TaniaJenkins.Doctors' orders: The making of status hierarchies in an elite profession

Abstract

The processes of status separation that assure rapid and legitimized stratification in modern American society are no secret. It is often forgotten that these same social forces exist even within highly prestigious occupational groups like physicians.As a student of health policy who finds himself increasingly drawn to the field of medical sociology, I was excited at the prospect of reading and reviewing Tania Jenkins' Doctors' Orders: The Making of Status Hierarchies in an Elite Profession. Noting a stark trend-the segregation of residency programs based on medical pedigree despite the lack of any formal rules or regulations dictating such separation-Jenkins, who is Assistant Professor of Sociology at the University of North Carolina-Chapel Hill, conducts a thorough and fascinating ethnography of two contrasting internal medicine programs.At Stonewood Hospital (a pseudonym for one of her study sites, both of which are located in the Northeastern U.S.), residents are overwhelmingly U.S. graduates of allopathic medical schools (hereafter USMDs), train with highly complex patients, and find themselves supported from start to finish. At Legacy Hospital (also a pseudonym), comprised mostly of graduates from osteopathic and international schools (hereafter non-USMDs), Jenkins finds an entirely different training environment which largely deprives residents of the experiences they need to find success within the profession. Unsurprisingly, those from Stonewood have more success at matching into subspecialties of their choice. The sorting of USMDs and non-USMDs into programs of disparate educational quality and the subsequent disparate outcomes could ostensibly be explained by a narrative where USMDs are objectively better doctors, thus deserving of the best opportunities within the profession. Jenkins' powerful qualitative data, however, suggest that this justification is wielded disingenuously by the professional establishment, masking the structural factors that stymie success for non-USMDs while all but guaranteeing elite ascension for USMDs.At the core of Jenkins' findings is what she refers to as a "self-fulfilling prophecy" (p. 173). First, non-USMDs are regarded as lower-quality candidates for the field of medicine, a stigmatization process undergirded by both classist and nativist sentiments. Admission to an allopathic medical school is highly dependent on a stable and supportive upbringing so that one is set up for "playing the game" (p. 39). Despite these underlying structural barriers for those without early access to resources, individuals attending nonallopathic schools were assumed to be intellectually inferior. However, prosperous upbringing is not the only important driver: many international medical graduates also had positive early life experiences. These candidates experienced stigmatization not from a lack of early social support to grant them advantages, but rather from powerful societal status beliefs dictating that foreign people, even those intending to work in a highly prestigious occupation, a...