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:

Predefined sequences characterized by rigidity, formality, and repetition
Embedded in a larger system of symbolism and meaning
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.

On Rituals

What is a Ritual?

Examples of Rituals in Medical Education

Intentionally Unintentional

Responses

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