Review: Doctor’s Orders (Hierarchies in Medicine)

Sociologist Tania M. Jenkins compares and contrasts two geographically similar academic and community internal medicine residencies in her book, Doctor’s Orders, which discusses hierarchy in medicine. Her overall thrust:

Amidst a widespread and pervasive emphasis on individual merit in medicine, I found that largely structural advantages and disadvantages, often dating back to childhood differences in social class, are frequently misidentified as differences in individual achievement and motivation among medical graduates, helping USMDs float to the top of the status hierarchy while pushing non-USMDs toward the bottom.

Jenkins lumps everything other than US allopathic grads together as non-USMDs (DO, Caribbean MD, US citizen IMGs, and non-US IMGs)

Hierarchies in status, defined as collective understandings of social worth or prestige, such as those between USMDs and non-USMDs, remain highly informal, as do the processes for climbing the ranks. In fact, as I will argue, it is precisely this informality and the accompanying belief that anyone can become part of the elite with enough work and dedication that allow such status distinctions to persist.

This is part of the pervasive myth of Step 1 as the great equalizer for non-USMDs. The idea that if you absolutely destroyed Step 1 you could go far. Anecdotes abound, because yes, an IMG has absolutely needed to do well on Step 1 in order to successfully match. But, but, these successful IMGs are using Step 1 largely to compete with other IMGs. Many of the dozens of programs they apply to aren’t really considering their applications. The AAMC, which runs ERAS, is happy to take applicants’ money to apply to ever more programs while providing program directors with the tools they need to filter out those very same apps.

It’s the perception of true meritocracy, but insofar as we use standard metrics like exam scores, we use them largely within bins/tiers and not equally across all-comers.

These findings also remind us that artifacts of standardization, like Board exams and program accreditation, should not be confused with indicators of equality in medical education.

No big secret there. In many cases, they also probably shouldn’t be used as indicators of quality either, but that’s a different story.

But I think the most interesting thing about the book is that it focuses on physicians exclusively and ignores the real substantive hierarchal change happening in medicine today, which is rapid rise and expansion of midlevel providers. Take, for example, her brief discussion of the sociological history of modern medicine dating back to Eliot Freidson’s Professional Dominance in 1970:

Freidson, the primary proponent of professional dominance, maintained that as long as doctors held sole control over their gatekeeping functions (such as deciding who could become a doctor and who should be admitted to a hospital), they would continue to exert dominance over paramedical professionals and patients—despite incursions from nonmedical sources.In response, scholars criticized Freidson for being out of touch with the massive macrosocietal changes happening in the healthcare system and instead proposed their own theories of professional decline. One of the more serious challenges to Freidson’s professional dominance theory came from the proletarianization thesis. Proponents heavily criticized Freidson’s contention that the medical profession was impervious to the considerable socioeconomic changes happening around it. These scholars contended that increasing bureaucratization (especially the shift from self-employment to hospital employment) was creating a proletarianized profession, with formerly self-employed practitioners becoming constrained by bureaucratic controls within hospitals.

They predicted that, as medical practice became increasingly bureaucratized and specialized, physicians would become mere salaried employees, lose control over the terms and conditions of their professional work, and thereby become proletarianized. In turn, Freidson strongly criticized proletarianization theorists for overstating physicians’ loss of independence. He rejected the notion that simply by joining a bureaucratic organization like a hospital, “[doctors] become mere cogs in a machine of production.” He pointed to other professionals, like engineers and professors, who have long worked in bureaucratic organizations without having their knowledge and skill “expropriated” by nonprofessional superiors, and he noted that even with increased government and organizational control, physicians look nothing like typical alienated blue- or white-collar workers. While there is no doubt that some aspects of proletarianization have materialized (for example, Medicare, rather than physicians, largely dictates reimbursement rates for specific diagnostic codes), for the most part Freidson remains correct that doctors continue to control the processes of entry and the content of their professional work, suggesting that the professional decline forecast by so many sociologists in the 1980s has not come to pass.

I find this conclusion fascinating because I think it’s largely incorrect (or at the least, incomplete). And I suspect most physicians would agree.

Many doctors do (or at least certainly believe they do) function as cogs in the machine, working within a bureaucracy in which they typically have minimal input, where they control little about the day to day logistics of their jobs, and for which their main leverage for change (if any) is to quit. The process is overall gathering momentum.

While doctors may have maintained control over their fiefdom, they’ve instead been sidestepped by the large healthcare organizations that employ them and increasingly by the legislators who have historically protected them. So that strict control has become increasingly irrelevant and the inflexibility of the residency system even more damaging when organizations willingly and knowingly and sometimes preferentially choose to replace physicians with non-physicians providers as a cost-savings and/or profit-generating measure.

This part of the narrative is supremely complex (book-length to be sure), but physicians have some blame here by not producing sufficient numbers of doctors in the right critical fields to meet demand. Nature abhors a vacuum. We’ve also somehow tried to simultaneously maintain that only doctors can do the vast majority of clinical medical tasks while also training and using physician extenders to do many similar tasks nearly autonomously when it’s convenient for the bottom line. We shouldn’t be surprised that the boundaries get blurred when there is big money at stake and time to compound.

Which brings me to this last point:

The free-standing internship was eventually abolished in 1975, making a multiyear residency required for all medical graduates.

In a world where non-physicians providers increasingly have full practice authority fresh out of school, I think there’s a compelling argument for bringing back the internship-is-enough-to-meaningfully practice. While there are still standalone transitional and preliminary years, it’s not really a pathway to respected independent practice. A medical doctorate should count for something other than just a prerequisite to multiyear residency training. It’s increasingly naive and unsustainable to pretend that a doctor can only learn new aspects of medicine within a residency, or even that a residency is the best way to learn all relevant skills. For better or worse, the marketplace is proving otherwise.

When physicians burn out of their chosen calling, they typically leave clinical medicine altogether. I think one of the big factors at play that we rarely talk about is that the combination of residency and the board certification racket locks many doctors into a narrow specialization (or subspecialization) from which there is no escape.

There are lots of doctors who can’t get a residency or who want to change professions that essentially barred from meaningful clinical work, and that’s an incredible waste.


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