Solitary and Supported Autonomy: Hospital Structure and its Impacts on Graduate Medical Education

• In Event: 448 - Section on Medical Sociology Paper Session. The Social Organization of Medicine

Abstract

While sociologists have studied residency training since the 1960s, little is known about how hospital organization (i.e. attending structure or hospital type) impacts residents’ training or experiences of autonomy. Nearly two-thirds of internal medicine residency programs are housed in community hospitals while the other 35% are university-based (American Medical Association, 2015), but few have compared educational experiences in these two settings. Community and university programs furthermore tend to be segregated along educational pedigree lines, such that the former are often disproportionately staffed by osteopaths and international medical graduates (non-USMDs), while the latter are mostly staffed by USMDs. One way of understanding the implications of such segregation is to examine how educational experiences vary across contexts, and in particular, how hospital structures may exacerbate professional inequality.

This article therefore explores how approaches to medical education differ between medical residencies at a community and university hospital. Drawing on ethnographic data from 2011-2014, I show how the community program’s attending structure lent itself to a very hands-off approach that paradoxically granted residents both a lot of autonomy and robbed them of it at the same time, leading to what I term "solitary autonomy". In contrast, the attending structure at the university hospital meant that the residents were strongly supported and supervised, allowing them to flex their autonomy without posing a risk to patient care: "supported autonomy." Ultimately, I find that segregating medical residents by pedigree into solitary versus supported autonomy programs can exacerbate existing stigmas and inequalities between USMDs and non-USMDs.

Author

• Tania M. Jenkins, University of Chicago