In looking beyond medicine’s traditional boundaries, there is potential to gain new perspectives and insight for the enhancement of our profession. In this article, the theme of bullying in medical school will be discussed through the lens of art. Analysis and discussion of art are most commonly used in medical education to hone skills of clinical observation and sensitivity to patients [1-7], even among more-seasoned practitioners . Arts-related interventions have also been used to enhance teamwork and communication skills in both students [1, 9] and postgraduates . Additionally, such activities have led to an improved tolerance for ambiguity [1, 10, 11] important in the clinical setting in which diagnoses may not present themselves immediately.
The integration of arts-related exercises beginning early in medical education contributes to an environment of learners and teachers in which medical student mistreatment can be curtailed at a foundational level. Art interventions, for example, emphasize positive communication among colleagues and discourage unhealthy dialogue that leads to bullying. Furthermore, because they center on topics outside the practice of health care, artistic discussions can foster equitable contribution from all participants, irrespective of professional role. In some sense this levels the playing field among health care workers, which helps counter the negative impact of hospital hierarchies . Given the emerging roles that art and the humanities have come to play in medical education, it seems fitting to use art as a reference point in discussing themes of medical student mistreatment.
The bullying and mistreatment of medical students is a complex and contentious topic. There is a tendency to see bullying as a “necessary evil” and a rite of passage in medical education, valuable because it instills resilience and cements bonds between fellow doctors. Certainly there is a need to prepare medical students for the stress and responsibility that go hand-in-hand with the practice of medicine. However, is the “hazing” that may occur on the wards an ethical means of attaining this goal? There is no easy answer to this question, but it is imperative to consider that both present and future patient care is compromised in an environment that tolerates disrespectful behavior .
Figure 1. Tripp Leavitt, Le Pendu, 2010, lithograph and watercolor on paper, 11 × 15 (Click the magnifier to enlarge image.)
The lithograph (figure 1), entitled Le Pendu, translated as The Hanged Man, is an interpretation of the pursuit of knowledge and enlightenment referred to in the tarot card of the same name, which served as its inspiration. Le Pendu can represent the transition that occurs through medical school: preclinical instruction provides the foundation of knowledge that is later developed and applied in the treatment of patients. Hands are a recurring theme in my work because I believe they symbolize so much of what it can mean to be human and because they have been historically associated with the art of healing. The living foliage represents the natural world from which we derive our knowledge of the basic sciences. Traditional perceptions of scale are made irrelevant as a laminin molecule appears comparable in size to a hand, emphasizing the fundamental links between microscopic and macroscopic realms of the natural world and the idea that we exist because of things too small to see or sometimes even comprehend.
Though depicted in its cross-shaped diagrammatic form, the laminin molecule refers to an aspect of medical education that is anything but straightforward. On a cellular level, laminin is a fundamental structural protein, serving the critical function of binding our cells together, akin to molecular glue. This rendering of the laminin molecule represents a link, in this case between scientific theory and its successful implementation in patient care. It is during these years that students take their crucial first steps from acquisition of medical knowledge to its patient-centered application. This linkage also contains the hidden, unwritten curriculum of the clerkship years. Between different students and hospitals it may be filled with inconsistency, and for some it may go so far as to become a “religious” experience; we may be deeply influenced by the dogma of our institutions, emblematized by the laminin cross. The quality of this link influences how a medical student practices as a licensed clinician. It is also during this transition that bullying can exert its more insidious effect, draining the empathy and quality of patient care in the years to come.
Looking at Le Pendu through the lens of the tarot card reveals a deeper narrative about the developing medical student. The Hanged Man is traditionally depicted as a figure suspended upside-down from a gallows, tied at one ankle, with his arms bound behind him, forming a triangle (figure 2). His free leg is crossed behind the one from which he hangs. The man’s face is not one of suffering; instead he exudes a sense of peace and contemplation.
Figure 2. The Hanged Man tarot card (Click the magnifier to enlarge image.)
There are several parallels between the tarot figure of the Hanged Man and the student within the institution of medical education.
Central to The Hanged Man card are themes of contemplation and the attainment of knowledge and new perspectives through sacrifice. As his expression of peacefulness suggests, the Hanged Man is a willing victim, accepting that he must sacrifice in the name of a higher calling. In the twenty-first century, medical students invest significant time, energy, and money to eventually join the ranks of health care workers. It is a long road, and like the Hanged Man, one must exercise patience to achieve enlightenment.
