PI: Margot Jackson Co-PI: Tania Jenkins Brown University
In 2012, 55 percent of all residency positions in internal medicine were filled by graduates from American medical schools (USMGs). The remaining 45 percent went to foreign medical graduates, US-born foreign medical graduates and osteopaths (DOs). This dissertation examines the experiences of this 45 percent by questioning the widely-held assumption that physicians are a monolithic "community of equals." As growing numbers non-US medical graduates fill less desirable positions within the medical profession, there is the potential for an unequal opportunity structure to form, putting these residents at a disadvantage relative to US-trained MDs. By pursuing the medical sociological tradition of hospital ethnography, this project will compare the experiences of residents in two types of residency programs - one that caters to USMGs and another to non-USMGs - in order to answer the following research questions: 1) How is medical education organized hierarchically and how does this organization lend itself to stratification among internal medicine residents of different training backgrounds? and 2) How does the occupational structure of graduate medical education affect the professional mobility of internal medicine residents? This dissertation will contribute to sociological understandings of occupational stratification by focusing not on gender or race, as other scholars have done, but on educational pedigree (degree type and location of medical school) as the driving force behind inequalities in professional status.
Broader impacts: The results may help us make sense of the implications associated with a wide range of health care policies and the experiences of both patients and physicians. For example, internal medicine is a pivotal residency, as it offers graduates the option of either practicing primary care or going on to subspecialize. With health insurance extending to millions of new patients, there is a need for primary care practitioners. By understanding the experiences of internal medicine residents - including the opportunity structure that constrains their decisions to remain generalists or subspecialize - there can be better preparation for facing the growing need for these services.
Project Outcomes A puzzle emerged early on in my dissertation research on internal medicine residents. I came across two types of residency programs: 1) There are ‘friendly’ programs (as they’re called on the blogosphere), housed in community hospitals staffing mostly (if not only) non-US medical grads, including foreign medical grads (FMGs), American citizens who study abroad (USFMGs) and osteopaths (DOs). And 2) there are ‘traditional’ programs, typically housed in prestigious tertiary hospitals, staffing almost only US medical graduates (USMGs) from allopathic medical schools. This is a study about two such programs, one ‘friendly,’ known as ‘Legacy Community Hospital’ and the other ‘traditional,’ known as ‘Stonewood University Hospital,’ and the processes that lead to such polarization in graduate medical education. The research questions I address are: What are the systematic forces of inclusion and exclusion that lead to polarization in residency programs? How do key players make sense of these forces of polarization? That’s another way of asking, how and why are traditional power asymmetries between US and non-US grads (re)produced and maintained in internal medicine training? What is the impact of polarization on residents’ training and on their opportunity structure for mobility post-residency? Significant results have emerged from this study on professional inequality. Specifically, the data suggest that major social forces of systematic exclusion lead to polarized residency programs (and inequality within the profession, ultimately), whereby "Legacy" Community Hospital staffs only non-US medical graduates while Stonewood University Hospital staffs only US graduates. These forces include systematic bias against non-US medical graduates (manifested through structural obstacles, such as visa restrictions), beliefs about a social contract with US-trained doctors (whereby they invest time and money in the profession so they deserve to get the best training positions afterwards), and a strong preference for recruiting 'known quanitities' in residency programs. Self-selection also plays a role, whereby US graduates will avoid applying to community hospital programs because they are less prestigious, offer fewer professional opportunities, and are typically staffed by non-US graduates, while international or osteopathic applicants will sometimes avoid applying to large university programs out of a belief that they will not get admitted. The resulting polarization of residency training has important implications for the training of these future physicians. I found significant differences in approaches to medical education and professional development between the two hospitals, suggesting that the training they receive is not necesarily equal. Residents at Legacy Community Hospital were mostly treated like workers, called upon to implement senior physicians' orders in their absence, whereas at Stonewood, residents are treated much more like trainees, with senior physicians acting like 'training wheels' for the residents. This begs important questions about implications, especially for residents' future career opportunities. Unsurprisingly, the residents at Legacy faced much more significant constraints in terms of opportunities post-residency, whereas the residents at Stonewood were hardly restricted at all in their opportunities. Part of this has to do with bias against non-US graduates, as well as assumptions about the training obtained in community hospitals settings. A recurring and important theme that has emerged from the data is the idea of 'Playing the Game.' Getting admitted to medical school, then applying for residency and eventually fellowship is conceptualized by medical professionals as a 'game,' whereby those who are familiar with the rules early on tend to succeed the most. I find that the rules of the game differ depending on how well you play, such that individuals who might have played less well in the beginning (for example, by not scoring exceptionally high in college) will have a tougher time later on. Non-US medical graduates face different rules of the game altogether, whereby they have additional hurdles to overcome in order to get accepted to residency, for example. This notion of 'rules of the game' may prove quite important to the sociology of professions, as we advance our understandings of how professions create intra-professional inequalities. The polarization of residents may represent a sort of 'proletarianization' of physicians but not in the way most scholars have considered. Instead of regular physicians becoming subordinated to physician-owners of medical establishments (in a more classic Marxist understanding of proletarianization), I suggest that by segregating and restricting opportunities for non-US medical graduates, this creates a sort of reserve army of labor which allows US medical graduates to then accede to higher, more desirable positions, while ensuring that less desirable positions are still being filled. This has important implications for our understandings of medicine as a profession, but also medical care more broadly, as well as professions in other fields.
