Crossing the threshold: my story of liminality

Michael Zervos, Foundation Year Two doctor in Devon

Published in JHH17.1 – Stories in medicine

Although I only studied anthropology for a year, it has profoundly changed how I view the world of healthcare. As my professional identity matured from medical student to doctor, I have grown to appreciate the privileged position that we occupy, and how we can use this to help our patients and colleagues. As a doctor, I am driven by a desire to build connections with those around me, and to that end am heavily involved in clinical education at my trust, combining teaching and simulation with the facilitation of reflective practice. I hope to work in mental health, and am endlessly fascinated by the myriad ways that humans relate to each other.

Social anthropology is the study of human societies and the relationships that make them up. For example, political anthropology – the study of relationships of power and hierarchy – allows social scientists to analyse why and how certain people have control over others. Similarly, medical anthropology is a broad field that looks at relationships based in and around health and healthcare. Studying social anthropology at the University of Cambridge became a crucial feature of
my education.

One of the most important concepts I learnt about was that of ‘liminality’ – the ambiguous and confusing position that exists in the middle of events that anthropologists consider to be rites of passage. The term liminality, which comes from the Latin limen meaning threshold, is one that anthropologists have used for a wide range of cross-culturally translatable rites of passage surrounding for instance birth, death, religious rites, marriage, coming of age etc.

I found this resonated with me as a medical student who – having carved up a cadaver in anatomy – was no longer a layperson, but had not yet become a doctor with the faith in myself or the qualification to represent myself as one. It was also disorienting for me to be the only ‘scientist’ in lectures full of arts students. This
position of tension and uncertainty continued throughout my medical school experience, so to me, it seemed thereafter that medical students are constantly faced with the issue of ‘where do I belong.

Applying the anthropological lens to this question helped me understand more about the process of ‘becoming a doctor’, that it involves something more than a course we study at university. In order to do the job of a ‘doctor’, we must go through a fundamental change. Where once I was socialised to not cause harm to
others, as a medical student I was taught to divorce the brutal reality of stabbing someone with a needle from the act of doing harm. The medical humanities literature offers a wide range of metaphors for this process (Hafferty, 1991; Davis, 1968): of being melted down and recast in the mould of a doctor: of being cut and trimmed into a topiary shape; of being indoctrinated and brainwashed into the ‘cults’ of physicians and surgeons. All of these analogies make sense to me, and all of them help me tolerate the complexity and uncertainty of each day in my life as a (necessarily) resilient junior doctor. Naming this process has been the first step in managing its impact on my life, and reconciling the work I do, with the person I view myself to be.

If we return to the anthropological idea of liminality, we can analyse the medical school experience as a rite of passage. Van Gennep (1960) posited three steps in any rite. First come rites of separation (leaving home and going to university), then transition rites (procedural education and yearly exams and so forth), and finally rites of incorporation (final year apprenticeship, graduation, induction as a foundation year 1, ‘Black Wednesday’). The symposium panel on which I spoke had representatives of the three stages – someone about to begin at medical school, another in the midst of her undergraduate medical education, and myself just out on the other side and now having to reintegrate into society as a doctor.

Little of this journey is addressed explicitly in a curriculum necessarily filled with anatomy, pharmacology or neurology. Yet it is something we are supposed to glean between clinics and ward rounds, because this process of tolerating uncertainty is a key feature and without it we are unlikely to develop resilience. And our ability to distance ourselves emotionally from every patient who deteriorates is arguably a key to a long and happy career. Schwartz Rounds (SRs) (Barker et al, 2016) fulfil a similarly reflective role but in an opposite and complementary way. Rather than asking us to dissociate and distance ourselves from these difficult feelings and the risk of objectifying our patients, SRs ask us to empathise skilfully with people’s suffering and to bear witness to our own emotional responses. As a student I was fortunate to attend a Schwartz Round on the theme of courage. This was the first time I had seen clinicians discuss the real emotional hardship our work in medicine entails, and I found it groundbreaking that a senior practitioner could openly talk about an episode of failure that had stayed with them throughout their career. I realised that one need not sacrifice one’s humanity in becoming a doctor. Since that Schwartz Round, I have trained as a Schwartz facilitator and helped develop the student Schwartz Rounds atUniversity College London Medical School.

Themes of liminality, of not belonging and of the emotional burden of working in healthcare, are often echoed at the student rounds. One of our rounds focused
on the cancer patient pathway, where over a year students follow a patient through their cancer journey. The student is asked to develop rapport, attend appointments, and try to understand what living with cancer and undergoing treatment might be like from a patient, not clinician, perspective. This pathway is incredibly powerful for students. They gain a true insight into their patient’s journey, and the discussion at this particular round revolved principally around a student’s role alongside that patient. Students spoke of the ‘in between’ position they occupied – sometimes like a friend, sometimes like a doctor, sometimes feeling like a nobody – and what it was like to be expected to shift seamlessly and rapidly from one state to the other.

On the day before I took part in the symposium I was involved in a peri-arrest call for a patient who was having a massive gastrointestinal bleed. At the time I spoke at the meeting, I still had no idea what had ultimately happened to that man, for the last I had seen of him was as he was wheeled urgently off the ward and the elevator doors closed behind him. Even though my colleagues and I had been there at a crucial moment in this man’s life, and possibly just before his death, I was at an academic meeting without answers or any sense of closure. Though we seldom talk about it, this uncertainty is a fact of life for doctors
and we are expected to cope with it, manage its impact and somehow learn to live with it. And adding to the poignancy of this typically challenging event, was the presence of a medical student who had run down with me to that peri-arrest situation. She spent the entire time hovering in the doorway; not of enough use to help, but reluctant to leave. In so many ways she embodied the very essence of liminality – a young woman unsure of her place, on the threshold of both the room and of being a doctor.

Once applied, it is very hard to remove the anthropological lens. As a student, I was fortunate to learn these lessons about perspective and my place in this scary
medical world. As an educator, my greatest hope is that I will give to scientific young minds a glimpse of this perspective, and that it will help them navigate the
academic and emotional challenges of a career in healthcare.

Many thanks to Dr Faye Gishen for inviting me to participate in the symposium and for her ongoing support and mentorship, and to Professor David Peters and Dr Chris Horn for organising the symposium.


  • Barker R, Cornwell J, Gishen F (2016) Introducing compassion into the education of health care professionals; can Schwartz Rounds help? Journal of Compassionate Health Care, 3(3).
  • Davis F (1968) Professional socialization as subjective experience: the process of doctrinal conversion among student nurses. In HS Becker, B Geer, D Reisman and RS Weiss (eds) Institutions and the Person, pp 235–51. Chicago, IL: Aldine.
  • Hafferty F (1991) Into the valley: Death and the socialization of medical students. New Haven, CT: Yale University Press.
  • Van Gennep A (1960) The rites of passage. London: Routledge and Kegan Paul