Medicine is a very hierarchical profession. When a doctor officially writes an order to a nurse, the nurse is legally required to follow that order. But where do mid-level providers fit in? Which kinds of doctors have more training? And in what settings does that hierarchy become less important? Ladies and gentlemen, we present to you a completely subjective list of the medical “ranks”!
All doctors require 4 years of undergraduate study with pre-med courses (organic and inorganic chemistry, physics, calculus, statistics are the usual), 4 years of medical school (divided into 2 years in classroom with coursework, and 2 years in clinical rotation), and a number of years of residency. Most doctors spend at least 3 years as a resident, but surgeons must spend a minimum of 5 years as one, and specialist surgeons spend even longer. All of this adds up to about 11 to 15 years of intense training (sometimes more)! All of this goes to good use, however, as Howard remarked “I have never seen a doctor who came out of the program unprepared." Even the least educated doctor still has 4 more years of training than an NP does, training full of 100-hour workweeks (and not great pay, as a resident), so their position at the “top of the food chain” is not undeserved. Though doctors can’t usually write orders for other doctors, some still informally outrank others, in terms of education, expertise, or respect. Among doctors, the list goes:
Surgeons go through some of the most rigorous and long-lasting training in the medical profession. They also take more frequent (and difficult) tests to keep their license. Why? Because surgery can cause incredible damage if it’s done poorly, and creates incredible solutions when done well. Some specialties of surgery are held in higher esteem (and paid better) than others (pediatric neurosurgery generally sits at the very top), but all surgeons command respect. Surgeons are paid very well.
Sitting very close behind surgeons are the specialists. There are many different kinds of specialties, and some are more “in vogue” than others. Electrophysiology is currently “in”, but neurology, nephrology, and endocrinology are generally regarded as the most difficult. Also near the top are pathology and radiology, which are generally also the highest paid (those are jobs that really have to be done correctly). Specialist-surgeons, regardless of field, are the rarest and (generally) most respected. Of course, when it comes to their field, specialists outrank everyone. Most specialists are paid very well.
Generalists such as OBGYNs and internal medicine, pediatrics, geriatrics, and family providers, are the lowest and most common doctors on the totem pole (of course, they still formally outrank all non-doctors). Part of this is because, as generalists will tell you, they spend much of their time doing paperwork: redirecting patients to the right specialists, billing, refilling prescriptions, and doing routine check-ups. Being a generalist isn’t necessarily less exciting compared to being a Big S, though: generalists see a much wider variety of patients, and often have to detangle psyche issues from physical issues, as well as diagnose patients normally. The public tends to see ER docs as a little above the rest, because of TV shows, and while the ER is more hectic, ER docs aren’t so different from other generalists. Generalists also get paid well.
NPs (Nurse Practitioners) and PAs (Physician’s Assistants) are both considered “mid-levels”. They require only 4 years of undergrad, a master’s degree, and 2 years of post-grad training (the training is different for PAs and NPs), much less than doctors, but they are still considered providers. Therefore, mid-levels can see patients independently, make diagnoses, write prescriptions, and order and receive lab tests. However, unlike physicians, mid-levels have no formal “residency” year(s), and are paid less than doctors, as they can’t usually treat the more complex patients, and this is generally considered fair. In some states, NPs powers are more limited, so that they can only work “under” a physician; this is usually in states with a large population of doctors, who wish to control the work opportunities. Neither NPs or PAs are “ranked” higher than the other.
Nurses are the “bottom” (in major air quotes) of the food chain. They require at least 2 years of college education, and a Bachelor’s in Nursing (BSN). Some kinds of nurses, sort of the specialist-nurses called LPNs (Licensed Practical Nurses), also have more training. Nurses do not get a residency year, and are not paid nearly as much as doctors (though often spend as much if not more time at work than doctors). Nurses are not considered “providers”, and cannot prescribe, diagnose, etc. However, nurses’ roles in hospitals and clinics are not to be downplayed: they are vital to the function of a hospital. “All good nurses can smell trouble”, says Howard, and (good) doctors and mid-levels consult nurses frequently, especially when the nurse is much more experienced than the provider, and “One of the marks of an inexperienced doctor is condescending to nurses." Nurses have their own informal hierarchy, but generally the ones at the top are ICU, OR, and ER nurses.
How Present is the Hierarchy?
The hierarchy exists in medicine for a very good reason: you have to know what you know and what you don’t know, and have to stay in your lane. More complex cases get funneled up the ladder to the surgeons and specialists, while the mid-levels and generalists see the (overwhelmingly present tide of) simpler cases and check-ups, and nurses keep things running at every level. However, that’s only for the big-picture system. Ask any medical worker, and they’ll tell you that (with experienced staff) a floor operates much more like a team, a “partnership among equals." The more complex and intricate a situation / operation is, the more you rely on each other. The pay and time might not be equal, but the effort and respect between coworkers certainly is (with a good crew, at least).
Race and Gender in the Hierarchy
There is a race and gender problem in the hierarchy. Women are now in about equal representation with men as providers (though they still dominate the nursing field), which is great, but that’s not the issue. Women and people of color (and especially women of color) are often automatically assumed to be lower down in the hierarchy, and tall white male staff are just assumed to be doctors. Any black or female doctor could name at least one time when a patient assumed the white male nurse next to them was the physician, or times when other physicians assumed they were a nurse. Better colored or female representation in media (and simply in stock photos) about high-level medical work could counteract this.
Doctors do also have a little more privilege than other staff when it comes to behavior, especially when the doctor is tall, white, or male. Doctors are allowed to be more uncooperative, mean, or (more bluntly) bitchy, for no other reason than they’re doctors. Generally, this gets fixed through some experience and maybe a few talking-tos by the unflappable Elder Nurse, but it would do the next generation of physicians good to remember that extra education does not permit bad behavior. Most of the interpersonal strife in medical practice comes from new doctors not listening to the rest of the staff and writing orders over them, so it would be good for the next generation of providers to think of medicine as a team sport, not a one-man show. Everyone contributes, and this hierarchy is only accurate for income and education, not respectability.
Thank you to Gallaudet Howard (NP) for giving us a look at the medical “law of the land."