Shame: the elephant in the room

In the 1960s the results of a large randomised controlled study by the University Group Diabetes Program showed that tolbutamide, virtually the only blood sugar lowering agent available at the time in pill form, was associated with a significant increase in mortality in patients who developed myocardial infarction. The obvious response from the medical profession should have been gratitude: here was an important way to improve the safety of clinical practice. But in fact the response was doubt, outrage, even legal proceedings against the investigators; the controversy went on for years. Why? An important clue surfaced at the annual meeting of the American Diabetes Association soon after the study was 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, …