By Meaghan Ruddy

I do not consider myself a Christian. A fan of Jesus of Nazereth, particularly as the community of Luke told of him, sure, but not a congregant of any kind. Still, I woke up one Saturday morning thinking about Jesus taking lashes, and it occurred to me that this is a useful metaphor for a lot of what happens when someone is brought into a professionalism moment or are on an improvement plan of some kind because of a perceived professional lapse. I speak specifically here about professional lapses that have to do with attitude or tone. I find this kind of thing interesting because I am in a “new normal” moment in my own life where I’m coming to earnestly reckon with the systemic oppressors that we have built into organizational hierarchies, particularly in medicine, and even more particularly in medical education. This reckoning includes a growing understanding of the ways in which systems of oppression have infiltrated things like psychology, coaching, and profession-typical (analogous to neurotypical) modes of expressing how one shows up as professional.

It is a well-known and not-so-secret secret in medical education that education tends to be ahead of practice. It is similarly known that education-leveraged advancement can be hampered by practice because trainees want to, and often need to, adhere to the rules of the structures in the given specialty by which they wish to be accepted. Given that medicine is toxic, perhaps not more so than any other entrenched profession but uniquely to itself and its environments, practices, and hierarchies, the pressures on medical students and residents end up becoming backward pressures on medical educators. This occurs because, however inadvertently, learners are set up by the tension between education and practice in situ to either fail or attempt resistance then fail. Even programming that happens in astute and well-funded academic health systems finds itself forced to rotate in clinical environments that are often much too overwhelmed with the activities of engaging in clinical care delivery to give much thought to intentional progress.

Adding to this tension is the twisted fetish medical education has with learners being change agents. It is right up there with the false hope of self-directed education and military envy, which of course are opposing forces. Medicine wants so badly to generate rote followers that it tends to call intensives “boot camps” then turns on a dime to expect agency from those same recruits. Then we are surprised at the rampant mental health and addiction in medicine. As someone who works to be engaged with evidence and who saw a loved one come home from an actual military boot camp, this dark fantasy is an insult upon an injury. The positions of education leadership, be it DIO, program director, accreditor, what have you, have more power to change the clinical environments than residents and students and truth be told, even they will fail against the pressures of for-profit motivations, which can and do exist even in nonprofit systems.

I woke up thinking about Jesus in relation to all of this because for some reason it occurred to me that when we think about Jesus accepting lashes and punishment for our sins, there is, I think, a tendency to focus on how and why Jesus is willing to accept this; his grace in the face of those who would punish him. Such a focus quickly becomes a rationale for deriding anyone who is not so willing to forgive, to just take it. In the instance of students and trainees, this derision shows up as directives to placate, keep heads down, and just get the work done.  What might be a more helpful framework for this metaphor is to look at those who are delivering the lashes (and remember that when Jesus turned the other cheek it was a dare to engage in a cultural slight on the part of his violator). What if we asked what violence says about those who do the whipping, those who uphold the structures of oppression, that they would continue to do so, even when the focus of their ire forgave them? If we become more interested in focusing on those in power in moments where a learner, or even a faculty member, are brought before some sort of body for a professionalism review, would the deliberative body be not only more just but also more capable of itself becoming a change agent? If there is someone who is repeatedly brought before such a body, and that body were to look more deeply at the context rather than defaulting to enforcing fit with broken systems, it might see the truth of the needs within the systems with increasing clarity.

This is not to say that there are no professionalism issues, no attitude issues, no individuals that should be addressed and corrected. This is not to say that there is no entitlement or immaturity in medical professionals. There absolutely is, are there is in every profession, and truly, even though I’m not sure as of this writing what the percentages are, after more than a decade in this industry it would not surprise me to find out that people who feel particularly suited to heal or to help also are afflicted with certain types of attitudes to do so as they wish. However, both of these things can be true. It can be true that there are a lot of rebels without causes in medicine, and that there are rebels with causes in problematic systems. The fact that there are still labs that are forcing racial differentials on metrics where race has no bearing is evidence of the entrenchment of systems of oppression and medicine. The fact that medical students and faculty of color have had to be the generators of textbooks and learning materials about what skin-based conditions look like in non-white skin is evidence of the entrenchment of systems of oppression in medicine. The fact that powerful male physicians condemn and demean their female colleagues and residents by making snide comments about needing lactation rooms is evidence of the entrenchment of systems of oppression and medicine. The fact that so many medical professionals would prefer to die in silence than admit to anyone that they need help with a health condition such as addiction and mental illness is damning evidence of the systems of oppression in medicine.

