“I’m not going to stop the wheel. I’m going to break the wheel.”
–Daenerys Targaryen, Game of Thrones

A ubiquitous hierarchy pervades all levels of medicine. Medical students are anchored firmly at the bottom of medicine’s social ladder, rendering them functionally powerless. Although students theoretically have a “voice,” their precarious position low down makes them apprehensive to use it. Students’ grades, evaluations, recommendations, etc. — which have real, tangible impacts, not only on students’ academics, but also their future careers and lives — are contingent on appeasing those higher up on the so-called social ladder.

This hierarchical construct in medicine is the single most important ethical challenge facing medical education today. The reason being, it can be considered the origin of all other ethical dilemmas in today’s medical education milieu. For instance, a student may feel pressured by an attending physician into unethical conduct, such as doing a rectal exam on a patient under general anesthesia without informed consent. Many residents and students fail to report working over the legal 80-hour limit, as they fear the consequences of angering a program director. Any medical student can recall an incident when they witnessed an archaic procedure, medication or test being ordered, and decided to remain silent, rather than challenge an obstinate attending. Perhaps more disturbing are the sundry anecdotes of students suppressing their right to defend their own personal beliefs (religious, racial, political, etc.) in the face of prejudice, when the person holding the bigoted views is an individual high on the medical hierarchy.

The aforementioned list of ethical dilemmas is far from exclusive — a multitude of ethical quandaries arise from medicine’s current ranking framework. At its crux, the issue is that medical students must continuously accept coercion and compromise their personal values, ethics and mental health, or risk challenging the hierarchy that dictates their future careers and  lives.

It is hard to imagine medical students alone shifting a pervasive paradigm in medical culture. However, one day we will hopefully all be residents and physicians, and it is at this point where we must be prepared to take a stand and alter the current construct. In order to accomplish this, we, as a community, need to first elucidate the concept of medical hierarchy and its impact on medical student learning and functioning. Second, we must acknowledge and discuss the inherent ethical dilemmas this type of construct creates. Finally, we ought to continually search for diverse solutions to this challenge. An effective way to accomplish this goal is to look to proven models from other professions as examples. For instance, at Facebook Mark Zuckerberg regularly holds town hall-esque meetings during which any employee, regardless of their position, has the opportunity to ask him questions, voice suggestions and showcase innovative ideas. Although a hierarchy still exists at Facebook, simple practices such as this foster creativity by bolstering camaraderie and confidence in the workforce. Such systems do not eliminate the ladder. Rather, they simply decrease the distance between the rungs.

In fairness, I am far from an expert in the aforementioned predicament. However, I do firmly believe that if we value this topic within the medical student community, we will be ready to make positive changes in the future. Ironically, for the benefit of medicine’s disciples, we will have to use the very “power” granted to us by the medical hierarchy — as residents and attendings — to positively transform the system.

In summation, unlike Khaleesi, we do not need to “break the wheel.” Medicine needs structure. There must always be capable mentors sitting at the top of the pyramid, guiding the students below them. Nevertheless, with our collective brainpower, I am convinced that we can come up with a more successful system. A system that is not only better for all healthcare professionals — from the lowly medical student to the attending — but will also improve patient care, foster a collaborative environment and promote innovation. We do not have to, nor should we, break the wheel. We just need to figure out how to roll it in the right direction.

Parsa Salehi (3 Posts)

Contributing Writer

Yale University School of Medicine

Parsa attended Cornell University as an undergraduate, where he majored in Human Biology. He had a particular interest in nutrition, healthcare policy, near eastern studies, and human development while in Ithaca. He completed medical school as part of Drexel University College of Medicine's Class of 2017. He is currently an Otolaryngology-Head and Neck Surgery Resident at Yale University.