Shame and its impacts beyond the west: A mixed-methods study of Japanese medical students

Shame is a deeply uncomfortable self-conscious emotion that can influence learning and identity. Empirical evidence on shame in health professions education is largely derived from Western contexts. We aimed to examine the prevalence of shame experiences among Japanese medical students, their associations with key outcomes, and the contextual meanings.

From November to December 2025, we conducted a nationwide, cross-sectional, convergent mixed-methods study across eight medical schools. Shame frequency was assessed with an online survey using the Shame Frequency Questionnaire (SFQ), along with burnout and belongingness using previously published scales with validity evidence, and an open-ended item on leaners' shame experiences and impacts. Descriptive statistics and multivariable regression analyses were conducted, along with inductive content analysis of narrative responses.

1030 students provided quantitative data and 533 provided free-text responses. Mean and median SFQ scores were 2.39 and 2.17 of 6, respectively. On adjustment, shame frequency was higher in women than men, and lower in private than national university students. Higher frequency was associated with higher odds of burnout and lower odds of belongingness. Content analysis generated 587 codes, most reflecting shame experiences. Reported shame experiences were most frequently linked to academic performance, particularly examinations, as well as context-specific experiences, including perceived lack of aspiration and past ronin student (i.e. student retaking the entrance exams) experiences. Reported impacts included professional identity formation crisis, sometimes with positive transformation through deliberate self-improvement.

In this non-Western undergraduate medical education sample, shame experiences were relatively prevalent; varied across learner and institutional characteristics; and were associated with burnout and sense of belonging. Qualitative findings identified examination-centered triggers, Japan-specific experiences, and impacts on developing professional identity. Our findings extend empirical evidence on shame beyond Western contexts and inform future research and educational initiatives to address shame.