The album, largely conceived by bassist and lyricist Roger Waters, follows Pink, a rock musician who erects an imaginary wall brick by brick, each brick a loss, a humiliation or a costly adaptation: a father killed in the Second World War, an overprotective mother, an authoritarian teacher, the loneliness of fame. The story is partly autobiographical — Waters modeled the protagonist on himself and the dead father on his own. When the wall is complete, Pink is protected from everything and incapable of genuine contact. The narrative arc is cumulative and non-linear, assembling apparently disconnected events that only in retrospect reveal a logic of construction, a structure the author compares directly to the trajectory of professional formation. Each brick, he writes, is a unit of undeclared learning.

The conceptual anchor of the essay is the scholarship on the hidden curriculum, formalized by Frederic Hafferty and Ronald Franks in the 1990s. They proposed that medical schools teach through three simultaneous registers: the formal curriculum that institutions declare, the informal curriculum learned in everyday interactions outside structured spaces such as corridors and rounds, and the hidden curriculum transmitted through institutional culture — unwritten policies, implicit assessment criteria, resource allocation and the rituals regulating professional belonging. The hidden register is the hardest to reform precisely because it operates without its agents recognizing it as teaching. Reforms confined to the formal curriculum are necessary but insufficient, the author notes, when they do not address what operates beneath the surface. One of the phenomenon’s most-cited formulations, from William Gofton and Glenn Regehr, holds that the hidden curriculum is what teachers teach without knowing they teach and what students learn without knowing they learn.

Among the best-documented effects of this silent pedagogy is the erosion of empathy. A longitudinal study by Mohammadreza Hojat and colleagues found that empathy scores decline from the third year of medical school onward — when clinical activity with real patients begins — and continue falling through residency. The finding is contested: other researchers argue the decline is largely an artifact of self-report measurement and is small or absent in many countries. The essay adopts the concept with caution, emphasizing that the training environment acts upon empathy regardless of its measured trajectory. What distinguishes psychiatric training, the author argues, is the nature of its clinical material — delusion, suicidality, abuse, psychotic disorganization — and a peculiar reflexive bind: psychiatrists are trained to recognize in others precisely what they learn not to recognize in themselves. The unsaid lesson is that this material must be borne without the personal cost being named, and that naming the cost may be read as fragility rather than reflective competence.

The essay then maps four moments of the album onto four bricks of psychiatric formation. The first, drawn from the tracks Mother and The Thin Ice, concerns what students carry before they arrive. The literature documents a recurrent profile among medical entrants: high perfectionism, identity organized around performance, and an early relation to caring for others that precedes the choice of profession. The parentified child — who learns early that their value lies in caring — enters a profession organized around care and rediscovers a familiar position. Medicine does not create the compulsive caregiver; it inherits them. In psychiatry, the dynamic deepens, because specialty choice is rarely random: trainees who excel intellectually while carrying significant psychic suffering are more common than institutions perceive, and what is rarely asked is whether the brilliance exists despite the pain or because of it.

The second brick comes from the album’s school tracks and describes teaching by humiliation. The cruel teacher in the album teaches no content; he teaches that humiliation can be constitutive of the pedagogical relation and that bearing it is the price of belonging. In medical education the mechanism has a name in the literature, but the author insists Waters captures what empirical accounts describe: the cumulative effect. No single episode of humiliation builds the wall; the repetition does, each apparently innocuous episode adding to the last. A specific variant appears in psychiatric training: the supervisor who interviews an emergency-room patient without privacy never explicitly teaches that privacy is dispensable, yet the observing student learns both the interview technique and the silent, durable norm that certain conditions are tolerable.

The third brick, from Comfortably Numb, offers a phenomenology of depersonalization. In the narrative, Pink stops feeling — not by decision but by exhaustion, arriving at something that looks like peace and is anesthesia. The educational correlate is burnout, and particularly the depersonalization central to Christina Maslach’s account: an emotional distancing that lets the professional keep functioning. Those who numb do not decide to stop feeling; they stop because the environment teaches, without saying so, that feeling is an obstacle to efficiency. The essay’s sharpest observation here is the contradiction the formation produces: a psychiatrist who identifies dissociation in a patient but does not perceive their own depersonalization as a response to the work — clinical competence and personal blindness in the same person.

