close colleague recently described a conversation about hierarchy in medical education in a meeting he had with the medical school’s curriculum committee. He was surprised when the committee reacted with skepticism to the notion that he interacts with medical students on a first name basis.
Medical hierarchy has its origins at the turn of the 20th century, when the center of medical education transitioned from apprenticeships to hospitals.(1) The ‘good ingredients’ of the apprenticeship model—mentoring, coordination, and constant observation between teacher and learner—were replaced by a hierarchy with each rank subject to the authority of the next level up.(2)
Today, learners work with numerous health professionals on a day-to-day basis and are required to understand and implement instructions following different ‘rules’ from each of their ‘bosses.’
My fondest training experiences were, in fact, apprenticeships. In medical school, I spent several dedicated weeks on family practice and surgery rotations partnered with community-based solo practitioners. The surgeon I worked with occasionally ‘pimpedThe term pimping comes from the German pumpfrage. It refers to an attending physician’s practice of rapidly asking a trainee a series of questions until the student fails to answer correctly.’ me, but he never did so in the OR, only when we drove together from place to place. It was OK if I didn’t know the answer to his repeated questions, because we both knew I would go home and try to figure it out. As a learner, I was psychologically safe.
As a pediatric resident, I was equally fortunate to have a unique ‘continuity clinic’ experience. As one of few residents with a car in Boston I was assigned to a preceptor in Andover, nearly 45 minutes away. I looked forward to my weekly time in Andover. Sometimes I would join my preceptor for lunch at her house.
Once I shared with her that, after a busy night shift, I made the drive to Andover, and on my way home, I fell asleep at a stop light. I only jerked awake when my foot fell off the brake. She responded with concern and insisted I never let this happen again. “It is okay, Michelle, if you miss clinic once and awhile,” she said. “You can’t help your patients if you’re dead.” As a teacher, she was preoccupied with the causes of failure (including when we were too tired to provide care), and she wanted to make sure I was too. We had barrier-less communication.
The medical hierarchy of hospital-based training has endured despite radical changes in the complexity of healthcare, rapid advances in science and technology, and a changing workforce. Today, learners work with numerous health professionals on a day-to-day basis and are required to understand and implement instructions following different ‘rules’ from each of their ‘bosses.’
The result is inadequate communication, fragmented supervision, and feelings of shame and disillusionment for subordinates,(2) some of whom may avoid revealing their uncertainty when faced with complex patient management issues for fear of appearing inadequate or being the object of a supervisor’s anger.(3,4,5) It is not at all surprising that, as evidence mounts linking patient safety to the quality of training,(6) that the medical hierarchy has come under increased scrutiny.(3)
My apprenticeship experiences were not the norm, nor were they the bulk of my training. Eventually, I succumbed to the tradition and torment of the medical hierarchy, emulating the "command and control" leadership style I had experienced as a trainee.(7)
Not long ago, a gentle, humble colleague came to me. “Michelle, this is really hard to say,” he said. “I heard from a few residents that you have such high standards they are afraid to talk to you. A couple even said you made them cry.” The feedback wasn't a shock, but I wish it had come sooner. It took a personal struggle with burnout to become more self-aware. My achievement orientation and deep committment to patients and families were sometimes at odds with how I functioned in teams, as a leader, and as a teacher.
The time has come to break with tradition. I want to be the kind of leader who can simultaneously guide patients and families through the trials of illness while shepherding trainees on a path of personal discovery and learning in medicine.
The time has come to break with tradition. I want to be the kind of leader who can simultaneously guide patients and families through the trials of illness while shepherding trainees on a path of personal discovery and learning in medicine. As I emerge on the other side of burnout, I now view burnout as a potential cause when a learner is having performance issues. When we sit down to talk, I take the first opportunity I have to flatten the hierarchy. “Please,” I say. “Call me Michelle.”
- Starr P. The social transformation of American medicine. New York: Basic Books, 1982.
- Walton MM. Hierarchies: the Berlin Wall of patient safety. Qual Saf Health Care. 2006;15(4):229–230.
- Crowe, Sophie, Nicholas Clarke, and Ruairi Brugha. "‘You do not cross them’: Hierarchy and emotion in doctors' narratives of power relations in specialist training." Social Science & Medicine 186 (2017): 70-77.
- Chen, P. "The bullying culture of medical school." New York Times (2012).
- Lempp, Heidi. "Medical-school culture." Handbook of the sociology of medical education. Routledge, 2009. 85-102.
- Feinstein A R. System, supervision, standards and the epidemic of negligent medical errors. Arch Intern Med 19971571285–1289.
- Stoller JK. The clinician as leader: Why, how, and when. Ann ATS (2017):14(11):122-1626.