From Digital Storytelling to Critical Consciousness: Adapting Critical Pedagogy Through Medical Memes in a Hierarchical Context.

Problem: In Taiwan's hierarchical medical culture, postgraduate year (PGY) physicians face significant workplace challenges, exacerbated by Confucian values of hierarchical deference and collective harmony, which discourage open discussion of power imbalances. Approaches rooted in individualism, such as speaking-up initiatives and direct feedback pedagogies, encounter cultural barriers in this high-power-distance, collectivist context. While digital-native trainees increasingly use medical memes to express workplace frustrations, these community-generated expressions have not been systematically used for structured reflection in hierarchical medical education contexts. Intervention: In this pilot study, we designed a meme-based reflective learning curriculum integrating Kolb's experiential learning cycle, Palmer's "third things" approach, and Schön's mediating artifacts. Eight PGY physicians completed six monthly 90-minute sessions (January-June 2024), with follow-up interviews conducted six months post-intervention (December 2024). We curated memes from Taiwanese medical social media that depict workplace challenges, including hierarchical powerlessness, interprofessional tensions, emotional regulation, unclear workplace rules, time management, and patient-doctor communication. Sessions guided participants through Kolb's cycle: concrete experience (meme viewing), reflective observation (discussions), abstract conceptualization (consensus-building), and active experimentation (implementation). Context: The study was conducted at a medical center in Taiwan, where PGY physicians, competing for residency positions through an informal but widespread internal recruitment practice, faced intense pressure to maintain favorable impressions among seniors. This precarious status fostered reluctance to voice concerns as they navigated monthly rotations across departments with different cultures and unwritten rules. Impact: Participants demonstrated learning across all Kolb stages. Framed as an untested feasibility, the approach made previously unspeakable experiences discussable, creating resonance as participants recognized shared struggles. They developed practical strategies for emotional regulation and for navigating interprofessional relationships. However, encountering systemic barriers to implementation prompted an unexpected transformation: participants developed critical consciousness, shifting from seeking adaptation strategies to questioning the structures themselves. They articulated, "The problem isn't us. It's the whole unreasonable system," shifting the focus from coping to why this system exists. This evolution, which moves beyond an adaptation-focused curriculum toward Freire's dialogical education, emerged alongside a sense of powerlessness, as participants lacked the authority to enact structural change. Lessons learned: Drawing on Freire's concept of generative words, we theorize that community-generated memes functioned as generative artifacts: culturally embedded materials that fostered both workplace reflection and critical consciousness. This approach reframes Confucian collectivist orientations as empowering resources through what we term "safe subversion," in which humor's incongruity, ambiguity, and collective ownership keep critique within culturally tolerable limits. However, translating consciousness into structural change requires strategic alliances with educators who wield hierarchical authority in service of learning, bridging trainee awareness and institutional reform.