Doctors' Orders: The Making of Status Hierarchies in an Elite Profession by Tania M. Jenkins (review)

One characteristic that has long been seen to distinguish professions from some other occupations is their internal homogeneity. Standardized training and exams, combined with professional socialization and licensing laws, are believed to transform somewhat varied students into virtually interchangeable professionals with shared skills and values. In her book, Doctors' Orders', Tania M. Jenkins explodes this view, revealing how the medical profession is rife with internal social inequalities that are produced and reproduced in the course of professional training. In so doing, Jenkins shows how professional exams and training mechanisms, which may outwardly appear meritocratic, reproduce privilege for the fortunate and bolster professional power, but in the process create an underclass of practitioners, potentially compromising the quality of professional healthcare services.

Jenkins' book is based on extensive ethnographic research at two hospitals—one a community hospital, the other a more prestigious university-affiliated hospital—in an unnamed state. Jenkins spent 23 months in the field between 2011 and 2014, not only completing over a thousand hours of participant observation, but also 123 interviews and 9 focus groups. Her research focused on medical residents specializing in internal medicine, and especially how residents' education, experiences, and opportunities—as well as the residents themselves—varied across the two settings. This extensive research allows Jenkins to produce a rich ethnography, shedding light on processes of professional education, and internal status hierarchies that are otherwise hidden from view.

Comparing residents at the two hospital locations, Jenkins identifies striking differences. At the university-affiliated hospital, which Jenkins calls Stonewood, internal medicine residents are primarily US trained (USMDs). In contrast, at the smaller community hospital (called Legacy), residents are different: they are foreign-trained US medical graduates, graduates from osteopathic medicine programs (DO's), or foreign-born and foreign-trained medical graduates (all of whom she refers to as non-USMDs). The USMDs at Stonewood are privileged. They enjoy the prestige of training at a higher-status facility, as well as more hospital resources, a varied patient base, a more exacting and extensive curriculum, better mentorship, and more opportunities upon residency completion. All of this sets them up for careers in prestigious, high-paying subspecialties. In contrast, the non-USMDs at Legacy have fewer opportunities and are treated as workers first and students second. They experience what Jenkins calls "inconsistent autonomy": They are often left to their own devices in patient care, allowing for some autonomy, and yet they are required to follow the orders of absent attending physicians, rather than being encouraged to think on their own, under the guidance and mentorship of others. They have fewer opportunities for prestigious specialties.

Jenkins meticulously unpacks these differences, and explores their implications. She traces the origins of these differences to the social backgrounds and opportunities of medical residents. USMDs are quite often from privileged backgrounds, prepared from an early age for a professional career by parents who draw on their resources not only to encourage good grades, but well-rounded education, and extracurricular activities designed to open up opportunities for future success. Parents, social connections, and school mentors make sure that these young people take the right courses and do what is necessary to maximize their opportunities to get into medical school. Once in, these students benefit from an implicit (and at times explicit) social contract. Those who obtain entry to a US medical school, pay the high tuition, and complete the work assigned enjoy smooth pathways into the profession, with supports in place to help any who have difficulty; a residency and a secure career in medicine are basically guaranteed. Non-USMDs are not so fortunate. Some are the first in their families to go to college. Others are economically disadvantaged, pursuing a second career, or late bloomers. For various reasons, they lack the grades, extracurriculars, and mentors to ensure entry into medical school. Others are foreign trained or they chose to pursue osteopathic instead of allopathic medicine. Despite facing...