If we are not taking the opportunity that we have as leaders in medical education to specifically hold the magnifying glass over such things, what are we doing? If we are not actively reviewing and critiquing long-held assumptions in the structures of medicine, are we not simply yet another generation that upholds them?

It is without question that change takes time, and that turning the policies and procedures and attitudes and behaviors of longtime leaders in health systems is akin to trying to turn the titanic with oars and elbow grease. This does not mean that it is not a worthy, important, and vital activity. In fact, given all that has occurred with COVID and the powerful rising of anti-racism and related movements, it may mean precisely that it is so worthy. Perhaps the lesson of the 40 lashes is not to accept punishment with grace, but rather to hold up the mirror to those holding the whips to say, what are you actually doing?

By Nikita Mehdiratta

Seared into the depths of my being, this profound encounter unfolded during my tenure as an intern doctor in 2020 amid the bustling chaos of the emergency room in India. The scene is set in a small, dimly lit hospital room with medical equipment scattered around. The air is heavy with tension, pain, and the smell of antiseptics. As I walked into the emergency ward, my eyes were immediately drawn to a young, 17-year-old boy lying in a corner bed, his body covered in burn wounds. My solemn expression was concealed behind a surgical mask. The suffering he must be experiencing seemed unimaginable. Taking a deep breath, I approached him, offering a reassuring smile.

I tried my best to remain composed, reminding myself of my duty as a doctor to alleviate pain and provide comfort. “Hold on, my friend,” I whispered, my voice filled with empathy. I removed the damaged tissue with painstaking care, exposing raw, vulnerable flesh beneath. The stench of burnt flesh filled the room, making breathing difficult. As I worked, I exchanged glances with the nurses, their expressions mirroring my sadness and determination. Throughout the procedure, the boy’s family stood by his side, their anguish palpable. The mother clutched onto a pendant of her deity, silently praying for her son’s recovery. The father stood silently, his face etched with guilt and despair.

Despite his efforts to remain strong, the patient, let’s call him Alex, winced in pain as I began tending to his injuries. As I continued to work on dressing the burn wounds, the screams of the teenage boy echoed in the minor operating room. Each peel of charred skin brought a fresh wave of agony to his already tormented body. I could see tears streaming down his face, mixing with the sweat and grime that covered his skin. “Please… make it stop!” Alex screamed, overwhelmed by the pain. I paused momentarily, assuring him we would take breaks whenever he needed them. “Just remember,” I said, “talking might help distract you from the pain.” With tears streaming down his face, Alex weakly nodded, trying to divert his attention from the torment. I conversed as I continued my work, hoping to alleviate his suffering. I asked him about his daily routine and what he enjoyed doing. His voice trembled as he spoke. “Well, I go to school every day,” Alex began, his voice shaky. “And after finishing my homework, I love playing cricket with my friends. It’s the best part of my day.” His words struck me like a dagger, and I couldn’t help but wonder what had led him to this point. What could drive a young boy to inflict such immense suffering upon himself? Summoning my courage, I decided to ask the question that haunted my thoughts. “Alex, if you don’t mind me asking, how did this happen to you?” His response struck me with disbelief and confusion. “My girlfriend… she broke up with me,” he confessed. I struggled to comprehend how heartbreak could lead someone so full of life and joy to such a desperate act.

Finally, after an eternity, I finished dressing his wounds. As the conversation with Alex ended, it became evident that healing wasn’t just about treating physical ailments but addressing the emotional and psychological scars that often remained hidden. As I left the minor operating room, I couldn’t shake off the heavy weight in my chest. The boy’s cries haunted me, and a whirlwind of inquiries surged through my mind, urging me to delve deeper into the intricacies of human behavior. It left me pondering perplexing questions. We have inevitably encountered heartbreak, traversing the emotional labyrinth of loss and pain. Yet, in the face of adversity, why do some people contemplate ending their own lives while others even suppress any inclination or thought of such despair? Is it conceivable that a complex interplay of genetics and environment shapes our cognitive frameworks, influencing how we perceive the world and respond to its tumultuous challenges? Mental illnesses can transcend generations, their origins entwined in our inherited traits and the environmental triggers surrounding us.

This experience forever changed me as a doctor, leaving an indelible mark on my professional journey. As the scene concluded, a newfound resolve filled my being. I made a solemn vow to truly hear the cries that extend far beyond the realm of the physical. Driven by the sincere desire to provide enhanced support to those grappling with mental anguish, I chose psychiatry as my specialization. With compassion as my guiding light, I have embarked on this chosen path.