Guilt: The Elephant in the (exam) Room.

“I don’t do guilt.”

Dr. Robin Taylor is a pulmonologist who practices in Glasgow, Scotland. Most of the patients who come to see him in his respiratory clinic, smoke. And one of the most important things he could help them do for their health is to quit. And as simple as it sounds, it is notoriously a difficult thing to do. And it is not just about the dependence on nicotine.

“I don’t do guilt,” didn’t start automatically. After all, it is not the usual way a doctors greet their patients. It was a process he honed over time. He wrote in the November 26th issue of the New England Journal of Medicine. The simple opening statement evolved; now it is a routine:

“Now, before we go any further, you need to know something about this room.” I pause for a few seconds and allow my eyes to scan the ceiling and the walls. “This room is a guilt-free zone.”

In his essay he narrates a story of a 54-year-old woman who came to see him because of her chronic shortness of breath. Smoking naturally came up. He delivered his usual statement.

“She dropped her head and gazed at her feet. You feel guilty already,” I said quietly.”

She then told him her story. A tragic story of losing her family. And he quickly recognized she was entrenched in guilt: “being a failed mother was at the heart of her feelings of guilt.”

The guilt related to her smoking was only one of many aspects of interconnected and deeply seated negative feelings that had a significant indirect (and perhaps even direct) impact on her health. There would not be any progress, he quickly realized, without at least an attempt to help her process it. He listened. At the confusion of the visit she turned to him and said: “Thank you. No one has ever listened to me before.”

It may seem obvious. A compassionate doctor listens to his patient story and through it builds trust that in turn allows him to have a significant positive impact on her health. But, it wasn’t automatic. It took Dr Taylor years to hone it. Addressing a patient’s guilt is not something anyone is really taught in medical school. It took deep understanding, clearly gained over years of listening to his patients. It took ingenuity. It took time and extra effort. Primarily, though, it took the heavy emotional labor of connecting with his patients.

Are we ready for it in healthcare of the 21st century?

I searched medical literature about guilt and shame (they are not the same, but close cousins) and its effects on health. A quick pubmed.gov search resulted in few papers. Here is one of them: “Health-related shame: an affective determinant of health?”

This is how it starts:

“Although, shame has been identified as a powerful force in the clinical encounter, and the experience of illness, curiously it remains both undertheorised and commonly unacknowledged in the contexts of health and medicine”

Frank Davidoff, in the article from whom I stole the title for this blog post, “Shame: the elephant in the room” wrote about this exact issue of shame’s clinical importance and concomitant medical disinterest. “Despite its potential importance in medical life, shame has received little attention in the medical literature: a search on the term shame in Medline in November 2001 yielded only 947 references out of the millions indexed.”

The negative feelings of guilt and shame come up in my practice often. Primarily, in the context of the use of opioids (even in patients who never took them before) but also even when the diagnosis of cancer is made. I see often how it is deeply rooted and able to affect one’s behavior, unfortunately, often to the detriment of one’s health.

The authors call for making shame a determinant of health. The same way genetics or environment are.

“… our claim is that shame is so insidious, pervasive and pernicious, and so critical to clinical and political discourse around health, that it is imperative that its vital role in health, health-related behaviours and illness be recognised and assimilated into medical, social and political consciousness and practice.”

In our current health care system, emotions are still largely ignored, despite many new and fascinating neuroscientific discoveries that talk about their importance and connections to health.

“…over evolutionary time, the bodies, the structures of being human have adapted to and integrated themselves into the system where the social is everything. The psychologist Michael Tomasello says this great phrase: “a fish is born expecting water; a human is born expecting culture.” And so if we step out and think of the culture, the social, all of that dynamics as the water we live and breathe and move in, and how it shapes us and we shape it, then that statement makes sense.”

According to Matt Clancy, it takes on average 20 years to go from science to technology. I hope the same is not true for medicine. I hope we don’t have to wait decades before our medical education and our health care delivery systems catch up with science.

It took us less than a year to come up with a COVID vaccine. What would happen if we applied the same urgency to other health-care related issues?

Resources :

  1. Dr. Taylor’s full article: “You Are Now Entering a Guilt-free Zone”
  2. Pubmed link to the article on shame in health
  3. Frank Davidov’s article: “Shame, the elephant in the room”
  4. A transcript of the interview with Agustin Fuentes
  5. Matt Clancy’s blog post: “How long does it take to go from science to technology?”
  6. Photo by Anthony Tran on Unsplash

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