Institutional Narcissism and Renewal: Tarot Insights into Residency Training and Academic Leadership, Part 1

This reflective essay provides a systems-level analysis of recurring themes reported anecdotally by attending physicians across specialties. It explores how hierarchical, interpersonal, and institutional dynamics in academic medicine can undermine faculty well-being and professional integrity. Tarot is employed not for divination but as a symbolic, Jungian framework for understanding these recurring relational patterns.¹

Most attending-resident supervisory relationships are collegial, constructive, and growth-oriented. This essay does not argue that residents are inherently entitled nor that institutional leadership is uniformly dysfunctional. Rather, it explores recurring patterns described by some attending physicians when systems fail under stress. As such, this essay serves to examine such instances from the attending physician’s perspective, independent of specialty, of when residents behave unprofessionally or incompetently—and when program directors, coordinators, departmental and/or hospital administrative leadership fail to appropriately intervene—the attending physician may experience profound discouragement, moral injury, and emotional trauma. Such dynamics can drive highly competent, empathetic, and dedicated attendings to leave academic medicine entirely.^2,3

Mel Robbins describes in her “just let them” theory to “detach yourself from the emotional or mental struggle that you can get yourself into when you’re thinking about either what other people are doing or how things should be going.”⁴ While this sounds liberating, this can pose a challenge for attendings who often cannot simply detach. They are financially, professionally, and legally bound to institutions that may not provide reciprocal protection. Many describe feeling “stuck,” echoing Stealers Wheel’s Stuck in the Middle With You: caught between competing pressures with no viable exit. This can produce chronic cognitive dissonance, emotional exhaustion, and erosion of institutional trust.

When Institutions Mirror the Archetypes of Narcissism

Across many academic centers, attending physicians who uphold high standards—and provide honest, constructive evaluations—report feeling unsupported, undermined, or scapegoated. Some describe institutional behaviors that resemble narcissistic relational patterns identified in clinical psychology: gaslighting, triangulation, weaponized incompetence, smear campaigns, and the mobilization of “flying monkeys.” Research indicates that organizational leadership style and institutional support (or the lack thereof) strongly influence whether attendings feel valued, supported, or at risk of burnout—beyond individual-level factors.^5-7

Attendings across institutions report:

• Residents weaponizing discomfort to evade accountability.^8,9
• Leadership rewarding mediocrity while punishing rigor.
• Program directors and coordinators discouraging appropriate chain-of-command communication.¹⁰
• Chief medical officers (CMOs) intervening prematurely, acting solely on trainee complaints.
• Leadership avoiding conflict at the expense of integrity and patient safety.
• Being pressured or coerced to modify accurate evaluations.¹¹
• Feeling dismayed when programs dismiss or minimize concerns, leaving them unsupported, unseen, and unheard.

This raises a critical question: Have essential skills—face-to-face communication, conflict resolution, and reflective dialogue—become deprioritized in some training environments?

Brief Literature Review

Psychiatrist Murray Bowen developed the family systems theory, which can be applied in a professional setting for attending physicians. In essence, it aids in the examination of the elements of systems that escalate problems as well as help the individual find solutions. “Seeing the system takes people beyond blame to seeing the relationship forces that set people on their different paths. This way of seeing our life challenges avoids fault-finding and provides a unique path to maturing throughout our adult lives.”

Recent empirical studies document widespread burnout, moral distress, and institutional dissatisfaction among attending-level physicians in academic and hospital settings. For example, a cross-sectional survey of nearly 19,000 academic physicians found that 37.9% met criteria for burnout, and 32.6% reported a moderate or greater intention to leave their institution within 2 years—burnout and lack of professional fulfillment were strongly associated with turnover intent.^13-15

Similarly, attending physicians supervising inpatient teaching services have reported substantial burnout, feelings of being undervalued, and strain balancing clinical duties, educational responsibilities, and administrative demands.

The concept of moral injury—a deeper distress experienced when systemic constraints or institutional failures force attending physicians to act (or prevent acting) against their ethical or moral values—has also gained attention.^17-21 Qualitative research among physicians caring for COVID-19 patients identified key sources of moral injury, including resource scarcity, institutional constraints, and conflicts between patient needs and institutional policies.

A broader narrative literature review implicates systemic factors such as lack of autonomy, organizational betrayal, administrative burden, and the corporatization of healthcare as root causes of moral distress and injury across healthcare professionals.^22-28

Despite this growing body of research documenting physician distress and turnover, minimal scholarship addresses the experience of attending physicians who feel scapegoated or professionally betrayed by trainee behavior or institutional politics—especially through symbolic, psychoarchetypal, or narrative frameworks.¹⁶ To date, no peer-reviewed article combines attending-level institutional betrayal, moral injury, and narrative-symbolic analysis (eg, archetypes, myth, tarot). This gap underscores the need for a reflective, theoretically grounded analysis like the present manuscript.

Tarot Cards, Carl Jung, and the Psychology of Institutional Archetypes

Carl Jung conceptualized symbolic systems such as alchemy, myth, and tarot as representations of universal psychological dynamics.¹ While he did not employ tarot clinically, the deck’s archetypes mirror unconscious roles enacted by individuals and institutions.

Tarot consists of 78 cards, each rich with symbolic imagery.²⁷ Used for reflection and guidance, tarot readings do not predict a fixed destiny; rather, they highlight potential outcomes and possibilities based on current energies, encouraging informed choice.

The Rider-Waite Tarot, the most widely recognized modern deck, was created by Arthur Edward Waite, illustrated by Pamela Colman Smith, and published in 1909 by Rider.²⁷ The 22-card Major Arcana represents life’s major themes, chronicling “The Fool’s Journey.” Cards can reflect astrological signs, spiritual journeys, or energies embodied by the individual or circumstances under consideration.

