The White Coat: Understanding the Contemporary Role of Hierarchy in the Medical Sector
July 30, 2024
The White Coat: Understanding the Contemporary Role of Hierarchy in the Medical Sector
By Adrian Richard Salazar, UPCM Class 2028
In medicine, what you wear somehow dictates your “level” in the field. I, for one, wear a white uniform as a medical student; medical interns wear coats with short sleeves. On the other hand, residents don coats with longer sleeves, while fellows and consultants clothe themselves in coats that go beyond their waists.
I have always been told to, at least, be aware of some kind of social order among people in medicine—a hierarchy—that seems to resonate throughout generations of physicians. As cursory as it might seem to me, hierarchy seems to be so visible—so tangible—that it would be difficult to say that it doesn’t exist at all.
Don’t get me wrong: hierarchy has a purpose in the medical sector. It was born out of the desire for organization, where certain groups or individuals needed to be in-charge in order to ensure efficient delivery of patient care. It is necessary for proper communication, organizational structure, stability, and order—aspects of medicine that are crucial for service delivery [1]. It is the complexity of the hierarchy that makes it more efficient—more room for feedback mechanisms, more avenues for corrective action. Hierarchy is what allows people in the medical sector to prioritize properly. In a field that deals with human lives, the burden of efficient prioritization is a big challenge that people involved in the hierarchy will always possess.
This is why it remains persistent even after generations of physicians and health care workers have lived and are continuing to live through it. The hierarchy exists because, to some extent, it still works.
But at what cost?
As hierarchy becomes a part of a system that has been entrenched in medical practice, wherein skills transfer is an important aspect, its role in medical education becomes debatable. On one hand, it is through structure that education can be properly provided. This structural perspective is associated with notions of order—that there is a systematic approach to achieving a set outcome through already-established protocols and assessments and this is the framework for which skills are transferred in the education sector, because there is a means to assess for compliance and competence. Within this hierarchy, there exists a relatively well-established relationship between teachers and learners. There appears to be an inherent mechanism, within the system, that ensures learning among the learners, and a concomitant regulation on teachers based on learners’ feedback. However, the call to challenge hierarchies does not stem from the order nor from the structure it brings; if that were the case, then the alternative of having instability among the medical sector would probably be far less preferable, because of the chaos that could ensue. Questioning the hierarchy is correlated more to the unintended consequences of having a hierarchy, or at least the kind of hierarchy that tends to create harmful outcomes.
Paintings of White Coat by Dr. Myrna Fojas, displayed in the new Henry Sy. Building
Systems need hierarchies when they are congested and when they need some semblance of order and stability. In congested systems, hierarchies somehow serve as crucial frameworks that promote effective decision-making, streamline resource allocation, and facilitate clear communication. It allows for enhanced functionality and manages the complexity within a system. The desire for stability must have risen because of some level of instability which, at least in the medical sector, can be attributed to factors such as decision-making on patient care, saturation of human and non-human resources, and other complexities brought about by the environment. When hierarchy is necessitated, there obviously needs to be someone who’s positioned higher than others, since that is hierarchy by definition. In the optimal case, people can be organized and systems can be stabilized—which eventually translates to efficient transfer of skills to medical students through generations. However, the possibility of abusing the power given by the hierarchy becomes apparent. When this happens, students can be disenfranchised and made to feel as though they are and always will be incapable, but the system—in its most optimal form—would not have meant for it.
This unfavorable consequence can be attributed to certain authority disparities that may have persisted within the confinements of hierarchies. The problem with power asymmetry is that regardless of the outcome or incentive to act, there will always be some actor that will have more leverage over another. Whether they prefer to act benevolently or with an intent to abuse the power within the relationship, asymmetry essentially shifts how each individual acts in the relationship. When a physician-in-training responds to someone who has authority over them as granted by the hierarchical system, there is already an expected level of behavior. This could have been born as a result of political histories, in terms of management, that could have been adopted by those who have ascended to power, which provides a temporal mechanism for how the asymmetry could have been passed down. On another hand, the increasing responsibility of being at higher positions of authority could have also contributed to why those higher up in the hierarchy have an impetus to be at the upper end of the asymmetry. This asymmetry is not inherently negative. While power imbalances can sometimes lead to inequities, in this context, they are necessary to ensure stability and standardized care according to guidelines set by appropriate governing bodies.
