Doctors’ Orders: The Making of Status Hierarchies in an Elite Profession

Approximately 70% of the United States physician workforce consists of graduates of American MD-granting medical schools. The remainder is composed of osteopathic physicians and graduates of international medical schools.¹ To medical regulators, all of these licensed physicians — regardless of their educational background — are created equal. Yet, to the general public and among their physician peers, status hierarchies often shape the way these doctors are viewed and the practice opportunities that they will receive. How does this social scale get established — and why does it persist?

In Doctors’ Orders: The Making of Status Hierarchies in an Elite Profession (Columbia University Press, 2020), sociologist Tania Jenkins explores factors that create and calcify status hierarchies in medicine. Her approach is ethnographic: Jenkins conducted nearly two years of fieldwork embedded in two internal medicine residency programs. The first — pseudonymously known as Stonewood University Hospital — was a prestigious academic medical center whose residents were almost exclusively graduates of allopathic medical schools in the United States (USMDs). In contrast, at the so-called Legacy Community Hospital — a smaller hospital in the same city — almost all residents were graduates of osteopathic or international medical schools (non-USMDs).

Though the hospitals were separated by only a few miles, they were worlds apart. At Stonewood, residents benefitted from world-class clinical resources, extensive faculty mentorship, an intentional and evidence-based educational curriculum and layers of clinical supervision and graded autonomy. At Legacy, faculty supervision was often lax, professional mentorship was inconsistent, educational activities were generally perfunctory, and residents were regarded primarily as workers rather than learners. Unsurprisingly, residents from Stonewood were more likely to enter competitive (and financially lucrative) careers in cardiology, gastroenterology, and allergy-immunology than those from Legacy, who entered less-competitive specialties or primary care.

Yet the differences between Stonewood and Legacy residents began well before they entered their residency programs. Jenkins meticulously traces the path dependence in the careers of the USMDs and non-USMDs, noting systemic differences in advantage that begin early in life. Compared to the non-USMDs, USMDs were more likely to come from privileged backgrounds, where they learned early how to “play the game” to gain access to selective medical schools. Once accepted to these schools, Jenkins argues, USMDs benefit from an implicit social contract: In return for their hard work and high tuition, they receive the support necessary to obtain a secure, respected, and high-paying position in society. Career success for USMDs is constrained not by structural deficiencies, but by their own internalized definitions of success.

In contrast, non-USMDs were often first-generation college students or economically disadvantaged. Few had physicians as parents. They learned how to play the game later than their USMD counterparts — and faced a more challenging career path because of it. Rather than the extensive support and safety nets enjoyed by the USMDs, non-USMDs functioned in a highly competitive environment with clear winners and losers. The winners obtained residency training at residency programs that were unable to recruit USMDs; the losers were weeded out from medical school or, if they graduated, were unable to secure a residency position altogether.

Doctors’ Orders demonstrates how structural inequalities, rather than differences in innate ability, result in the training of physicians with quite different competencies. Jenkins provides an inside look at how all the different players — residents, faculty, program and fellowship directors — conceptualize and justify the status hierarchies in medicine. The separation of the elite from the rank and file is the sum total of often individually-small differences and personal biases that culminate in fixed professional norms and status beliefs.

Jenkins casts a discerning eye, and her observations are astute and incisive. Yet several blind spots are apparent. First, the book largely ignores the role of race in shaping physician hierarchies. This colorblind approach ignores deep inequality that shapes the experience of doctors from backgrounds underrepresented in medicine. For instance, while most USMDs come from socioeconomically privileged positions, Black students are overrepresented among the lowest strata of household income and the highest strata of premedical school debt,² and face significantly lower odds of securing a residency position than other groups.³ Second, Jenkins seems to regard standardized test scores as an accurate and unambiguous reflection of merit rather than a measure that is highly influenced by the same societal advantages that she often regards suspiciously. Yet, on Step 1 of the United States Medical Licensing Examination (USMLE), female test-takers — as well as Black and Hispanic examinees — score lower than white male students.⁴ Similarly, among applicants in the Match in 2020, USMDs scored 7–8 points higher than non-USMDs on USMLE Step 1,^5–7 raising the question of whether these scores function more to perpetuate status hierarchies than as a leveling device.

With Doctors’ Orders, Jenkins has provided an accessible yet authoritative book that holds a mirror to the medical status hierarchy. Altogether, it is an enjoyable and worthwhile read that should inspire physicians to critically examine how we perpetuate inequality for the sake of prestige.