May 7, 1999

Medical encounters frequently produce a sense of shame or humiliation for patients and sometimes for doctors. The typical patient gown with the open back symbolizes the powerlessness patients often feel in medical settings.

"Even our medical terminology sounds humiliating," said Aaron Lazare, M.D., at the March meeting of the American Association of Directors of Psychiatric Residency Training in Santa Monica, Calif.

"Cardiologists use such terms as inferior infarction; gynecologists talk about an incompetent cervix and an habitual aborter; and psychiatrists describe patients as histrionic, narcissistic, and borderline," said Lazare, a psychiatrist who is a dean and chancellor at the University of Massachusetts Medical School in Worcester, Mass. Lazare has researched and lectured on the topic of shame and humiliation in medical encounters for the past 12 years.

Feelings of shame and humiliation are often compounded by the way physicians and hospital staff treat patients, according to Lazare.

How to handle these feelings "is not something I was taught in medical school or learned in psychoanalysis. Psychiatrists need to study the psychology of everyday life, not just psychopathology, to understand the dynamics of humiliation and how restoring dignity is critical to the healing process."

Lazare first became interested in this topic when he discovered that medical students listed shame as the most traumatic aspect of medical care.

"I also found that the most common patient complaint was related to feeling humiliated by doctors and nurses. Patients expressed being treated as less than human, like children, and feeling abandoned and betrayed," he commented.

Lazare described humiliation as a feeling of being unfairly debased or diminished by another person.

Being humiliated can lead to long-term grudges and rage, he noted. Physicians who do not acknowledge mistakes or at least communicate empathy for a patient's pain or distress are more likely to be sued, said Lazare.

He recalled interviewing a patient who was injured accidentally in surgery. "He said, 'There I was lying flat on my back when the doctor came by riding on his high horse and never even said he was sorry. That was when I decided to sue.' Even a simple apology for keeping someone waiting helps restore a person's dignity."

For an apology to be effective, there needs to be an exchange of the feeling of shame or humiliation from the person affected to the offender. "For example, saying 'It had nothing to do with you but with me' relieves the offended person of the hurt and gives him or her the power to forgive or not forgive."

Also, the offense shouldn't be trivialized by making such remarks as, "I am sorry if you are upset by this," he observed.

Lazare noted that people rarely use the word "humiliated" but may use such terms as "insulted," "hurt," "resentful," and "upset."

Physicians are also vulnerable to feelings of shame and humiliation. Lazare has collected about 300 stories from mostly primary care physicians about events that produce those feelings. There were four main categories: diagnosis and treatment failure, criticism by patients and families, personal feelings or interpersonal behavior, and being a patient.

He recalled a woman physician's feelings of shame involving a male patient. "She was examining his pelvic area when he had an erection. She ran from the room feeling certain she had done something to cause it. Later she was upset by her reaction," said Lazare.

Doctors find it so humiliating to be patients because they are used to being in a position of power and believe they are never supposed to be sick or weak, explained Lazare.

He recalled a physician who described being hospitalized in a psychiatric unit for depression as a third-year medical student. "In this diminished world, two fellow medical students and former friends entered the room talking earnestly with an attending. Their clipboards, stethoscopes, and white jackets spoke of title, meaning, and purpose. Our eyes met briefly, and I wanted to die even more. More than that, I wanted to disappear. Instead, I picked up the newspaper to hide behind it, aware that my ears were burning hot with shame."

Twenty years later, that physician could not look at one of these colleagues without "wanting to sink into the ground," said Lazare.-C.L.