Title: Initiation and Death in Becoming a Doctor
Szerző(k): Lázár Imre dr. - Semmelweis Egyetem Magatartástudományi Intézet
Rovat: A gyógyítás hagyományai - hiedelem, tudás és gyakorlat
bonctermi gyakorlatok, az orvossá válás szertartásai, szembesülés a halállal, az emberi test tárgyiasítása és „abjektivációja”,” karneváli” rituselemek az orvostanhallgatók között, a rituális distressz
dissection of cadavers (DC), rites of medical initiation, ”encountering death”, objectivation/abjectification of the human being, carnivalian rituals, distress ritual complex
In this paper the authors examine the initiation aspects of „”encountering death”, the first impressions of confrontation with a cadaver in context of the theory of ritual initiations based on the vast literarture of psychological influences exerted by cadavers, abject bodies, human remnants on medical students. We connect these hidden elements of becoming a doctor with the traditional initiation rites incorporating extreme challenges, physical exhaustion and near death experiences, involving issues of distress and confrontation with death at the same time. The common element is the critical change in perception of life and death, while it makes a difference that mysteries enforce belief in the afterlife, and the ”survival” of the ghostly, spiritual or pneumatic content of human existence in spite of the medical confrontation with the death inducing rational reification and objectification/abjectification of the human being. The paradigmatic difference comes from the antagonistic opposition of the sacral (traditional, religious views of the human being) and the secular credo of bioreductionist biomedical view of the human being.The supportive elaboration of this early preclinical experience with the cadaver, as impersonal dead body may help to gain more empathy and respect in the clinical practice and counteract the early burnout of some medical students.
The medical student has his first, imprinting-like meeting with the patients at the threshold of life and death in the rooms of anatomy, dissecting the preserved dead body. Qualitative studies verify the importance of learning anatomy by experiencing the dissection of cadavers in the development of professionalism in being a doctor (Swick, 2006; Netterstrom and Kayser, 2008), and according to Boecker et al. dissection courses foster professional competencies like team spirit, the development of learning strategies, self-reflection and time management.
Finkelstein and Mathers write that instead of the professional detachment that the school expects of them based on the belief that this anatomical experience is an emotional routine, ”the detailed observation of over 300 students in this four-year study shows that students' responses to the gross anatomy dissection lab are neither routine nor unremarkable.” (Finkelstein and Mathers 1990). Their study based on analysis of daily personal accounts of dreams and comments, and questionnaire data proved that students encounter a pointed challenge to their existing adaptive strategies.
The students exhibit their response publicly in their talk and in their sarcastic humor in the lab, and conceal aspects of their subjective responses from their teachers and colleagues. In a Hungarian study Turcsányi, Rigó (2006) also verified that encounters with the dead in anatomy and pathology labs induce unconscious defense mechanisms which has outstanding importance as it is in strong conflict with the special sense of the infiniteness of human life in the teenage years.
On the other hand this initiation or imprinting-like early confrontation with death may cause distress which may be one of the side effects of medical education inducing personality changes, generating cynicism (Wolf et al. 1989), a changing value system (Bánfalvi 2003) and depersonalizing tendencies pushing the care giving empathy to the background.(Hojat et al. 2004).
The ritual distress concept of medical education during the ”rite of passages” of becoming a doctor is not far from the concept which handles dissection course as a source of traumatic experiences lending ”post-traumatic stress” status to this experience, for example Silver (1982) proposes the term „battered child” phenomenon, drawing parallels between common observable features and changes in case of medical students and abused children. This landmark study presented in JAMA pointed out that both children and medical students had suffered largely ignored and/or unrecognized abusive episodes leading to a gradual transformation from eagerness and enthusiasm to depression and fear. The same parallel was shown by another article with the statement that “like neglectful and abusive families, medical training is often characterized by unrealistic expectations, denial, indirect communication patterns, rigidity and isolation.” (McKegney 1989)
In our theory of medical where the experience of stress by medical students is an integral part of the rite of passage of becoming a doctor during the process of medical professionalization (Zsinkó-Szabó 2012),it cannot be denied that encountering the problem of death in the frame of dissection of the cadaver is part of circle of ”initiative stressors”. According to Gustavson (1988) anatomy lab practice is a source of distress, and coping with abhorrence put pressure on the students, while there are other reports conferring about much less stress caused by these practices (Dinsmore et al. 2001) It offers a cross-cultural perspective when we compare the reactions of medical students with different cultural backgrounds to their anatomical tasks. 30% of Australian students showed physical symptoms on first exposure to cadavers in the dissecting room. (Horne 1990) Abu-Hijelh et al. (1997) found the anatomy practice a strong stressor accompanied by tremor, loosing appetite in almost on fifth among the students, and 38 % reported the repeated frightening appearance of an image of the corpse. 46% of Arabic medical students from Muscat and Oman experienced some level of fear before and during the initial dissecting room practices and 17.1% of first year students and 21.1% of second year students suffered prolonged symptoms, lasting over a year. In African reports one can find also higher distress compared to the European reports, as in the University of Benin, Nigeria, medical students identified the dissecting room as a very important source of stress. (Nnodim 1996) It has been reported that although the majority of American students expressed a positive attitude toward the initial experience of cadaver dissection, a small percentage of students found it traumatic, while Malaysian students were more likely to rate the stress level as “moderate” or higher.
