Tired of the Medical Hierarchy? Pick Your Battles

Daniel J. Egan, MD


May 30, 2012


I'm having a hard time adjusting to the hierarchy of the hospital and the way people treat each other. Are there tricks to getting through to the end?

Response from Daniel J. Egan, MD
Associate Residency Director, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, New York

If only there were an easy answer. There is definitely a hierarchy of the system, and it will follow you for the rest of your career -- although you may find that there are certain areas where it is less true than others.

Medicine is an old society and, as I am sure you have seen, its people fill an entire spectrum. More casual members introduce themselves by first name. Others would never think of not donning the white coat and being addressed (or addressing others) as "Doctor."

If you are a nontraditional student -- in particular, if you started this process later -- you may have a harder time with the hierarchy. I remember that this was true for my school classmates who had had careers and lives outside of school. It is very difficult to suddenly be thrust into a role where you are working "under" other people who may be younger than you.

However, because medicine is taught as an apprenticeship, it is the years of practice that bring wisdom and experience rather than a person's age. For instance, I may have an intern next year who is older than me. In fact, I have interviewed applicants who are older than me. It may seem weird for them to report to me; conversely, in the clinical setting, it is my years of experience that have me in the role I am in. I think it becomes easier to process for them in that situation.

You may wonder about the general attitude and hierarchy that will be present through your training. You have probably witnessed some specialties where there is almost a hazing process for young doctors or even students. You may find yourself in a situation where you want to cry because you saw someone get torn apart by his senior resident. Or you may wonder why on some clinical rotations, residents and attendings have a more collegial, first-name-basis relationship, whereas in others a resident would never call an attending by her first name.

If you have never been in this type of situation before, the best piece of advice is to play by the rules. The house of medicine is an old, established institution, and certain things will never change. To get to the end point, you will need positive evaluations. If that means that your senior supervising resident wants you to call him "Doctor" even though he is only 2 years older than you (or maybe younger than you), you should probably just do it. In many ways, it feels like you are caving in and not standing up for yourself; on the other hand, ask yourself what you are trying to prove. Many people will play only a small part in your career, and with time they will pass. It's not worth the battle.

If the structure truly bothers you, then as you move forward and begin to think about choosing a specialty, you should keep this in mind. Some specialties are very traditional in their hierarchy (eg, surgery, obstetrics/gynecology), and some are more casual (eg, emergency medicine, pediatrics). These are generalizations. You should ultimately go into whatever specialty interests you most, but keep in mind that your colleagues in your field will be present for the rest of your career.

In summary, there isn't always a clear answer as to what to do. There is a lot of "not doing" and just going along with the flow. Unfortunately, that is part of the apprenticeship model. Like I said, everything is temporary. Before you know it, you'll be on to another rotation or in a new teaching environment.