title: Shame in Medical Education: A Randomized Study of the Acquisition of Intimate Examination Skills and Its Effect on Subsequent Performance.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
authors.affiliation: a Universitäres Notfallzentrum, Inselspital Bern , Switzerland.
authors.forename: Wolf E
authors.initials: WE
authors.lastname: Hautz
authors.affiliation: b Department for Curriculum Management , Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Therese
authors.initials: T
authors.lastname: Schröder
authors.affiliation: b Department for Curriculum Management , Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Katja A
authors.initials: KA
authors.lastname: Dannenberg
authors.affiliation: c Department of Assessment , Vice-Deanery for Teaching, Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Maren
authors.initials: M
authors.lastname: März
authors.affiliation: b Department for Curriculum Management , Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Henrike
authors.initials: H
authors.lastname: Hölzer
authors.affiliation: b Department for Curriculum Management , Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Olaf
authors.initials: O
authors.lastname: Ahlers
authors.affiliation: d Department of Gynecology and Obstetrics , Campus Charité Mitte, Charité - Universitätsmedizin Berlin , Germany.
authors.forename: Anke
authors.initials: A
authors.lastname: Thomas
mesh_terms: D000293:Adolescent; D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis; D002983:Clinical Competence; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008348:Manikins; D016544:Patient Simulation; D010808:Physical Examination; D012752:Shame; D016037:Single-Blind Method; D013337:Students, Medical / Q000523:psychology*; D055815:Young Adult
keywords: Shame; emotion; manual skills; medical education