But aren’t these bodies even higher in the hierarchy? They are. It’s because there needs to be someone governing policies at the macroscopic level. There needs to be some level of regulation for which medical decisions must be standardized, especially as these usually cater to situations when lives are at stake. However, this is also why asymmetry tends to predominate—the hierarchy has been so entrenched that it exists on virtually every single level in the medical sector.
As a result of the increasing responsibilities with higher levels of authority, there will be unintended consequences of the hierarchy, such as behavioral changes and alterations in social dynamics with those who are still in training – in order to instill discipline and competence, of which the response can vary greatly. However, in its absence, it can be argued that certain aspects of medical education would not have reached the level of efficiency required in training. Additionally, in the absence of this asymmetry, the pressure of responsibility would be far too much for those in positions of authority, considering that they are also managing teams training within the system; hence, it may be posited that it is unjust for these individuals to bear the majority of the brunt of the health care system.
Where do we draw the line?
Inasmuch as hierarchy remains to have purpose, the changing landscape of society today presents opportunities where improvements can be made, in order to ensure that hierarchies are actually accomplishing their purpose. This is not to say that all forms of stability should be removed; rather, it’s a call towards alleviating the unintended consequences of hierarchy, and ensuring its effectiveness is maximized.
Paintings of White Coat by Dr. Myrna Fojas, displayed in the new Henry Sy. Building
When the same people the system aims to mobilize, teach, and train are also the same people who are the most likely to be abused by it—whether intended, unintended, or otherwise—then this would most likely mean that these people are not as catered to as they should be. Not only would this be harmful in terms of the individuals who are involved, but this would also be detrimental to ensuring the effectiveness of the system as a whole. While it can be easy to say that these people can cater to what the system requires of them, medical teams especially would benefit from addressing the unintended impacts of hierarchies being abolished, or at the very least reduced. While the problems of heavier and unjust responsibilities of those up in the hierarchy remains to be an issue that the system needs to address, this does not necessarily mean that the medical sector should be oblivious to the harms that have been persisting for generations—where those below the hierarchy will always be worse off—being devitalized by the same system they chose to serve. The unbalanced nature of hierarchy has shifted power dynamics to disfavor those at the bottom – resulting in social tendencies for abuse; the very least that can be done is to consider reducing its consequences, which can be accomplished by reducing the root cause of these consequences—the social dimension of the hierarchy itself.
A reductionist approach towards hierarchy is one that acts as a social equalizer—one that maintains the same level of quality of care, while also ensuring that asymmetries are not affecting the social dynamics between stakeholders. Equalizing in this sense does not refer to an abolition of the hierarchy itself; rather, it is simply addressing the problems that arise due to social constructs. The hierarchy may continue to exist to maintain order and stability—to ensure competence among those in training—but its implementation should also be regulated at the same time, which has been a crucial component of contemporary perspectives that favor the avoidance of power abuse in health care decisions of the state and private markets [2]. This means that, while there are intrinsic regulations on the standards of care and service delivery, there are also concrete checks and balances between those involved – in an attempt to reduce the unwanted, tangible consequences of hierarchy.
At worst, reducing the hierarchy will impact the social dynamics between those on top of the hierarchy and those below it. The harm here will exist when the balance is lost—when reduction becomes too far that it penetrates the same stability that keeps the medical sector afloat. However, in a health care sector where stability exists at the expense of individual healthcare worker sanity—at the expense of their ability to make the proper decisions for themselves and others—do we ever still consider that stability?
Maybe it’s not all about the coat, but what the coat represents, and what that means to the person wearing it.
References:
[1] Essex, R., Kennedy, J., Miller, D., & Jameson, J. (2023, June 20). A scoping review exploring the impact and negotiation of ... https://onlinelibrary.wiley.com/doi/10.1111/nin.12571
[2] Kreutzberg A, Reichebner C, Maier CB, et al. Regulating the input: health professions. In: Busse R, Klazinga N, Panteli D, et al., editors. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. (Health Policy Series, No. 53.) 5. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549267/