The 56-card Minor Arcana is divided into 4 suits, akin to a standard playing card deck. Depending on the context, the cards may reflect the 4 elements or indicate astrological, spiritual, or personal energies:

• Cups (water): Emotions, relationships, and the heart; sometimes linked to Scorpio, Pisces, or Cancer.
• Pentacles/Coins (earth): Material world, work, finances; sometimes linked to Capricorn, Taurus, or Virgo.
• Wands/Rods (fire): Action, passion, creativity; sometimes linked to Sagittarius, Aries, or Leo.
• Swords (air): Intellect, communication, conflict; sometimes linked to Aquarius, Gemini, or Libra.

Upright cards generally indicate a clear expression of the archetype, whereas reversed cards suggest blocked, distorted, or shadowed manifestations.

Within residency training and academic medicine, these archetypes manifest vividly at the institutional level^1,27:

• The Shadow (Three of Swords, upright/reversed): Represents unacknowledged incompetence, entitlement, avoidance, and hidden or denied aspects of residents and institutional systems that disrupt learning and patient safety.
• The Trickster (Seven of Swords, upright/reversed): Appears as leadership or administrative behaviors that manipulate truth, distort narratives, evade accountability, or covertly undermine others.
• The False King (The Emperor reversed): Embodies department chairs or CMOs who wield power performatively but abdicate responsibility.
• The Martyr (Hanged Man Shadow reversed): Manifests in the attending scapegoated for upholding standards, subjected to forced suspension or political timeouts, punishment rather than insight, and institutional paralysis framed as reflection or corrective action. Martyrdom is imposed, not chosen.
• The Tower (upright/reversed): Emerges during moments of institutional betrayal or sudden professional crisis.

Thus, Tarot serves as a symbolic vocabulary to describe what organizational psychology often softens: hierarchical systems can replicate narcissistic dynamics through fear, avoidance, and manipulation, particularly under stress. Tarot-based archetypes are metaphorical and illustrative, not empirical or evidence-based scientific research.

Part 2 of this essay is upcoming.

Dr Tirado is a forensic psychiatrist and academic clinician based in New York City.

Author’s note: This manuscript offers a psychiatrist’s perspective upon systemic reflection on patterns observed in some segments of academic medicine and residency training. It does not aim to describe or critique any specific individuals or institutions, nor is it a personal grievance. Any resemblance to real persons or situations is purely coincidental. The focus is on systems, not individuals or trainees. Structural conditions that fail both residents and attendings create dysfunctional interactions. Remarkably, the attending physician’s perspective is largely absent from the literature, despite their ultimate legal and supervisory responsibility for patient care.

References

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3. Sales PMG, Arshed A, Cosmo C, et al. Burnout and moral injury among consultation-liaison psychiatry trainees. Psychodyn Psychiatry. 2021;49(4):543-561

4. Robbins M. The “let them theory”: a life-changing mindset hack that 15 million people can’t stop talking about. Accessed February 9, 2026. https://www.melrobbins.com/episode/episode-70/

5. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129–146.

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8. Reddy ST, Zegarek MH, Fromme HB, et al. Barriers and facilitators to effective feedback: a qualitative analysis of data from multispecialty resident focus groups. J Grad Med Educ. 2015;7(2):214-219.

9. Duitsman ME, van Braak M, Stommel W, et al. Using conversation analysis to explore feedback on resident performance. Adv Health Sci Educ Theory Pract. 2019;24(3):577-594.

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12. Bowen M. Family Therapy in Clinical Practice. Jason Aronson; 1978.

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14. Lee BY. Academic physician unhappiness: 32.6% plan to leave their institutions. Forbes. January 31, 2024. Accessed February 9, 2026. https://www.forbes.com/sites/brucelee/2024/01/31/academic-physician-unhappiness-326-plan-to-leave-their-institutions/

15. Brender TD, Axelrod JK, Goitiandia SW, et al. Clinicians’ perceptions about institutional factors in moral distress related to potentially nonbeneficial treatments. JAMA Netw Open. 2025;8(6):e2516089

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17. Sonis J, Pathman DE, Read S, et al. A national study of moral distress among US internal medicine physicians during the COVID‑19 pandemic. PLoS One. 2022;17(5):e0268375.

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19. van Zuylen ML, de Snoo-Trimp JC, Metselaar S, et al. Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned. BMC Med Eth. 2023;24:40.

20. Washington W. A qualitative study of moral distress in physicians during the COVID‑19 pandemic. Walden Dissertations and Doctoral Studies. 2023. Accessed February 9, 2026. https://scholarworks.waldenu.edu/dissertations/14590

21. Keskin Kızıltepe S, Kurtgöz A. Understanding physicians’ moral distress in the COVID‑19 pandemic. J Exp Clin Med. 2022;39(4):958–965.

22. Smith CP, Freyd JJ. Institutional betrayal. Am Psychol. 2014;69(6):575-587.

23. Freyd JJ. Preventing betrayal. J Trauma Dissociation. 2013;14(2):159-162.

24. Freyd JJ, Birrell PJ. Blind to Betrayal: Why We Fool Ourselves We Aren’t Being Fooled. Wiley; 2013.

25. Gómez JM, Smith CP, Gobin RL, et al. Collusion, torture, and inequality: understanding the actions of the American Psychological Association as institutional betrayal. J Trauma Dissociation. 2016;17(5):527-544.

26. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383.

27. Rider-Waite deck. Tarot.com. Accessed February 16, 2026. https://www.tarot.com/tarot/decks/rider

28. Appelbaum NP, Santen SA, Aboff BM, et al. Psychological safety and support: assessing resident perceptions of the clinical learning environment. J Grad Med Educ. 2018;10(6):651-656.