A social worker lights a single candle, and the entire primary care staff watches the flame. In turn, we jot the names of deceased patients on slips of paper. When moved to speak, we place a name in the basket. Sometimes we speak. For Ian, whose laugh could light up a room. Other times, we bear witness in silence and sit back down. The gathering feels recent, but it last happened eight years ago. After COVID, much of primary care went virtual. At first, the flexibility to work from home felt liberating. Years later, I realize that virtual work has taken a darker toll on primary care. We’ve gained efficiency but lost the social glue of ritual.
Why medicine runs on ritual
During training, I took its layers of ritual for granted. Like the fish asking, “What is water?” I never realized I was swimming in ritual. Nearly every month offered an event marking our accumulation of knowledge, from resident graduations to award ceremonies to research days. On the wards, each year brought new milestones of responsibility. As a medical student, you might “pre-pre-round” at 5 a.m.; by senior year, you could stroll in at 7 a.m. for the rounding report from your underlings. The communal marking of time and accomplishment helps explain my unexpected desire to return to residency whenever I walk by the hospital. I didn’t miss the sleep deprivation, family sacrifices, or rigid hierarchy. On some level, I missed the ritual.
Ritual is easy to recognize but surprisingly hard to define. After traveling to sixteen countries to observe weddings, funerals, and other rituals, writer Bruce Feiler arrived at this definition: Ritual is a structured, repeated, and meaningful act that connects people in times of change. Many aspects of primary care fit only part of the definition. A performance review with your boss may be meaningful and repeated yearly, but it’s not communal. The morning huddle is structured but rarely connected to times of change.
The centrality of ritual in medical training also serves a darker function. For soldiers training for battle or monks living in monasteries, ritual provides the scaffolding for submitting individual identity to a larger whole. In short, rituals can train people to conform within what sociologist Erving Goffman called “total institutions”: places separated from wider society where daily life unfolds under highly regulated rules. Think prisons, boarding schools, and psychiatric hospitals.
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But medical training can fit the bill as well: The institution governs how and where people work, eat, and socialize. As I finished internal medicine training, I couldn’t walk down the hall without someone asking, “What fellowship are you doing?” The idea that I might simply leave the institution seemed unthinkable.
Bringing ritual back
Those of us in primary care leave the total institution of the hospital yet retain a desire for the deep connections forged in training. I’d go further: We miss ritual. We treat patients in isolated exam rooms, then retreat behind screens for virtual team meetings. Late at night, our inboxes beckon with notifications and alerts. Like teenagers tethered to social media, we’ve made our screens a kind of total institution. In moving toward a virtual existence, we’ve lost the hallmarks of hospital ritual: accomplishment, milestones, and community. How might primary care recover ritual?
One challenge lies in another facet of ritual noted by Feiler: It is fundamentally unnecessary. Unlike many tasks in medical clinics, ritual serves no obvious functional purpose. It’s neither billable nor measurable. Sure, ritual and community may improve retention and reduce burnout, but I’m skeptical that corporations will invest in them.
Since reading Feiler, I’ve noticed two promising avenues for restoring ritual. First, during patient visits, I ask about upbringing or what brings a patient joy. I make time for open-ended questions about illness, aging, and grief. If I’m running behind, the exchange may be brief. On slower days, I let myself linger and go deeper into patients’ stories. The second is restoring ritual within our care teams.
Before the world went virtual, a senior clinician led an outpatient morbidity and mortality (M&M) conference, a ritual typically reserved for hospitals. As we discussed cases, we ate oversized bagels and made eye contact across a conference table. He dissected each case: what went well, what he could have done better, and how it affected him personally. Notably, both require getting off our screens and being willing to sit with uncertainty, either with patients or with our own vulnerabilities.
This past week, my phone dinged with an email offering condolences for a patient who had died. I rolled my eyes, exasperated that this is how we now learn of death: stopped at a red light. I considered detouring to the hardware store for a wicker basket, a candle, and some index cards to revive the ritual of mourning our patients. But my inbox was ballooning, and I was already running behind. I took a breath and silently acknowledged my patient. Then the light turned green.
Tom Peteet is a board-certified internal medicine physician, educator, and writer. For nearly a decade, he has practiced at Commonwealth Care Alliance, focusing on home-based care for patients with complex disabilities. He also cares for patients in long-term care facilities and works with InstED, a mobile health program that brings acute care into patients’ homes.
As an adjunct professor at Massachusetts College of Pharmacy and Health Sciences, he directs a year-long pharmacology course for physician assistant students. At Boston University, he has taught more than ten courses through its prison education program and is developing courses in neuroscience and medical anthropology.
His scholarship spans medical ethics, medical education, and health equity, including work on the treatment rights of incarcerated patients, the role of theory and the humanities in medical training, and the intersection of quality improvement and equity in residency. His writing has appeared in the AMA Journal of Ethics, Medical Teacher, and the Journal of Family Medicine, and he authored a 2025 textbook chapter on renal disorders in Pathophysiology in Focus.
His writing explores health care ethics, medical education, and the overlooked paradoxes of human physiology. He writes Against Medical Advice, a Substack on the hidden science of medicine, and is working on a nonfiction book about the strange science of blood pressure. More of his work is available on his personal website.
