Hierarchy

A hospital is often set up like the military: there is an inherent rank system. When I first started working in the hospital, I remember thinking it was stupid that as a medical student I could ask some questions to residents but was not to bother the higher ups (senior residents, attendings) with these questions. I thought it was silly that people to treat people on the same team differently. Now that I have a bit more hospital experience under my belt, both in the US and abroad, I really respect the system of hierarchy in teaching hospitals. Now it makes total sense why I would ask an intern how to chart a patient’s findings but only trouble the attending with what he thought those findings suggested about the patient’s condition given the most recent publications in the field. I also think that the system is in place not just to feel great once you reach the top, but also for patient’s safety. As a medical student, I was responsible for my patients. I had an intern co-sign my orders and oversee everything that I did. Together we would present my patient to the team of residents. The senior resident would ensure that no mistakes were made with the team of patients. The senior resident would double check any concerns with the attending faculty staff. Built into this hierarchy are many levels of double-checking. So to people who hesitate to go to a teaching hospital because residents work there, I would like to argue that you are more likely to get excellent care at a teaching hospital because there are so many different types of people (i.e. rank) taking care of you that often have different perspectives on the same clinical problem.

Anyway, now that the background stuff is taken care of, I want to write about the hierarchy here in the DR. The inherent rank system in here is very strict and ordered. Residents are not only color-coded with particular uniforms depending on rank, but they also get to do completely different tasks during their day. For example, the intern takes care of absolutely all paperwork for everyone. The second year resident gets to assist in surgeries and do vaginal deliveries. The third year resident gets to be primary surgeon but not if the fourth year wants the case. So far this doesn’t sound tooooo different from what happens in academic centers in the US. Some hospitals tend to make a bigger deal out of hierarchy than others in the US. For example, in obstetrics, southern hospitals tend to be quite stringent about hierarchy and each person’s defined role within the system.

Well here in the DR things intensify. If an R2 disagrees with an R3 (R2- second year resident, R3- third year resident) they are falling out of rank. Today, I saw someone disobey their rank by disagreeing with a treatment plan. Not only were they humiliated by a team of superiors in front of the completely naked and exposed patient as this resident was suturing her up, but later the educational director came down to talk to this resident about his misconduct. The director punished this resident to 30 hours of call effective immediately and assigned the rest of the team additional call too for not being able to settle this within the team. What I saw today was a down-right denigration and humiliation of a resident for speaking his mind. Pretty crazy huh?

For those of you not in medicine, most teams of residents in the US would agree that patient safety is key. If someone does not agree with the treatment plan they are generally encouraged to speak up. Granted, there are proper times and places to bring this up (not appropriate to ever make another team member look bad because it makes the team look bad) but in general it is encouraged. If there is a conflict between team members (it happens to the best of us, especially in a field like OBGYN!), in no ways is this EVER discussed in front of a patient.

I’m learning a lot here in the DR. I am not as scared of hierarchy- I can appreciate its value now. And I kind of like that superiors are given proper respect (i.e. standing up when an attending enters the room, etc). That said, I also am happy that I will be going back to the US for about a million reasons, one of them being that as a team member I will probably always have a voice in the decision-making process involving my patients.