It’s capitalism, it’s greed, it’s the hospitals, it’s all those things, but for me, it’s sadness, it’s loss, it’s crying myself to sleep. Lest I sound ungrateful, I am appreciative of the income and career it has afforded me. I am not the victim but also not the perpetrator. In reality, we are all both at one time or another.

It’s the hushed calls to let me know a dear patient has passed. It’s my knee-jerk reaction to say, “but not by suicide,” to unhelpfully reassure myself that I am not at fault—as if to feel loss or pain, I first have to explain I did nothing wrong.

It’s the completed on-call shifts after finding out I had cancer, the return to work four weeks after delivering my third child, the Monday morning clinic after terminating a very desired pregnancy due to medical complications the previous Friday. I understand that there are many careers that have the same type of sacrifices. This is the only job I know, so it is the only one I can speak about.

I am increasingly grappling with the knowledge that it’s all those things, but it is possibly the shame that nags at my soul most. I have long realized the caustic, mordant quality of shame and recognized it at play in my life and the lives of my patients. However, inexplicably, I had not applied it to my experience in medicine until recently, realizing that no other word exactly does the feeling justice.

When shame shows up anywhere, it fills the metaphoric room. It is large and unwieldy, tending to show up at inopportune times. Those affected immediately bristle and react. Often, only the experiencer knows it is there and can feel its sway. Shame causes stomachs to drop, hearts to race, breaths to hasten—often before the person acknowledges its presence. Some people are never able to exactly name the beast. I missed it, despite years of experience literally dealing with human emotion. The Oxford English Dictionary defines shame as “the painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior.” In short, something bad happened, and you believe it was your fault. I think I never fully embraced the word because it implies fault.

In medicine, using the term feels risky, partially because shame suggests a mistake—a shortcoming. The type of fault I grapple with is not the direct action-to-outcome type—it is more nuanced. It is the type felt under scrutiny, sometimes from your own mind and sometimes external. It is the tiny pieces, the failure to have performed perfectly though you were damn close. Not naming the feeling does nothing to remedy the internal blame that is already occurring. In fact, it makes it worse and encourages isolation. To admit to shame, we have to admit to mistakes—or at least the perception of them. Though our rational brains understand that it is a fool’s errand to expect never to fall short, we are enculturated to strive for this goal. Weakness was not tolerated when I was in medical school, though I have begun to see a much-needed change in perspective during my residency and career. There has been a greater realization that not expressing our feelings does not make them disappear.

Even when medicine is practiced well and in line with all standards, bad outcomes occur. There is a period after a bad outcome that leaves practitioners—and sometimes institutions—reeling. In that space, when attempting to ascertain if things were done correctly, the physicians involved feel highly scrutinized. While we are used to scrutiny, it still can feel damning. We work in specialized fields, and while we understand why we made a particular decision, others may not.

In a heightened state of emotion, this can feel like daggers. We feel like failures and sometimes even feel like the world might be better without us in it. Such a severe punishment for a sin of not being perfect. To be in medicine is to have at least—but likely far more—instances where we walk into a room and feel the shame dripping off us so much we know everyone in the room sees it.

The nature of shame lends itself to attempts to numb, to make it go away. Sometimes numbing can be through healthy endeavors such as pouring oneself into a hobby, but even that can become obsessive in nature. And then there are the obviously unhealthy attempts to numb—alcohol, drugs, and many others. These behaviors are often aimed at just allowing us to function at times when we are feeling less than able. The rates of addiction and suicide are higher in physician cohorts than in the general population. This is multifactorial, but I have to believe some of this is our tenuous relationship with shame. It is no secret that many physicians use compartmentalization to cope with the traumas of our profession. I imagine a large angry ape sitting in the room with us, and we place the wall or compartment up—wall after wall, compartment after compartment—always knowing this ape is there and could escape.

At times, I feel that those of us in medicine are largely broken people, in various states of disarray and rebuilding. Some of us arrived here a little haphazardly put together, and some are just a product of the wear and tear of the practice of caring for people in such an intimate way and then meeting the inevitable end of that relationship, whatever it may be. Sometimes it feels like those long corridors where we pass are much less hallowed than haunted.

Sometimes we share with each other our shames and sorrows, and sometimes we carry them alone. Regardless of whether an outcome was our fault, if we believe it was, it causes the same wear and tear on our psyches and bodies. For psychiatrists, the shame often orbits around some aspect of a patient suicide. Ironically, it can—and has—caused members of our specialty and profession to believe that our punishment for some perceived error is just that: to end our own life.

Few rational people would hear our “sin” and apply a punishment as severe, but in isolation, alone with ourselves, it can feel this way. Often, this passes, and maybe it is more the acuity of the shame—but for those for whom it doesn’t pass, those who end their lives, it is felt acutely and for decades—not only by their family and friends but also by their patients. The holes leave an outward exhibition of our failure as a system of individuals dedicated to helping others but not understanding how to help each other—or individually, to believe at times that we don’t deserve the help or compassion of others due to our perceived mistakes.

I have no answers about how to fix things or even how to deal with the last call I received that someone I cared deeply for died (not of suicide). But there I go again—I cannot even make it through this writing without attempting to mitigate shame. I think talking about it and writing about it helps. Maybe this musing will help someone—it has helped me.

Courtney Markham-Abedi is a psychiatrist.