revisions to the paper for important intellectual content. Wolf E. Hautz and Anke Thomas obtained funding. Anke Thomas supervised the study.

We are grateful to Silvia Fisch, Stephanie Matthews, and Susanne Werner for help with data acquisition, as well as all raters. We thank June P. Tangney, Jeannine E. Turner, and Nicolas Rüsch for sharing questionnaires and thoughtful comments. We further thank Mary McKee for language editing and Professor Geoff Norman for his constructive criticism on the manuscript. We also thank four anonymous reviewers for their highly constructive comments on an earlier version of the manuscript.

Funding

The study was funded by an unrestricted grant from “Deutsche Ärztefinanz” to the medical skills lab at Charité Berlin. The sponsor did not interfere with the design, condition or analysis of the study or the interpretation or publication of the studies findings.