The Hanged Man’s fate is also intertwined with that of an authority figure. His legs cross in the shape of the number 4, implying his link to the fourth trump card, The Emperor (figure 3).
Figure 3. The Emperor tarot card (Click the magnifier to enlarge image.)
The Emperor is interpreted as a figure of authority, power, and discipline. His granite throne—sometimes understood as a kind of intellectual throne—emphasizes his fixed state, and he is the embodiment of law and rationality, knowledge, and consciousness. As the Hanged Man is connected to The Emperor, the fates of medical students, too, are connected to those of their mentors. Unlike students in many other graduate educational programs, medical students for the most part do not pave their own paths to discovery. Instead, we rely significantly on others to teach us. We must follow the guidance of our superiors, for they have the knowledge and experience that can transform us into effective clinicians. The aspect of apprenticeship in medical education has been one of medicine’s greatest draws in my own choice of career. However, this apprenticeship also feeds into the rigid hierarchy that has become the accepted order in the health care setting. The prevalence of demeaning behavior directed towards subordinates is varied, but the general consensus suggests that it is far from uncommon [13, 14]. Medical students, particularly in their third year, are common targets as they are at the bottom of this hierarchy. Burnout and clinical depression are two potential results of this behavior [15, 16], and mistreatment of members of the health care team seeps over into suboptimal patient care .
Medical students on clinical rotations are perhaps especially likely to empathize with The Hanged Man, for The Hanged Man card, when drawn together with The Emperor card, suggests that the best approach to conflict with a superior is complete passivity, echoing what may occur during clerkships. Leape et al. attributed significant underreporting of student mistreatment to concern for “being seen as trouble makers and fear of reprisal or vindictive retaliation,” including negative evaluations and implications for residency applications .
On its own, a reading of The Emperor card would suggest basing future decisions on a firm foundation, such as repeating learned actions rather than establishing new paradigms. Simply put, we teach the way we were taught. In the decades of practice after graduation, medical students may perhaps change from sympathizing with The Hanged Man to identifying with, or acting as, The Emperor. Repetition of the harsh training methods of the past is often considered to be a root cause of health care worker mistreatment patterns, when practicing clinicians echo the treatment they received as students to those now in their charge. Such a phenomenon is not necessarily surprising, nor is it necessarily bad, given the generations of competent medical practitioners that have emerged from our teaching institutions. But we must be wary of whether educational practices foster environments of disrespect so that the capacity for empathy is not lost in the quest for competency.
In subjecting himself to this fate, the Hanged Man also demonstrates a sacrifice of ego. Though the details of the associated arcane symbolism are not of great relevance to the practice of medicine, the general principles of sacrificing ego and coming together to create something greater than the sum of its parts are certainly applicable. Successfully navigating the wards also requires a sense of humility and a will to help both patients and all other members of the health care team. As medicine becomes ever more specialized, effective teamwork is imperative in securing the future of positive clinical outcomes. The bullying that occurs in the health care setting has been identified as a major block to achieving this goal. If a culture of disrespect is impressed upon physicians in training, then the cycle is likely to continue. As Leape et al. once again say, “Everyone suffers in an atmosphere of intimidation. A hostile work environment lowers morale, creates self-doubt, and is a cause of burnout” .
Discussion and analysis of art have been used to enhance communication among colleagues and to circumvent some of the aforementioned issues of power abuse and maltreatment associated with contemporary clinical practice [9, 10, 12]. In this regard, art provides an avenue for health care teams to achieve goals beyond the reach of individuals working in isolation.
The abundant foliage adorning the tree from which the man is hung suggests that his situation, though seemingly unfortunate, will actually be fruitful. A similar outlook can be ascribed to Le Pendu, in which living vines and healing hands symbolize hope and progress. Despite the ongoing prevalence of mistreatment within medical education, much is being done to combat it. The spectrum of medical student bullying is wide indeed, and it is important to remember that the stern words of an attending may stand as a beneficial learning experience. Finding a healthy mean between hierarchical assertions of power and sheltering medical students from the high-stakes and often-stressful life of a physician is a lofty, but necessary task. We must hope that, when future generations of medical students are “turned on their heads” in clinical years, their newfound perspectives will be imbued with enlightenment and empathy for patients and colleagues alike.
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