The Myth of Meritocracy in the American Medical Profession

The United States currently graduates approximately 40% fewer physicians than are needed to fill postgraduate residency positions. The remaining positions are filled by American graduates of foreign universities, foreign medical graduates and osteopaths. The result is that US medical graduates (USMGs) are the most competitive candidates for residency, getting priority access to the most desirable positions. Last year, for example, over 90% of spots in plastic and orthopedic surgery were filled by USMGs. In contrast, non-USMGs fill lower-prestige residency positions in less desirable geographical locations and specialties (like internal medicine). In some cases, this has resulted in very polarized training environments, with so-called ‘friendly’ programs staffing only non-USMGs, and highly prestigious ‘traditional’ programs training only USMGs. Because of major differences in resources and medical service offerings, these programs have vastly different approaches to teaching which can affect residents’ opportunity structure post-residency, especially in subspecialty training.

This study examines why this arrangement persists, in spite of its implications for inequality. What are the social forces and beliefs that sustain this system of stratification among internal medicine residents? Drawing on two years of ethnographic observation and interviewing at one such ‘friendly’ hospital, this paper presents evidence for a ‘myth of meritocracy’ among residents. Doctors feel they are individually responsible for their own success, and conversely, that they are to be individually blamed for not reaching certain goals, such as getting into competitive residency and fellowship programs. They also deploy examples of non-USMGs successfully achieving these goals as evidence for this belief, rather than as evidence of considerable structural barriers (eg. visa restrictions) which constrain opportunities for non-USMGs. By elaborating local understandings of social mobility and advantage among medical residents, the paper reveals the power of this myth of meritocracy in obscuring, sustaining, and perpetuating the role of significant social and institutional constraint.