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Management of shame in quality improvement
Shame: the elephant in the room
  1. F Davidoff
  1. Correspondence to:
 Professor F Davidoff, 143 Garden Street, Wethersfield, CT 06109, USA;
 fdavidoff{at}mail.acponline.organdoff{at}earthlink.net

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Shame is the “elephant in the room”—something so big and disturbing that we don't even see it, despite the fact that we keep bumping into it. It is hoped that open discussion of safety issues in QSHC will remove some of the shame relating to them

In the 1960s the results of a large randomised controlled study by the University Group Diabetes Program (UGDP) indicated that the use of tolbutamide, virtually the only blood sugar lowering agent available at the time in pill form, was associated with a significant increase in mortality rate in patients who developed myocardial infarctions. The obvious response on the part of the medical profession should have been gratitude: here was an important way to improve the safety of clinical practice. But the response was, in fact, quite different: doubt, outrage, even legal proceedings against the investigators; the controversy went on for years. Why?

An important clue to the origins of this curious anomaly surfaced at the annual meeting of the American Diabetes Association soon after the UDGP study findings were published. During the discussion a practitioner stood up and said he simply could not, and would not, accept the findings, because admitting to his patients that he had been using an unsafe treatment would shame him in their eyes. Other examples of such reactions to improvement efforts are not hard to find.1 Indeed, it is arguable that shame is the universal “dark side” of improvement. After all, improvement means that, however good your performance has been, it is not as good as it could be. As such, the experience of shame helps …

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