The fourth brick, from the album’s closing sequence The Trial, resonates with disproportionate self-criticism and the impostor phenomenon, widely documented among students and residents: not merely the feeling of inadequacy but the conviction that others will eventually discover the fraud. The concept has been justly criticized for individualizing what is structural, locating in the trainee a fault that belongs to the culture producing it. That criticism, the author writes, is the essay’s point: the self-judgment is a brick laid by the environment, internalized until it feels like one’s own. He is careful to add that none of this is destiny — the same hidden curriculum transmits much that is good, and many learners emerge determined not to repeat it. The most personal section of the essay discloses that the author himself stopped teaching the class in 2020, during the pandemic, describing what clinical language calls experiential avoidance: unelaborated personal material was being repeatedly enacted in front of students, and at some point the cost of re-exposure exceeded what he could sustain. He draws on Ronaldo Cassorla’s concept of enactment — unsymbolized emotional material acted out rather than thought — and observes that an educator withdrawing from a subject without explanation teaches students, silently, that certain subjects disappear from the curriculum for invisible reasons. That, too, is a brick.

What can be done? The essay is deliberately modest about dismantling and emphasizes the patient work of opening breaches. Formal curricular reform is necessary but not sufficient; the next step is institutional conditions in which what is felt during training can be said — not as complaint but as formative data. Balint groups, reflective portfolios and formative supervision are not new; what determines whether they work is the culture that sustains them. A portfolio read with care and answered with feedback is a device of elaboration, while a portfolio filled in by obligation and ignored is another brick. Within such spaces, art can accomplish what no didactic lecture on professional distress can: it lets the subject recognize themselves without feeling diagnosed. Drawing on Parker Palmer’s idea of a third thing, introduced into medical education by Elaine Gaufberg and colleagues, the author describes The Wall as an oblique mirror that shows what is felt without demanding it be said. He also invokes institutional enactment — the collective acting-out of unthought material transmitted between generations of formators — to argue that reform demands educators recognize the wall built in themselves, and that institutions make such recognition possible. The album ends not with triumph but with the fragile voices outside the wall; in medical education, the author concludes, those voices are the students who write in portfolios what they actually felt, the faculty who admit that the material affects them, and those who ask how someone else is and wait for the real answer.

Subject of Research: The use of Pink Floyd's The Wall as a phenomenological model of the hidden curriculum in psychiatric and medical education

Article Title: Another Brick in the Wall: Pink Floyd’s The Wall as a Phenomenological Model of the Hidden Curriculum in Psychiatric Education

Article References: dos Santos Júnior, A. (2026). Another Brick in the Wall: Pink Floyd’s The Wall as a Phenomenological Model of the Hidden Curriculum in Psychiatric Education. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02423-8

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02423-8

Keywords: hidden curriculum, medical education, psychiatric training, Pink Floyd, The Wall, empathy decline, burnout, depersonalization, impostor phenomenon, teaching by humiliation, educator distress, medical humanities

The core problem, the author explains, is that inpatient psychiatry and law enforcement operate under fundamentally different mandates. The primary goal of psychiatric admission is to stabilize an acute crisis, rebuild therapeutic trust, respect confidentiality, and set up a safe discharge with timely outpatient follow-up. Law enforcement, by contrast, is oriented toward public safety and legal process. Officers may transport individuals for emergency psychiatric evaluation or arrange other dispositions, but they are not engaged in clinical treatment, and they are generally not bound by clinical confidentiality obligations. Unlike clinicians, they are not required to warn patients that what they disclose may not remain confidential. When these two systems intersect on a locked unit, patients can be caught between competing institutional duties.

Existing literature has paid little attention to this problem from a medical education standpoint. Most research has focused on law enforcement interactions with patients in emergency departments and trauma units. Jones and colleagues, writing in JAMA nearly two decades ago, noted the absence of formal guidelines for law enforcement interviews of hospital patients and proposed principles including respect for autonomy, noninterference with medical care, protection of privacy, maintenance of professional boundaries, and multidisciplinary policy development. Those principles remain useful, the new commentary argues, but applying them to inpatient psychiatry is considerably more complicated. Inpatient units involve ongoing therapeutic relationships, secured environments, heightened privacy expectations, and patients whose decisional capacity, trauma responses, paranoia, and other symptoms can fluctuate dramatically during admission.

The scale of the underlying interface is substantial. A 2025 systematic review and meta-analysis found that approximately 13.7 percent of individuals evaluated in psychiatric emergency departments were referred by police, and that police-referred individuals were more likely to present with aggression, homelessness, substance use or psychotic disorders, and to be hospitalized involuntarily. Yet most of the limited literature specifically addressing inpatient units and law enforcement concerns a single question: whether psychiatric staff should press charges against violent inpatients. Other recurring interactions, the author contends, have been almost entirely ignored as teaching scenarios, leaving trainees to improvise in situations where improvisation can compromise both patient care and legal process.

