How Hierarchical Is Your Practice?

Last night at work, I strode back to my desk from a patient’s room to find a physician sitting in my chair. I didn’t know him. He was a specialist from another department in the emergency room consulting on a patient. I stood patiently in the proximity of my chair, waiting for him to wrap up his thought or for him to offer to finish his note elsewhere so I could get on with my work. I had things to do and people to see. Charting doesn’t take care of itself (I wish!).

After a few minutes, the physician was still scribbling away on his note pad without looking up. So, I moved awkwardly close to my chair, my disposition a little less patient. Still, he did not acknowledge my existence. I had a decision to make. Do I ask him to butt out and find somewhere else to finish his work? Do I find a computer outside my assigned area to finish my charting? Or, do I continue waiting? I wasn’t particularly keen on any of these options, so I elected to march myself into another patient’s room getting things started with that particular visit.

While the entire scenario played out over the course of only about ten minutes, it highlighted to me the hierarchical nature of my workplace. Administration comes first, then physicians. Nurse practitioners and physician assistants come next in the pecking order followed by nurses. The command chain continues with medical assistants and X-ray techs followed by phlebotomists. One could argue that the tiered system has to do with differing levels of education and job responsibilities. And, to an extent it does. But, my hesitancy to speak up to a physician was clear evidence of the ingrained hierarchical culture of my hospital and in many cases our healthcare system as a whole.

Had I more of a confrontational disposition, I might have spoken up in this particular situation, asking the physician to move so I could continue my work on my computer maintaining the flow of my designated area of the emergency department. But, this would have certainly meant challenging the cultural norms of my workplace. It was something I wasn’t looking to do in the moment.

The interactions within the emergency department where I work consistently take on a stratified order. Even parking is organized by stature. Physicians have their own designated spots front and center, nurses park outside the covered lot braving the elements as they walk through the doors to work. NPs and PAs find themselves in an awkward middle place, parking in the MD spots while trying not to get caught (I’m zero for one million myself).

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A sense of order and designating figures of authority are important in healthcare. Everyone has a job they are specifically trained to perform. Not to mention, someone needs to be the point person in high acuity situations. But, a less hierarchical workplace culture should be our ideal. Authoritarian relationships prevent coworkers from speaking up in cases where one may be making a mistake-which we all do, regardless of the initials behind our name. These kinds of relationships discourage growth and collaboration.

Right or wrong, I didn’t make any strides yesterday in helping to reverse the hierarchical trend where I work. It isn’t an easy thing to do.

What does your workplace look like? How do you fit in to the structure? Are you one to confront hierarchical commonplace or fall into place?


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4 thoughts on “How Hierarchical Is Your Practice?”

  1. Dave Mittman, PA, DFAAPA

    If I knew I was valued, worked there for awhile and had some backing of administration I would have very nicely told the “doctor” that this was my desk. That I would be happy to let him/her finish up their immediate work but I needed to hop back into mine. Maybe get a soda.
    There is no way an experienced NP or PA should ever stand for this.
    Funny, I was having lunch with a CEO of a large company recently. He has about 1,000 people under him. He pulled into the spot for the “Employee of the Week” which was NOT TAKEN at about 11 am. He then saw her car and excused himself and we pulled out and walked from the end of the lot (his spot was taken). He respected someone’s space. No one sits at your desk if it is not theirs without asking if they can. I was the “boss” of about 75 people. I would have come down hard on anyone who thought they could do that.

  2. Take this from whence it comes but to me, as long as you blog as a “mid-level” and think of yourself as a “mid-level” you are giving others permission to do the same. All of us have something valuable to offer to the team and to the patients and their families. So, always refer to yourself by your professional designation and others will also.

  3. Ann Marie Ramsey

    I find it interesting that this appeared on a site called “MidLevel U”. Hello…. we are calling ourselves “mid-levels” then complaining about hierarchy. If we are the mid-levels who are the high levels? Who are the low levels? The term “mid level” needs to go and go now! This term endorses hierarchy and kills a level playing field team approach to patient care. At my workplace we are actively removing this team for all our policies and institutional documents. We need to be called what we are: Nurse Practitioner or Physician Assistant.

  4. Hi, I have been in the same situation many times. The reality is that the hospitalists have no “work area” as they did even 20 years ago. Thus they are left “jockeying” for any unused chair or computer when they come to the ER to admit a patient. This is the reality of ER medicine. Working together and sharing resources for the good of our society was the right choice. I congratulate you, and I appreciate that you are a team player!

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