The authors found that experiencing of the dead push the focus of fear of death from the impersonal abstract to the intimate personal scenes, as some of the students provided descriptions in their dream diary about the intrusions of images of the dissected dead body attached to their relatives. The confrontation with the dead body in a lab simply links up with what has previously been repressed or actively excluded from consciousness. Bad memories or fearful anticipations come to the fore in dreams, as if hooked or dredged from the unconscious by the sights of dissection.The image of death is translated into symbols such a dream scene like Finkelstein’s some samples show :"My mother was dead but she was still walking around. I was crying because she was dead. She kept saying that she didn't know what she was going to do now." or another sample where: ”An escape artist was performing underwater with dangerous serpents. In the final trick the serpents would not let go and strangled me.”
Sometimes the dreams are about the own body, the Self as the dissected Other:”I was home watching my own body; it had no face, no skin. My father was operating on me. Later, he went out to work on the car.” or extreme visions like :„”I sat down at a greasy spoon type diner and ordered a cadaver.” (Finkelstein, Mathers 1990)
These dream-fragments show the unconscious reflections challenging of the notion of “unremarkable” exposition to the dead and dissected human Other.
Dissecting body parts, like the face and hands expressing human personality induces strong emotions. (Shalev and Nathan, 1985) It seems also disturbing to be confronted with a still intact cadaver. (Finkelstein and Mathers, 1990).A small part of medical students used to report nightmares, sleeplessness and learning difficulties(Finkelstein and Mathers, 1990; Druce and Johonson, 1994; Dinsmore et al., 2001).That is why Finkelstein compares this distress caused by a dissection course in a 5% minority of medical students to the PTSD (post traumatic stress disorder), which got McLachlan et al. (2004) to propose the abolition of dissections because of their disadvantageous effects.
The denial of the stressful stimuli includes re-framing the situation and the presence of several unconscious defense mechanisms, like joking, giving nicknames ”domesticating” the cadaver. Laughter in the lab is a way of re-framing that helps to diminish unconscious tension by reducing the status of the cadaver to one that is less human. In such cases we have to realize that dehumanization becomes one of the first hidden ritual elements of becoming a doctor.
Facing the cadavers generates psychosomatic bodily reactions as well, showing that this exposure of the novice to death is not a superficial, but a truly transformative and embodied experience just as it was in the early phase of the clinical age. As Boeckers et al. (2010) cite Platter in the “Theatrum anatomicum”, the mere sight of a dead person was often enough to be known to engender the greatest of terrors - it was reported to have serious effects such as “severe persistent melancholy” or even “a deadly convulsion which originated as a result of fright and fear of the corpse” (Platter, 1614).
Boeckers et al (2010) also deal with the problem of psychological support needed during the stressful dissection course, offering a step-by-step optimization of the confrontation with the cadaver to be dissected. One can say that this support may gain a meaning of a sort of ”counter ritual” which ”decompresses” the heavy elements of the anatomical period of medical initiation. The disclosure of trauma was facilitated by motivating students to talk about the dissection process by asking them to document the group’s dissection process in follow-up sheets at the end of each lab day on a voluntary basis, and students had the opportunity to creatively express their impressions on the cadaver by designing a poster as a team project. Another ritual, the so called funeral service helped harmonize impressions of the cadaver and the history of a human person after the course again. In this ceremony students could express their gratitude by readings, poems and personal reflections.
The ritual environment of the dissection
The milieu of anatomical dissections itself is full of cultural signals, the hygiene, the mix of the architectural elements of the historical fin de siècle buildings and high tech elements of the work lab, the aluminum tables with metal plates full of human remnants, and a wooden 100 years tumulus called ’tumba’ that students used to sit on, containing the dead wrapped in cheesecloth saturated with formaldehyde. The formaldehyde has not only penetrating smell, but it is a dangerous gas with a hidden meaning of unavoidable risks a doctor must accept.
