Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology

Otolaryngol Head Neck Surg. 2020 Nov;163(5):906-914. doi: 10.1177/0194599820926105. Epub 2020 Jun 2.


Objective: To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues.

Data sources: Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.

Review methods: A literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years.

Conclusions: Two types of hierarchies exist: "functional" and "dysfunctional." While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety.

Implications for practice: Otolaryngology-head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one's own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.

Keywords: ACGME; NRMP; burnout; depression; hierarchy; match; quality of life; residency; resident; stress; well-being; wellness.

MeSH terms

  • Curriculum
  • Education, Medical / organization & administration*
  • Harassment, Non-Sexual*
  • Humans
  • Internship and Residency*
  • Interprofessional Relations*
  • Otolaryngology / education*
  • Patient Safety
  • Personal Autonomy
  • Quality of Life
  • Sexual Harassment
  • Students, Medical / psychology*