Intermittently, third-year-students at my school are required to attend academic sessions in which students and faculty join together with the intention of generating discussions surrounding relevant topics in medicine (professionalism, social determinants of health, etc). This week we were asked to consider the role of medical students within the hierarchy of the medical team, and how this hierarchy influences patient care and our individual education. The hierarchy, if utilized appropriately, can function as a platform on which students can identify what their goals should be during each step of medical training. Simultaneously, developing the understanding of the role of medical students, interns, residents and attendings allows students to define what their current role should be in the healthcare team, which can often be of great benefit to the patient. When the topic of the hierarchical arrangement of the medical team is being discussed there is inevitably an uglier component that must be addressed: how common do medical students feel abused, discouraged and fearful of those higher in the chain of command? The 1996 JAMA publication ‘Medical student abuse during third year clerkships’ certainly reinforced the notion that students frequently experience abuse in a wide range of categories spanning from verbal, physical, sexual and academic. These staggering results call into question where the line between benefit and detriment is drawn in relation to the function of the medical student in the hierarchy of the healthcare team.   

Clinical education does not come with an instruction manual. For many, this grim and intimidating realization must be met with some sort of guidance on how to establish a platform on which to build the understanding of what is expected during each level of training. The hierarchy of the medical team has allowed me the opportunity to investigate the role of each level of provider (student, intern, resident, attending) so I can better understand what I should accomplish through each level of education. Working as a student on the healthcare team grants a unique opportunity to select mentors, decide who you want to emulate, and how to set appropriate goals and competencies. The efforts to understand the dynamics of the team hierarchy additionally affords students the opportunity to decide how we, as students, can make a difference in patient care. Medical students have the particular advantage of having time to accomplish specific tasks that others may not have time for. I can recall a specific example of a cerebral palsy patient who was in the ICU after being re-admitted to manage a wound infection; he had a significant seizure after being admitted and the history surrounding previous seizures was unclear. While the attending physician was managing a long list of other consults, my colleague and I spent a marked amount of time tracking down his history, discussing the patient with his nursing home staff and after being put on hold and transferred numerous times, we finally felt we had enough information to actually help this patient. Taking the time to do this is a luxury that only medical students have, and the recognition of that allowed us to feel like we have a role on the healthcare team.

The negative associations with the idea of medical team hierarchy can, on the surface, seem petty. Many could argue that students, who mostly have been in school for their entire lives, are finally being exposed to the real world experience of a hierarchy in any job. The commonality of the experience of being forced to work with (or under the supervision of) individuals you do not care for is almost comical. Yet, there are elements of medical education that makes this extraordinarily different from the typical pangs of hierarchical woes. We are paying, not getting paid. We are being evaluated not for the sake of maintaining a certain salary/position but rather receiving feedback that should shape our futures as physicals, and grades that will determine what that future will look like. The stakes are objectively much, much higher. With that being said, one would hope that the hierarchical system would be used appropriately and advantageously, yet the topic of abuse of medical students continues to be researched, studied and discussed as a serious issue. In my experience I have had a handful of unsavory interactions but would not proclaim feelings of abuse in the traditional categories as outlined in the JAMA article, rather I would want to acknowledge “abuse” in the form of neglect. There must be a line drawn between promoting self-directed learning and blatantly not fulfilling a duty to train the next generation of physicians. This is one of the bigger issues that I have seen students face. I am still aiming to learn how we can foster encouragement to teach students, to nurture the next generation of physicians, and to encourage mentorship that will inspire us to be the interns, residents and attendings that will utilize the medical hierarchy to help students establish goals for both their education and their role in helping to better the care of our patients.  I hope this is the future of medicine. 

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