The other meaningful ritual element that there are strong ethical features of conduct, as students are expected to "act like a doctor," in their white coats, when faced with the cadaver in the very first moments and far from the real clinical scenes. They have to treat the cadaver - their first patient - with respect, and to deal with any emotional tone, with inhibited expressions of true anxiety or sorrow, facing the reified, objectified former human being.
According to Finkelstein the message is written implicitly in the narrative of the field: ”study hard and learn a lot; learn to be objective; there is little place in the practice of medicine for the subjective response.”
But this experience is also a ritual transition itself with a liminality and a vulnerable transitory status of the medical student prolonged for two years under the weight of the extreme amount of the lexical knowledge and the emphasized uncertainty of the success of the final exam on anatomy, which symbolically provides the D in the Dr.
What are the meanings of the psychosomatic consequences and dream bursts of the unconscious, and the denial efforts, jokes, abstract terminology and cognitive frames or the sterile environment, the field worker may trace based on these reports, interviews. Another cluster of meaning is attached to the traditional architectural milieu of the Golden Age of the Clinical Epoch, the Anatomical theatre, which offers historical depth to the process of identification with the Clinical Paradigm gaining the medical gaze, the history of which was uncovered by Michel Foucault.(1973).
Narratives and metaphors about facing the Death
Our informants attending the Semmelweis Medical University as first and second year students of the preclinical years were asked to write reports of their field experience entering the ”world” and practice of Dissection Course, and the encounter with the dead body. Medical anthropological training includes field work to develop professional self reflections, and cultural openness towards other healing practices in the context of medical pluralism and cultural insights of medical phenomena based on holistic and relativist episteme (Zana, Zsinkó-Szabó 2013). This medical anthropological inquiry may be also part of medical rite of passages.
Meeting the dead happens step by step. In the first weeks the novice becomes acquainted with only bones, then the gray colorless corpse sunk in the formalin comes, and it takes still three years to be confronted with the real patients. The strange auditorium, where first anatomic lectures are kept is a close relative of the Anatomical Theaters of the 17th century.
Our students being asked to report about their encounters with the anatomical other reported special initiations as a sequential process, when first they take human bones, femur or scapula. A student described the moment of taking a human bone in the hand like to keep the ”keys of the world of life and death”, or feeling like an archaeologist who enter in the past via these fossils.
Observing bones doesn’t cause emotional difficulties, but legs and arms with ligaments, and muscle on them is usually very disturbing.
Sometimes they recall the iconography of crime movies, thrillers and horrors, as the mediascape of contemporary thrillers (e.g the movies of Eli Roth or Wan’s Saw) are filled with destructed or abject bodies. Even theatre plays are perfused with abject bodies. It is not surprising that some of the students are sinking in these distorted connotative tones during confrontation with bodily parts disconnected from the trunk. As one of them emphasized, anatomy is fantastic and interesting, but unbelievably terrifying at the same time.
In the beginning the body for dissection is covered or kept in the ”tumbas”, and the face remains uncovered for a long while. Later novices must dissect more complex parts of the trunk, like the pelvis or even genital organs. But the skull and faces are uncovered for dissection later. These former ”others” and ”peers” and neighbors are now dissected, fragmentary ”anatomic others”, called Samu, Juliska or Manfred. The horror induced by these corpses and bodily remnants is soon transformed to scientific distance and mastery and sarcastic dark humor and noir irony.
It is a usual task to get a skull, which is usually job to be done individually. Some students borrow one, some go to the cemetery where some graves are not be supported by family members anymore, or skulls can be borrowed from the legendary Master Dissector of the Institute. A series of urban legends are told about these transactions, how students go down to the cellar of the Pathological Institute, a scene of another descent, a transition to the Land of the Dead, where human bodies are transformed to be objects of the science, anatomical preparations.
It is another part of the initiation that when bringing these skulls home they experience the resistance or denial of the family members. They are usually asked to keep the skulls in a paper box, and not to deal with i in the presence of the members of the family.
The questions and reactions of friends and relatives regarding the anatomical experience generates boundaries around the students; they step by step become professional others for the former group members, members of a new minority.
We collected the field work reports of the ”encountering death” experience during dissection courses and analyzed them in categorical-content perspective.
The results of narrative analysis in categorical-content perspective
The above listed sentences prove that humor, reification and objectivation, distancing the dead as another human being has a stress-buffer function, and a special interface between fear of death and keeping empathy potential towards the patient. This generates a ritual liminality during the learning experience as well. This ritual function helps to work the mechanism that Turcsányi and Rigó (2006) offered in their paper.
