The Hierarchy: Medicine’s Pyramid Scheme

Medicine is a system built on hierarchy, whether we like to admit it or not. From the day you step into a hospital as a student, you start to understand your place — and your place is very much at the bottom with the other feeders and pond-scum.

JHOs get pecked by SHOs (I know they're not called that any more but f**ked if I can find a better way to summarise them), to do all the anal retentive things like Discharge letters and manual evacuations.

Those cock-sure SHOs then get dogsbody-jobs like holding retractors or chatting to relatives by Registrars, who's job is primarily to deal with the kids on the ward (aka the more Junior doctors) and work the coal face in front of the consultant like a Staffer making sure Maria Carey always had baby seal tears to drink at all times (citation needed).

In short - life is severely shit for Junior doctors, and it gets worse as you go predominantly.

Now before anyone get defensive it's not that crass all the time, naturally - but the ladder is still there, even if the job titles, language, training routes and general methods of torture have evolved.

And it’s not just symbolic; junior doctors experience a steep transition into practice where they must rapidly learn professional norms, prioritise under pressure, and decode an unspoken culture. That often means learning when to speak up — and when not to.

When I was starting out, Foundation Year training was still relatively new. We had protected hours on paper, but in reality, you'd end up doing seven nights in a row, clinging to consciousness by rota loopholes and goodwill. The hierarchy back then was rigid. You were seen, not heard — unless you were bleeped, in which case you were probably needed somewhere immediately and had better not ask too many questions.

It almost, honestly, feels ingenuous to speak so poorly of it - some of my better memories and indeed funniest stories were born out of this parity of disparity. Like the consultant that never said a kind word to anyone other than consultants and his own peers, then one day forgot the word for Rectum and flustered "Bumhole" repeately in front of a patient. He wasn't having a stroke, he was having a moment (and we were having a f**king belter).

My impression is that today’s junior doctors are more unionised, more rights-aware, and more attuned to mental health and toxic culture. But the hierarchy hasn’t disappeared — it has simply evolved. Power remains embedded in training structures and emotional dynamics, especially in high-stakes environments.

As mentioned, the registrar years — notoriously intense — bring that into sharp relief. You carry significant clinical risk but often lack full autonomy or support. The intoxicating role of the “Med Reg” remains both prestigious and punishing, with junior doctors describing it as “a pressure cooker” of competing demands, decision fatigue, and emotional exhaustion.

Indeed, as many of you who drink my Coolaid regularly know I jumped ship from training in a Hospital at about ST5 (I was out of program when I did, so it's a matter of perspective). I loved being a Med Reg overnight - the unselected, random and varied take of acutally sick people. The heirarchy was you - phone a consultant at night and prepare for a quizzing the likes of which even Police interrogators might say is "excessive".

That, however, was a double edged sword; who does the Pope speak to when the Almighty's bleep at home is switched off and the second on isn't answering? You're on your own chuck. There's no back-up really, it's seat-of-the-pants, squeaky bum time now.

Anyone who has looked that ICU consultant dead in the eye for the third time that evening to ask for another admission, only to watch that heavily sedated frequently-seizing-when-you-weren't-there-but-it-was-for-real-a-seizure man get bored of his functional seizure and pull out the Guidel airway making you look like a total arsehole. Yeah. It's a lot.

So by the time you make it to consultant level, you’ve clearly seen some shit. You’ve been broken and rebuilt multiple times. You’ve stayed late, been shouted at, missed family events, and shouldered the emotional labour of medicine for years. It's easy, then, to see how some consultants become hardened — disconnected even. Looking at juniors with the cynical eye of someone who survived the fire and resents that the flames are now hotter or that doctors these days can't just enjoy the vague baconey smell.

But here's the thing: the juniors of today aren’t soft. They’re just fighting different battles.

They’ve trained through COVID-era disruptions. They’ve entered a workforce underfunded and overstretched. They’re more open about neurodivergence and mental health (which, actually can put a target on you as much as help in some cases). Many junior doctors during the pandemic experienced isolation, poor supervision, and moral injury — all exacerbated by the rigid nature of hierarchy and limited feedback.

So yes, they may ask more questions. They may push back. But that’s not weakness — that’s a sign the system is shifting.

It's always worth sharing a wisdom earned in fire - in my case, and in all frankness, way to late to serve me at that time in my life. Good trainees aren’t always the most knowledgeable. They're the ones who are honest, curious, humble, and adaptable. Who admit their gaps and ask for help at the point they need it - not prophylactically or when the propellant feaces hits the shitty Dyson bladeless fan. They know their role in the team, but also know their worth. Medical students and trainees who actively navigate hierarchy — rather than passively accept it — often become better communicators and safer clinicians.

Consultants aren’t villains. Many are brilliant. Most are exhausted. A few are both. Often they’re juggling clinical practice, management duties, rota planning, teaching, and service redesign — all while fielding the daily chaos of a system on the edge and needing desperately to get back to their office for a Quantum of Solace and a nearby usable loo.

So how do you navigate the hierarchy? Start with humility. Know your level. Be curious, but don’t overstep for show. Use FY2s and registrars to learn expectations. Accept that some consultants will mentor, others will seem cold — neither is necessarily personal but not anticipating who's who can, and will, burn you. Ignorance, or poorly veined respect for equity of opinion, is not an excuse.

Want to stand out? Be efficient. Be dependable. Be respectful. You don’t need to be the loudest — but you do need to be the one the team trusts to follow through.

Medicine isn’t the military, but it is a team sport. Learn the hierarchy not to worship it, but to move through it — and one day, reshape it.

Because if you make it to the top, and you still remember what it felt like at the bottom, just don’t pull the ladder up behind you.

Stay positive

DW