Whatever one may think about the purpose and utility of royalty in the 21st century, the coronation of Charles III was a magnificent but eye-wateringly expensive spectacle. It may be the last of its kind in the UK, and I do feel that Australia will become a republic before too long.
This was a costume drama out-of-step with the modern world, steeped in history, a one-thousand-year-old ritual that has crowned many kings, and a few queens, including the loved, the cruel, the despotic and the weaklings.
Ritual is a word with different connotations depending on the dictionary. It is a religious ceremony or simply an action repeated in a customary way. The latter definition fits with much of what we do in health professional practice.
I worked as a nursing assistant at the local hospital for a few months before I went to medical school. Every morning there was a ward round when the doctors visited each of their patients to check their progress and oversee management of their conditions. These daily rounds were usually informal.
The consultant weekly rounds, however, were undertaken with a strict protocol depending on the specialist’s individual requirements. I think there were three different firms (teams) who had patients in my ward. So, three different expectations of how the round should be carried out. Sister was in attendance usually with one staff nurse, the rest of us had to be quiet and carry out our tasks without getting in the way. A junior doctor was in charge of the medical records and note taking. Flowers had to be removed to the sluice and bedside tables emptied. One of the consultants wanted each patient to have a urine sample in a flask beside their bed though I did not see him do anything with it – perhaps he noted its colour. Patients didn’t speak until spoken to. Looking back, this process was ritualistic.
Later I noted that a home visit by a GP was still a ceremonial occasion in some households. The house would be cleaned, and tea made. In return patients expected questions to be asked, a physical examination to be made (particularly the pulse and blood pressure with the ritual instrument – the stethoscope) and a prescription issued. In the consulting room we often tend to follow a set pattern of questions based on what we learned as students surrounded by the paraphernalia of our profession.
Historically healers have employed ritual in their work, frequently in sacred spaces, and this behaviour contributes to healing, in some part due to the placebo effect.[1] Healers traditionally have had their own costumes to distinguish their calling, including the regalia of shamans typically imitating an animal, and the rattles and masks of medicine men. In the west we moved from the decorous, simple and not over-elaborated dress advised by Hippocrates, via the plague doctors of medieval Europe with their take on PPE including a beak-like mask and gloves, to the white coats of modern medicine and covid-era PPE. Nursing uniforms have similarly evolved from starched white caps and aprons to polyester dresses and plastic hats to scrubs.
Perhaps we need to challenge some of the ways we do work and avoid the excuse of ‘we have always done it this way’. If rituals get in the way of patient-focused practice, they should be rethought. However, rituals that act to put patients at their ease should be encouraged, particularly those that increase treatment adherence and promote positive behavioural change. Research has indicated that the repetitive nature and functional properties of rituals facilitate the transmission of behaviours including health-related ones, within cultures and communities.[2]
In education the objective structured clinical examination (OSCE) can be viewed as a ritual. It has ‘performers, costumes, props and…theatre.’[3] This is not solely an assessment but a performance where students learn to play the role of the doctor,[4] the nurse or other health professional.
But at this present time, do we need to rethink our rituals in practice and in education? What works for and what hinders patient care?
[1] Welch J. Ritual in western medicine and its role in placebo healing. Journal of Religion and Health 2003; 43: 21-33
[2] Legare C, Burger O, Johnson T et al. Leverage the power of ritual to improve community health worker efficacy and public health outcomes. Lesson from Bihar, India. The Lancet Regional Health 2022. https://doi.org/10.1016/j.lansea.2022.04.002
[3] Gormley GJ, Johnston JL, Cullen KM, Corrigan M. Scenes, symbols and social roles: raising the curtain on OSCE performances. Perspect Med Educ. 2021; 10(1):14-22. doi: 10.1007/s40037-020-00593-1.
[4] Hodges B. OSCE! Variations on a theme by Harden. Medical Education 2003; 37: 1134-1140.
Health professional education and practice 