To fill that gap, the commentary organizes teaching around six ethical principles drawn from established frameworks in biomedical and psychiatric ethics. Patient autonomy requires that patients generally be informed about law enforcement requests involving them and, when clinically and legally feasible, given meaningful choices about whether to participate. Beneficence and nonmaleficence demand that teams promote recovery while avoiding foreseeable harms such as worsening symptoms, exacerbating trauma responses, undermining therapeutic trust, or increasing suicide risk. Justice requires that psychiatric inpatients not be denied access to reporting mechanisms, protective processes, or fair treatment because of their diagnosis, involuntary status, psychosis, or perceived lack of credibility. Confidentiality obliges teams to disclose information only when legally permissible, clinically justified, and limited to the minimum necessary. Duties to protect may arise when credible threats to identifiable others exist, and role clarity demands that clinicians never become agents of law enforcement or participate in investigative questioning on police behalf.

Three scenarios anchor the framework. In the first, a patient alleges mistreatment by staff. Even when allegations seem improbable or psychotically driven, the commentary argues, teams must not adjudicate the truth themselves; their role is to ensure safety, preserve access to reporting mechanisms, document the concern, and activate institutional processes. When an allegation describes conduct that could constitute criminal mistreatment, reporting channels may include law enforcement, and if police arrive, patients should be informed and given the choice to speak with them, with their preference respected and documented regardless of their answer.

The second scenario involves officers arriving to serve a personal protection order on a hospitalized patient. Being served legal paperwork mid-admission can cause substantial distress or worsen symptoms, particularly for patients with trauma histories, yet delaying service may endanger a petitioner after discharge. The author is careful to distinguish this from Tarasoff-type duties: the team may have received no direct threat, the legal process may originate outside the hospital, and the question often involves disclosure to law enforcement rather than warning an identifiable victim. The approach described, developed in consultation with nursing, medical, and legal leadership, involves informing the patient of the officer’s presence, offering a private meeting if the patient consents, and consulting legal counsel about permissible alternatives if the patient declines, including whether service could wait until discharge.

The third and arguably most technically demanding scenario concerns discharge to police custody. Patients may carry warrants ranging from trespassing to violent offenses, and officers may request notification at discharge to coordinate custody transfer. The commentary lays out a multi-step assessment: verify the legal documentation; evaluate the nature and severity of the alleged offense; assess for identifiable potential victims; screen for threats during hospitalization; determine access to weapons; analyze the relationship between psychiatric symptoms and risk behavior; evaluate clinical stability; consider confidentiality constraints; obtain legal or ethics consultation; and use the least-disclosing, least-harmful communication feasible. Crucially, the author notes, antisocial personality disorder alone is generally not sufficient grounds for involuntary hospitalization, a position supported by psychiatric and legal scholarship and by the Supreme Court’s 1992 ruling in Foucha v. Louisiana. Once acute psychiatric illness resolves, coordination with law enforcement may be appropriate only in select cases when legally permissible and clinically justified.

Three composite case vignettes illustrate how the framework plays out differently depending on context. A sheriff’s deputy arrives to serve a protection order on a depressed 38-year-old woman with trauma history; she declines to meet, and the team defers to institutional policy on post-discharge service. A 43-year-old man recovering from suicidal depression is found to have warrants for aggravated stalking, including threatening calls made from the unit; because his risk to his ex-wife stems from conduct rather than active symptoms requiring hospitalization, the team concludes that limited disclosure of discharge timing is justified. A 25-year-old recovering from an overdose has a drug possession warrant but no violent history; the team declines to coordinate custody transfer, concluding that police can address the warrant independently and that premature disclosure would erode trust early in recovery. The cases drive home a key teaching point: a warrant alone does not determine whether discharge timing may be disclosed.

The educational applications are deliberately flexible. The scenarios can be used in supervision, ethics seminars, case conferences, orientation, or simulation, asking learners to identify the law enforcement request, distinguish clinical from investigative roles, consider whether protected health information is implicated, and determine when to escalate to supervising physicians, legal counsel, risk management, security, or ethics consultants. The author is explicit that trainees are not expected to resolve these dilemmas independently; their role is to recognize the problem, preserve safety and confidentiality, seek supervision, and participate in team-based decision-making. The commentary acknowledges its own limitations, including the absence of empirical data on learner outcomes and its grounding in a single academic setting, and it closes with a clear call: institutions should develop clear policies and educational frameworks in advance, with input from clinical leadership, legal counsel, risk management, security, ethics committees, and law enforcement partners, rather than improvising when an officer appears at the unit door.

Subject of Research: Educating medical trainees on ethical law enforcement interactions in inpatient psychiatry

Article Title: Teaching Medical Students and Residents to Navigate Law Enforcement Interactions in Inpatient Psychiatry

Article References: Im, D. S. (2026). Teaching Medical Students and Residents to Navigate Law Enforcement Interactions in Inpatient Psychiatry. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02440-7

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02440-7

Keywords: inpatient psychiatry, law enforcement, medical education, confidentiality, patient autonomy, duty to protect, medical students, residents, medical ethics, protective orders, discharge planning, interprofessional collaboration