Hierarchies, clans and fiefdoms

Hierarchies, clans, and fiefdoms

Vijay Gopichandran

Nowhere else is the strict hierarchy stronger than in the medical fraternity. I have realized this as someone who has been trained in medicine for more than 9 years, practiced medicine for about 20 and worked outside of medicine in areas of writing, journalism, public health, and social work for about 6 years in the middle.

The hierarchy in medicine starts from day one of medical school. Fresh from a very forward-thinking and modern CBSE school in Chennai, when I entered the prestigious Madras Medical College, I was shocked to realize that I am not allowed to say “Hi” and wave my hands at a person from my own school who had joined the college the previous year. He was my senior in college and so I was supposed to show reverence and address him as “sir”. I was instantly identified as the rookie spoilt snob from an upper-class school who waves at his seniors and was subject to intense ‘ragging’ for several months. Even today, almost 20 years later, I still see my students address their seniors as “sir” and “madam”. The “sirs and madams” come and complain to me sometimes that their juniors do not show respect when they say, “sir and madam”. It makes me laugh!

Then, I remember our clinical postings in college. The Professor used to be seated and all of us stand around him/her as he/she teaches all about the patient. Note the capital letter I have used for Professor. Not only is the Professor a great person worthy of worship and deference, even while writing about her one needs to capitalize the first letter! The moment the Professor enters the ward for teaching, everybody drops whatever they are doing and stands with their head bowed low in deference. As a medical student, I once noticed a house-surgeon who was inserting a urinary catheter into a male patient, itself being one of the queasiest procedures, drop the half-finished job and stand up in deference when she noticed her Professor walk in. Not only was her respect flowing all over the ward, the patient’s urine from the half-inserted catheter which she just dropped was also overflowing all over the floor.

I thought hierarchies will disappear when I become a post-graduate student. It must have been all the episodes of House MD which I binge-watched in the period between my MBBS and obtaining an MD seat in a prestigious medical college near Chennai. In the series, the residents (Postgraduate students) address their Professor by name and challenge him and they are treated as professional colleagues. When I entered the college for the PG, I was welcomed by very professional colleagues, all of whom said, “there is no hierarchy in this institution” we all work for the patients here. In fact, I remember when I stood up when the head of the department entered the room and addressed everyone as “sir” I was laughed at as “an outsider”. This institution is a very prestigious one, with a strong history of having a large majority of their own undergraduates going on to do post-graduation there. So anyone from outside is initially scrutinized heavily and referred to as an ‘outsider’. It took a few months for this outsider, to get used to the ways of the new institution. I realized that there was ‘no hierarchy’ in the form of rituals. One would not typically stand when a Professor enters the room. One would not wear a fake smile and go all around the ward “wishing everyone good morning”. Yes, the rituals all had been done away with. But in the real things that mattered the institution was still steeped in the hierarchy. The pecking order was strictly maintained. The junior-most intern in the department seldom had a say, even if her idea was brilliant. There was a strong order of command, of military discipline, in matters of academia and intellect. This strengthened my ‘belief’ in the hierarchy.

Then after my MD, I took a forage out of clinical medicine. I worked in a community-based organization, doing social work. I realized how it is to work in a non-hierarchical setup. In this organization, the doctor is not God. The doctor is as human and as much fallible as everyone else. I was exposed to community meetings where people questioned doctors fearlessly. Doctors were asked to explain treatments that they provided to patients in front of committees, the members of which were common people. I remember a particular incident, where there was a community meeting in which I had to ask for an extra pair of hands for managing the overwhelming crowd in the OPD. One of the community members asked me “If you think you are overwhelmed and unable to function optimally, then aren’t you doing serious harm to the community? Why did you not bring this up much earlier?” I was shocked and stunned to hear this question from a lady who has not even completed her schooling. But then I realized this shock and stun came from my training and rooting in the hierarchy. What I was experiencing was the true absence of a hierarchical structure. I realized this is what I have been wanting from the beginning. But when it hit me, it hit me hard.

Then I went on to do my Ph.D. in Public Health, where again I had the opportunity to work with diverse groups of people who were not soaked in the hierarchy. This expanded my perspective. Now I am back in a medical institution teaching medicine to undergraduate students. I am in the deep ditch of hierarchy again. The difference is stark. In the middle, I was getting used to breathing freely without having to call everyone and their father “sir”. Now, I am calling everyone “sir and madam”, sometimes even my colleagues who are much younger than me. I am back to controlling my urge to speak out something sensible in front of my seniors, lest they get offended by the sense that I make! I am back to listening patiently to the nonsense that my seniors sometimes ramble, just thinking in my mind, “what a waste of time”. I am back to “obeying” rather than “working with” mode. Yes, life has come a full circle. I have realized that medicine is a hierarchical society, it is a modern fiefdom and a strong clan. I am hoping that one day all this will change. But will I have any semblance of my individuality by then?