Institutional Narcissism and Renewal: Tarot Insights into Residency Training and Academic Leadership, Part 2

This essay continues to explore 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 See part 1 of this commentary here.

The Misuse of “Psychological Safety” in Residency Culture

“Psychological safety,” as originally defined by Amy Edmondson, refers to the ability to take interpersonal risks during learning without fear of punishment or humiliation.² In many contemporary training environments, however, this concept has been distorted.

Originally, it meant:
“I feel safe making mistakes as I learn.”

It is increasingly interpreted as:
“I should never experience discomfort.”³^,⁴

This misinterpretation produces predictable patterns:

Tarot provides symbolic parallels to the attending’s lived experience in these circumstances:⁵

• Three of Swords (upright): heartbreak, grief, betrayal, sadness, and trauma.
• Five of Swords (upright): defeat through manipulation, hollow victories, degradation, unfairness, slander, cruelty, and cowardice.
• Seven of Swords (upright): strategy, evasion, reputation theft, and covert maneuvering.
• Eight of Swords (upright): constrained circumstances, indecision, inaction, betrayal, and fear of moving forward.
• Nine of Swords (upright): despair, sorrow, nightmares, grief, disappointment, and deception.

This observation does not negate the essential importance of non-weaponized psychological safety in training environments.

Observations From Academic Medicine

Across specialties, attending physicians increasingly report:

• Administrative politics: complex hierarchies and power dynamics that obstruct professional judgment.⁶^,⁷
• Fear of providing feedback: hesitancy stemming from anticipated retaliation or escalation.⁸^-¹⁰
• Resident entitlement: behaviors that challenge authority, evade accountability, or prioritize comfort over learning.⁸^-¹⁰
• Retaliation for upholding standards: negative repercussions when maintaining professional or ethical expectations.⁷^,⁸

This essay does not focus on overtly malignant programs, but rather on well-intentioned, committed faculty who are left unsupported despite carrying ultimate responsibility for patient safety, documentation, and supervision.⁶^,⁷^,¹¹

Although considerable research addresses resident wellness and physician burnout, there remains a notable gap in scholarship examining attending-level institutional betrayal—particularly through symbolic or archetypal frameworks such as tarot or narrative analysis.¹¹^-¹³

When Leadership Patterns Mirror Narcissistic Dynamics

In academic medicine, department chairs, residency program directors and coordinators, and CMOs can function as the institutional embodiment of the tarot’s Devil archetype: creating systems of coercion, manipulation, and professional constraint.¹⁴^-¹⁶

Common manifestations include:

• Coercion cloaked as professionalism.¹⁴^,¹⁵
• Pressure to alter or soften evaluations.⁷^,⁸
• Mandated compliance with political or administrative narrative.¹⁴^-¹⁶
• Threats or obstacles to career advancement.¹⁴^,¹⁵
• Retaliation against attendings who maintain high standards.⁷^,⁸^,¹⁰
• Leaders requiring subordinates to act on their behalf.¹⁴^,¹⁵
• Mischaracterization of the attending physician as part of a smear or narrative manipulation campaign.⁵^,¹⁴^-¹⁶

Tarot parallels:

• Emperor Reversed: abuse of authority, rigid control, and destabilization of systems. Leaders prioritize power over fairness and institutional integrity.
• King of Swords Reversed: decision-making driven by fear, self-interest, or political expedience rather than logic, ethics, or principle.
• Queen of Swords Reversed: communication deficits, malicious gossip, and lack of empathy; symbolizes leaders who weaponize relationships, distort narratives, or undermine trust.

Flying Monkeys: The Administrative Smear Campaign

The term “flying monkeys,” drawn from narcissistic abuse literature, describes individuals who execute the bidding of a narcissistic figure.¹⁰ In organizational psychology, analogous patterns have been described in which individuals may, consciously or unconsciously, reinforce dominant narratives without independent verification. In academic medicine, these actors may include:

• Residents who disseminate distorted narratives.⁶^,¹¹^,¹⁷
• Attendings who participate in gossip rather than fact-finding.³^,⁸
• Administrators who amplify one-sided complaints without verification.⁴^,⁸^,¹⁰
• Program directors and coordinators who permit escalation without review.³^,⁴
• Department chairs who mobilize staff against a targeted attending.³^,⁴
• CMOs who intervene prematurely based on rumor or incomplete information.³^,¹¹^,¹⁷

When Supervisory Authority Becomes Blurred

A concerning trend in some clinical training environments is the erosion of respect for attending authority. In programs influenced by administrative politics or dysfunctional culture, residents may increasingly perceive attendings as obstacles rather than supervisors.⁸^,¹¹^-¹³^,¹⁷ In such contexts, the attending often becomes the “acceptable target” for frustration, projection, or institutional blame, despite retaining ultimate legal responsibility for patient safety.⁸^,¹¹^-¹³^,¹⁷

Tarot resonances:

• Five of Swords represents underhanded behavior, triangulation, and weaponized communication.
• Five of Wands symbolizes conflict, friction, and challenges to legitimate authority.
• Seven of Swords signifies covert avoidance, distortion of facts, and operating in shadows.

