State of the Art Review Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology Otolaryngology– Head and Neck Surgery 1–9 Ó American Academy of Otolaryngology–Head and Neck Surgery Foundation 2020 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599820926105 http://otojournal.org Parsa P. Salehi, MD 1 , Daniel Jacobs 1 , Timur Suhail-Sindhu, MD 2 , Benjamin L. Judson, MD 1 , Babak Azizzadeh, MD 3,4 , and Yan Ho Lee, MD 1 Abstract Objective. To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues. Data Sources. Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists. Review Methods. A literature search was performed to iden- tify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years. Conclusions. Two types of hierarchies exist: ‘‘functional’’ and ‘‘dysfunctional.’’ While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunc- tional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environ- ment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety. Implications for Practice. Otolaryngology–head and neck sur- gery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one’s own environ- ment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized. Keywords hierarchy, residency, wellness, burnout, match, NRMP, ACGME, resident, stress, well-being, depression, quality of life Received October 27, 2019; accepted April 6, 2020. W orkplace hierarchies exist to achieve unified pro- fessional goals, and across professions, such as business and the military, a well-organized hierar- chy is vital for efficient, safe operations. In medicine, trainees and students undoubtedly benefit from mentorship, role mod- eling, teaching, guidance, and the safety net that their faculty provide. A common theme among these ‘‘functional,’’ as opposed to ‘‘dysfunctional,’’ hierarchies 1 is that lower-ranked individuals are empowered to use their voice, share relevant information, and be treated as valued members of the group. 1 While hierarchies may be beneficial, many examples exist of rigid hierarchies resulting in catastrophes—from airplane acci- dents to surgery mishaps. 2,3 Negative impacts of hierarchy have been documented in various medical professions, 4-6 and they have the potential to create moral distress and ethical dilemmas; endanger patient safety; amplify stress, fatigue, and burnout; undermine empathy; hamper learning; lower training satisfac- tion; discourage use of ‘‘voice’’; and legitimize trainee mistreat- ment. 5,7,8 These, in turn, may influence trainee career choices, decrease patient care quality, and contribute to poor health and well-being. 7,9 The negative impacts of hierarchy also affect attending physicians, in particular, junior faculty. 10,11 Therefore, while well-structured hierarchy in medicine is commonplace, 8,12 the consequences of hierarchy on trainee education have not been critically examined. 1 Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA 2 Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA 3 Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA 4 Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, David Geffen School of Medicine at the University of California–Los Angeles, Los Angeles, California, USA This article was presented as an oral presentation at the AAO-HNSF 2019 Annual Meeting and OTO Experience; September 15-18, 2019; New Orleans, Louisiana. Corresponding Author: Parsa P. Salehi, MD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, 47 College Street, Suite 216, New Haven, CT 06510, USA. Email: parsa.salehi@yale.edu