On Rituals

Ahhh, Thanksgiving. The all-American holiday dedicated to gratitude, football, and fryer fires.

This past Thursday, millions of families gathered around tables to share a traditional meal.

Sides were taken and lines drawn: pumpkin or sweet potato pie? Mac and cheese: side dish or main event? Cranberry sauce or can-shaped semisolid? (I’m all about the latter.)

It’s not just an event; it’s a ritual.

A ritual that ties you to your family, your forebears, and the broader community of celebrating Americans.

The ritual gives time meaning.

It reminds you that you belong.

And as I reflect on this annual event, I wonder about ritual in medical education.

Do rituals play a role in shaping physicians? If so, are they a force for good or something else entirely?

What is a Ritual?

There are several definitions of the word ritual. This one says that rituals fulfill 3 criteria:

1. Predefined sequences characterized by rigidity, formality, and repetition

2. Embedded in a larger system of symbolism and meaning

3. Contain elements that lack direct instrumental purpose.

Examples of Rituals in Medical Education

• White Coat Ceremony

  • Newly matriculated medical students receive their short white coats and, often, take an oath derived from the original Hippocratic Oath

• Anatomical Donation Remembrance Ceremonies

  • Medical students honor those who donated their bodies for anatomical study.

• Operation Bushmaster

  • The Uniformed Services University of the Health Sciences 5-day immersive exercise, established by Congress in 1972.

  • A 2023 study showed Operation Bushmaster participants improved their decision-making in stressful situations (p<.001) while students assigned to online modules did not.

  • Authors of a 2021 study describe Operation Bushmaster as a threshold experience, a transformative phase where participants cross into a new understanding of their professional identity:

    • New confidence as leaders and recognition that being a military physician is more than just combining medical and military roles.

• Coffin-lying

  • A study conducted from 2020 to 2021, in which 134 medical and nursing students from a medical university in northern Taiwan voluntarily:

    • Wore grave clothes.

    • Watched a video imagining themselves as terminally ill.

    • Wrote a will and epitaph.

    • Spent 10 minutes lying in a coffin, simulating death and rebirth.

  • The activity reduced death anxiety by 20–30% in participants, with the effects lasting 6–11 weeks.

Intentionally Unintentional

Of the three elements in the definition of ritual, the one that stands out to me is:

Contains elements that lack direct instrumental purpose.

At first, it seems out of place.

The purpose of medical education is clear: to train physicians for clinical practice. And clinical practice has a purpose: to promote health and treat the sick.

It all seems so utilitarian.

But the rituals listed above show that we do carve out space for something else - something more.

The Threshold Experience.

An event designed to bring about transformation in its participants, who may know it is expected but not how or when it will happen - because there is no way to know.

It just … happens.

Usually, the educator in me urges, “make the implicit explicit. Communicate the unspoken objectives”.

But maybe the educator in me is wrong.

Perhaps there is power in letting a ritual unfold without cataloging every detail. That there is something greater at play than what can be seen in the component parts.

That, if becoming a doctor involves more than accruing knowledge and skill (and I believe it does), then we must leave space for the becoming to occur.

• As you go about your life this week, take note of the rituals you engage in, even (or especially) if they usually go unnoticed.

• Be open to the parts of your days that have no “instrumental purpose” yet offer something unexpected, something intangible but valuable.

• Be mindful when, in the pursuit of efficiency or progress, you think about ending a tradition or canceling a recurring event. Make sure you’re not unknowingly giving up something irreplaceable, something that can’t be intentionally recreated once it’s gone.

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