Consequences:

These dynamics foster a generation of physicians who may lack humility, insight, accountability, and conflict-resolution skills—skills attendings are expected to model and cultivate, yet often without the psychological safety or institutional support to do so. Consequently, many attendings choose to leave academic medicine due to administrative politics, trainee entitlement, and inadequate support systems.⁸^,¹¹^-¹³^,¹⁷

The Manufactured Crisis: Judgment Without Justice

When institutions prioritize appeasing trainees or safeguarding flawed systems over seeking truth, attendings can find themselves in untenable positions: judged without inquiry, blamed without due process, and silenced without recourse.³^,⁴^,⁸^,¹⁰^-¹³^,¹⁷

Tarot resonances:

1. Justice Reversed represents bias, misalignment, and abuse of process.
2. Judgment Reversed reflects false narratives, refusal to engage in reflection, and premature conclusions.

In these scenarios, the attending embodies the Hanged Man—suspended, powerless, and effectively sacrificed to maintain institutional comfort.

The Departure and Leaving Behind

After enduring repeated cycles of institutional betrayal, the attending must step away—not as an act of weakness, but as an assertion of clarity and self-preservation.³^,⁴^,⁸^,¹⁰^-¹³^,¹⁷^,¹⁸

Tarot guidance for this phase:

1. Eight of Cups: leaving behind what no longer serves your highest good, embarking on a quest in pursuit of fulfillment (linked to the Nine of Cups).
2. Six of Swords: transitioning toward stability; a calm yet deliberate movement toward new institutions and professional horizons.

Such a departure should not be interpreted as failure. Rather, it marks the commencement of restoration and renewal.

Liberation, Renewal, and Reclamation

Upon distancing from the dysfunctional system, the attending enters a phase of renewal, marked by reflection, empowerment, and reclamation of agency:³^,⁵^,¹⁹^-²²

• Judgment (upright): awakening and recognition of institutional failures; acknowledging the cycle of betrayal.
• The World: completion of the narcissistic cycle; integration of lessons learned and mastery over prior challenges.
• The Fool: initiating a new journey, free from previous distortions and constraints.
• The Magician: reclaiming personal and professional agency; mastery of intellect, passion, emotion, and resources.
• Four Aces: opening new opportunities in identity, career, and purpose; laying foundational elements for sustained growth.

A Tarot Map of the Attending Physician’s Journey

This synthesized model frames the attending physician’s lived professional experience—rarely captured in the literature—through a symbolic sequence reflecting the hero’s journey via tarot archetypes. The model traces the psychological progression from institutional betrayal to renewal, from professional collapse to reconstruction, and from identity erosion to reclamation.¹⁰^,¹⁸^,²²^,²³

Wounding and disillusionment:

• Three of Swords (upright): betrayal, heartbreak, rupture; emotional shock upon realizing institutional failures and abandonment.

• Five of Swords (upright): manipulation, hollow victories; political maneuvering over merit or truth.

• Seven of Swords (upright): covert sabotage, evasion; triangulation and theft of professional narrative.

Attendings are rarely provided institutional protection, despite ultimate responsibility for patient care and supervision.

Transformation and awakening:

• The Tower (upright): sudden institutional collapse; realization that fragile foundations cannot withstand stress; breaking of illusion and exposure of systemic fragility.

• Death (upright): ending of illusions; necessary closure of misconceptions regarding loyalty and protection.

• Judgment (upright): awakening, self-recognition, and reclaiming of personal and professional truth.

• The World (upright): completion, mastery, and integration of lessons; full acceptance of the cycle and closure of prior challenges.

At this stage, the attending recognizes: “This system was never built to support me.”

The departure and renewal:

• Eight of Cups (upright): leaving behind what no longer serves your highest good; embarking on a quest toward personal and professional fulfillment, ultimately leading to the Nine of Cups.

• Six of Swords (upright): transition toward stability; a calm yet determined movement toward new institutions and professional horizons.

This departure is not a sign of failure; rather, it marks the beginning of restoration and self-directed growth.

Rebuilding and reclamation:

• Three of Pentacles (upright): collaboration, respect from peers, and professional reintegration.

• Eight of Pentacles (upright): dedication to mastery; refinement of skills, expertise, and craft.