Here we try to define two ritual elements derived from different rituals appearing in the same scene, one is the “initiation-distress” complex derived from the suppressed psychoterror of encountering the dead body (a former ”person like you and me”, and our close relatives) and the abusive distress content of the burden of learning material, and the other is the carnival inversion (humor, joking as adaptation and distancing etc.) generating a ritual liminality limited only for this dissection experience of the novices. These otherwise hardly tolerable, frequently embarrassing jokes, gestures create an atmosphere of inversion, ambivalence, and excess, which leads to an intermediate, liminal status of the situation
(Figure modified after Turcsányi&Rigó )
Rituals as overcoming Death
Fear of death and neardeath experiences play a prominent role in initiation rites and in other kinds of religious symbolism of the rituals. Resurrection and the Eucharist as the centre of Christian celebration of salvation is also about this final liminality of passage towards death and after-death status of crucifixion and the resurrection after three days.
But these mysteries are not about visibility, their essence is just the opposite. If comparing Eleusinian, Osirian, Adoniac or Pythagorean Mysteries, all of them happened in secret isolation far from the ”innocent bystander” audience. They discussed death in the framework of the secure option of life after death, or in the frame of the inevitable resurrection, with the notion of the supremacy of the spirit above its somatic capsule. Their symbolism represents the notion of the cyclic renewal of Nature nurturing their agricultural subsistence, and the way of the spirit through different somatic embodiments. The common narrative trajectory implies the cycle with three phases, the "descent" (loss), the "search" and the "ascent", be it in the story of Osiris, or Persephone and Demeter. Dionysos or Orpheus performs this Katabasis to seek and bring back the Other from the world of Hades. In the Dionysian cult the final event was the communion with God through shared wine. In the Orphic cult the death was about life and afterlife, where human souls as divine and immortal entities were sentenced to live in a "grievous circle" of successive bodily lives through metempsychosis or the transmigration of souls. Good and ascetic life and secret initiation rites guaranteed the release from the "grievous circle". This religious and mystic commitment was supported and reinforced by sacred writings about the origin of gods and human beings. The (Dionysian) soul of man was supposed to be divine, while the (Titanic) body held the soul in bondage.”Now you have died and now you have come into being, O thrice happy one, on this same day. Tell Persephone that the Bacchic One himself released you.”
That logic is reflected in the converging circle of these initiations be they Orphic, gnostic or other contemporary hidden sect rituals, or every day ”rite of passage” experiences of religious confirmation, wedding, graduation. So one can perceive these ”death rituals” as ceremonies about the victory over death.
The biomedical rite of passage in the dissection room has an analogous narrative trajectory with "descent" and a sort of loss of lay innocence regarding the human body, the "search", (seeking knowledge, the power of terminology, and deconstruction in the frame of personal immersion into an abstract human microcosm) and the "ascent", the return with knowledge on the final exam of anatomy. Dissection as biomedical ritual is about the symbolic and scientific victory over the mysteries of the human body. The novice has to accept, objectify and reify it, with suppression of own emotions and spiritual and mysterious understanding of the human being.
When entering the community of medical students the secondary school pupil dies and on the same day a university student arises with different norms, expectations and burdens . The Dionysian character of these student camps - the so called Gólya tábor- usually seems to be very striking, a Carnival, implying the content of this changing relationship with death. ”Gólya”(stork) means a novice, a freshman, a newcomer first year student, who has to build his or her new home in the university life. As the semantic web of the bird stork Gólya is linked with the myth that newborn babies are brought and dropped by storks, a skeleton of a stork as a symbol of the ”Gólya” camp bears strong inverted symbolism.
The freshmen students mask themselves as devils, worms, ghosts, mummies and vampires, a sort of underworld, or after-world status - beyond or afterlife symbolization.
The prominent presence of alcohol along the students’ program, their competition of gathering and stealing wine and drinking it from a basin, ecstatic dance parties lends a strong Dionysian character as well.
On the other hand the transformative character of the camp fulfils its role, and it is even expressed by the closing programs. For example the group of devils presented a show based on a song ”Half an angel, half a devil”
Vampires, zombies, mummies – all of them lent from horrifying mediascape idolized by this generation. Young teenager girls are fans of the darkest horrors, as the success of the movie ’Twilight” shows.
This Dionysian type of student ritualism expressed an escape from the socialized personality and ego into an ecstatic state with invigorating, cathartic, liberating and transformative content. As the ancient secret mysteries are generally accepted to be associated with the consumption of some substance(s), possibly as a beverage, these induced visions and a feeling of oneness with at least mankind, if not the universe. This made the event particularly secret enough, in addition to it being a special occasion and certainly subject to strict sanctions if secrecy was violated.
