The medical profession is organized as a rigidly delineated, legally mandated, and culturally reinforced pyramidal hierarchy within the larger hierarchical health services system. Advancement in the medical hierarchy is achieved in a number of ways. Pre-medical students just beginning their training must combine high academic achievement with competitive scoring on the standardized Medical College Admissions Test (MCAT), as well as demonstrate a number of desired but less quantifiable characteristics through scientific research and volunteer activities. With luck – and more often than not, according to statistics, a privileged socioeconomic background – the persistent pre-medical student will be among the less than 45% of applicants ultimately accepted to a medical college in the United States. However, this intense screening “at the gates” is apparently effective, as, nationally, more than 90% of matriculants graduate (“Medical School Graduation and Attrition Rates,” 2007) within five years.
By this time, medical school graduates in their first year of residency (known as interns) are, on average, $161,000 in debt (“American Association of Medical Colleges Debt Fact Card,” 2011). This astronomical debt burden has a significant influence on specialty choice among residency applicants, steering many from the so-called primary care specialties most needed in the US toward more lucrative surgical and diagnostic fields. After three to seven years of residency, many doctors choose to further specialize. Fellowships or other degree programs can extend training another two or more years.
Medical students comprise the lowest formal rung of the hierarchy. Traditionally, medical students begin clinical training during their third and fourth years through a series of clerkships and pre-internships. In the clinical setting, medical students often avoid much of the “scut work” they will later endure as interns and residents by virtue of being lucrative “consumers” of the medical school’s training services, which allows them more leverage in negotiating the training environment than interns and residents enjoy.
During medical school, these future physicians are further sifted, ranked, and steered, but ultimately self-selected into one of the more than twenty formal medical specialties. Fourth year students apply to residency programs in the specialty of their choice through what is known as “the Match”, which analyzes applicant rankings of programs and program rankings of applicants, using a proprietary algorithm, to match applicants to programs (“NRMP: Residency Match,” n.d.). Newly minted doctors have no alternative pathway to residency training, so contracts with the hospitals affiliated with the residency program to which they are matched are non-negotiable and binding.
In most major medical centers, residents are the secret ingredient that allows inflated administrative salaries and highly incentivized attending physician contracts via the $8.4 billion in subsidies paid, directly or indirectly, by Medicare for residency training (“Medicare (United States) – Wikipedia, the free encyclopedia,” 2011). Through a genuinely suspicious arrangement, Medicare pays intern and resident salaries and benefits, meaning that qualifying hospitals are granted a free mid-level workforce that contributes significantly to the billable patient care for which hospitals are reimbursed. But these same hospitals are also paid directly by Medicare for the “favor” of training the future medical workforce, as if the free labor they were already getting in the deal wasn’t quite sweet enough.
Working conditions for both residents and interns have historically been poor, characterized by long hours, low pay, and little institutional voice. The new 80-hour work limitation guidelines have had a mixed reception, and mixed results (Durkin, McDonald, Munoz, & Mahvi, January; Sneider, Larkin, & Shah, May). The duration of training is also inflated by the high proportion of “scut work” duties common in many programs, though some are beginning to mitigate this trend by employing mid-level providers such as physician associates and advanced nurses, which allows residents more time for specialized training.
The hierarchy doesn’t level after residency and fellowship training. For physicians in academic medicine, the hierarchy includes grades of professorship: assistant, associate, and full. There are division chiefs, department chairs, center directors, and an entire bureaucracy of graded administrators, many of whom are medically trained. There is even a hierarchy of specialties, in terms of resources, remuneration, and prestige, with neurosurgery on top and primary care and emergency medicine near the bottom. And for those physicians engaged in basic or translational research in addition to their clinical practice, a separate set of criteria defines career milestones and distinguishes the elite among their colleagues.
American Association of Medical Colleges Debt Fact Card. (2011, October).Debt Fact Card. Retrieved November 8, 2011, from https://www.aamc.org/download/152968/data/debtfactcard.pdf
Durkin, E. T., McDonald, R., Munoz, A., & Mahvi, D. (January). The Impact of Work Hour Restrictions on Surgical Resident Education. Journal of Surgical Education, 65(1), 54-60. doi:10.1016/j.jsurg.2007.08.008
Medical School Graduation and Attrition Rates. (2007, April).American Association of Medical Colleges. Retrieved November 8, 2011, from https://www.aamc.org/download/102346/data/aibvol7no2.pdf
Medicare (United States) – Wikipedia, the free encyclopedia. (2011, October 27).Wikipedia, the free encyclopedia. Retrieved November 8, 2011, from http://en.wikipedia.org/wiki/Medicare_(United_States)#cite_note-85
NRMP: Residency Match. (n.d.). Retrieved November 8, 2011, from http://www.nrmp.org/res_match/index.html
Sneider, E. B., Larkin, A. C., & Shah, S. A. (May). Has the 80-Hour Workweek Improved Surgical Resident Education in New England? Journal of Surgical Education, 66(3), 140-145. doi:10.1016/j.jsurg.2008.10.005
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.