• Six of Wands (upright): recovery of professional recognition; restoration of confidence and validation.

The attending begins to reclaim ground previously lost to institutional dysfunction, regaining authority, respect, and professional identity.

Momentum and empowerment:

• Wheel of Fortune (upright): alignment of circumstances; new opportunities emerge.

• The Chariot (upright): self-directed change; regained control over professional trajectory.

• The Magician (upright): restoration of agency; mastery of intellect, skills, and personal resources.

• The Fool (upright): new beginnings and optimism; entering unburdened professional chapters shaped by possibility rather than trauma.

The attending experiences both internal and external validation, recognizing that their skills, experience, and judgment are being applied at the right time and place, propelling them toward success defined on their own terms.

New foundations:

• Ace of Swords (upright): clarity, rebuilt professional identity, and decisive decision-making.

• Ace of Wands (upright): renewed motivation, creativity, and passion.

• Ace of Pentacles (upright): stability, financial security, and career grounding.

• Ace of Cups (upright): emotional renewal, restored trust, and healthy professional relationships.

The attending now possesses the resources, clarity, and potential to begin anew and pivot toward opportunities aligned with their highest good and professional abundance.

Arrival into authority and self-mastery:

• Kings (upright, all suits: wands, swords, cups, pentacles): mature authority, ethical leadership, and decisive action.

• Queens (upright, all suits: wands, swords, cups, pentacles): emotional intelligence, relational integrity, and mentorship.

• Emperor (upright): structured, principled leadership and system stability.

• Empress (upright): creativity, growth, generativity, and fostering professional flourishing.

The attending has either created or discovered environments in which they are valued, moving toward stability, professional fulfillment, and calmer waters.

Modern Cultural References

Tarot does not dictate one’s life; rather, it offers a symbolic framework through which meaning can be explored. Individuals retain full free will, agency, and choice.¹^,³^,⁴^,⁶^-⁸^,¹⁰^,¹¹^,¹⁸^,²²^,²³

In recent years, many tarot readers who have online channels and platforms have increasingly referenced concepts related to narcissism—paralleling a broader cultural focus on narcissistic dynamics and relational harm.⁸^-¹⁰

Two cultural figures—one fictional (Lillian Calderu) and one historical (Walter Mercado)—have reintroduced broader audiences to esoteric symbolism through contemporary streaming media.^23-27 Lillian Calderu (from Agatha All Along) illustrates Tarot as an action-oriented and intuitive instrument. Her abilities strengthen within a supportive collective, yet her divinations can emerge as involuntary visions—sometimes painful, and often experienced as nonlinear temporal gaps. Walter Mercado, the iconic Puerto Rican astrologer and television personality, became widely beloved across the Latin American diaspora for his uplifting approach to astrology and Tarot, punctuated by his signature blessing: “Con mucho, mucho, mucho amor.”^25-27

Concluding Thoughts

It is reasonable to conclude that academic medicine faces an underrecognized crisis: the experience of attending physician abandonment in the context of institutional narcissism. Although the literature richly documents resident wellness, trainee protections, and psychological safety for residents, it provides minimal insight into the parallel vulnerabilities faced by attending physicians. As a result, several domains remain critically overlooked:

• The professional and emotional impact of unprofessional trainee behavior and incompetence on supervising attendings
• Institutional reflexes to protect residents out of fear of repercussions from the Accreditation Council for Graduate Medical Education, even when this inadvertently compromises fairness or truth
• The absence of advocacy structures for attendings who face mischaracterization, false narratives, or administrative silence
• Moral injury stemming from being blamed, marginalized, or unsupported
• Systemic and cultural dynamics—sometimes mirroring narcissistic patterns—within academic leadership and organizational hierarchies

Framing these dynamics through Tarot as a symbolic, Jungian-aligned reflective system offers a metaphorically rich language for understanding the attending’s psychological journey. Within this lens, the attending’s trajectory mirrors a progression from the Hanged Man to the Magician—from enforced suspension, sacrifice, and institutional paralysis to renewed agency, clarity, and self-authorship.

Ultimately, this symbolic arc reflects the attending physician’s ability to:

• Reclaim truth in the face of distortion
• Rebuild identity after professional destabilization
• Release burdens rooted in systems rather than personal failure
• Move forward with clarity, strength, and restored purpose

This manuscript seeks to begin filling a significant gap in the medical literature: the emotional, professional, and ethical reality of attending physicians navigating dysfunctional or unsupportive institutional systems. These experiences—largely undocumented—deserve scholarly recognition, systematic exploration, and meaningful dialogue so that academic medicine can evolve toward structures that support all its clinicians, this includes both residents and attending physicians.

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.

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