The “gólya- camp” in spite of its Dionysian, more or less transgressive character is not kept in visual secrecy. Just the opposite happens, Facebook albums, JPG, bmp chronicles generate harsh publicity via their documentative presence and shared visions of the transition towards the biomedical novice, the master of the corpses at the anatomical theatre.
Confronted with the real dead
If we drew parallels between the initiative framework generated by the narrative trajectory of mysteries and the hidden ritual sequence of the medical curriculum, as a prolonged ”rite of passage”, the first preclinical years may be considered as a ”descent’ into the world of the spiritless, even impersonal somatic reality, when the student is immersed into the climate of anatomical practice surrounded by evaporating formalin, and deals with molecular, histological, biophysical deconstruction and the abstraction of the human body.
The period of search is a real search for the patient in the clinical manner, re-framed in a new clinical scientific cosmology immersed in the context of nosology, and clinical terminology, while the ”ascent” stage is the period of the synthesis of knowledge and the clinical encounter with the real patients.
Although the everyday presence of dead corpses induces insensitivity, suppressed emotions, nevertheless there are some horrific legends, which offer a concrete pilgrimage-like framework to the ”descent” into this ”underworld” content. The brave and curious groups of students frequently fight for the right to visit this underworld, to descend to dirty, dark cellars and halls, where the transformation of the everyday dead also creates a strange ”rite of passage” to become conserved flesh for scientific and educational use. According to the myth whispered by students the Forensic Pathology, the I. and II. Institute of Anatomy, and the II. Dept of Pathology were connected with a 50 meter long track of an underworld mini train, where the bodies were pulled from one place to another .The legendary figures of this hidden labyrinth-like world are the Boss, the Master Dissector (mentioned above), who is an older man who has been working among these dead corps since the late sixties, and his deputy is called ’Jesus’ because of his beard. This is a forbidden and closed place for common medical students except the chosen ones, ready to go down to make anatomic preparations for their ”scientific achievements”. A mystic fog and the weak light of glimmering light bulbs covers this underworld, ”where there are rooms with only one key, and basins where the parts of human bodies are floating in preparation fluids, and the Boss is so mighty with his ”supra-institutional” power, even “Jesus” cannot enter without his permission.” As the brave ”descending” students report, ”there are cauldrons like those in the public kitchen, where dozens of neonatal corpses are floating” and a vat covered by a blanket, and the ”Boss pulls down the pall saying: here you see cca. 250 hearts”. ”And we have seen saw the saw for the bodies, an industrial version, and a body that has just been filled with formalin, with fluid leaking from his eyes and other holes, just as in the horror or zombie movies”. ”It is an industrial or rather manufacture-like zone where the former person becomes an educative object, a thing.”
Joining to the clinical mesocosmos needs transformative rituals, real “rites of passage” which help to cope with distress caused by facing the death. Even the “Stork” freshman-camps seem to have a preparatory function for this descent with features of the carnivalian inversion generating a ritual liminality. But the „initiation-distress” complex is as important regarding the first student experiences related to the dead human body. Coping with the psychoterror derived from the encountering the dead body („a former person like you and me and our close relatives”) and the abusive distress content of the burden of learning material created an atmosphereof inversion, ambivalence, and excess, which leads to an intermediate, liminal status of the situation. In this situation one may cope withotherwise hardly tolerable, frequently embarrassing jokes, gestures generating a carnivalian inversion to ease the pressure by cognitive distancing. The dissection courses with their scientific framework, atmosphere and requirement of disciplined conduct and ethics helps to reify and objectivate the relationship with the dissected human Other. The so called „ritual distress complex” incorporates the challenging amount of learning, the confrontation with the dissected, dead remnants and the abject nature of human body and offers coping ways of scientific cooling of personal empathy for the dead Other person, a symbolic victory of knowledge over the fact of somatic reality of fate. Comparing Mysterium initiations and the hidden ritual of dissection course we foundthe critical change in perception of life and death as a common element, but based on the antagonistic features of disenchanted scientific and religious, mystic paradigm the cosmological core of the ritual proved to be different. It became obvious that while mysteries enforce belief in the afterlife, and the „survival” of ghostly, spiritual or pneumatic content of human existence, medical confrontation with the death induces rational reification and objectification/abjectification of the human being.
Based on the reviewed literature and the findings of our field work it seems reasonable to complete the medical curriculum with personal support to cope with the psychic burdens of reification and objectification of the Other Human Being, even if the above mentioned spontaneous hidden ritual elements are part of the behavioral arsenal of medical students in the early phase of their curriculum.
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