Academic Medicine and the Peter Principle


Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

The Three-legged Stool

Academic medicine is sometimes described as a three-legged stool, where the department/institution is balanced on the three pillars of clinical care, research, and education. There is a pervasive myth that academic physicians can do it all: be an outstanding clinician, an excellent teacher, and a prodigious researcher. The reality is that most people don’t have all three skills in sufficient measure, and even those that do are not given the requisite time to perform meaningfully in all three categories.

While polymaths exist, the idea of the physician-scientist is increasingly intractable in modern medicine. The demands of clinical work have increased substantially with increasingly advanced medicine, increased productivity/RVU expectations, often overwhelming documentation burdens, and greater trainee oversight. Meanwhile, research has gotten more complex at the same time that the grant money has dried up. More and more of the funding pie goes to fewer and fewer people. And, lastly, education is typically taken for granted as something that should just take care of itself, something we expect “clinician educators” to do without faculty development, dedicated time, or even credit.

It’s very easy to have an unbalanced stool. Departments tend to lean in one direction or another precisely because they are aligned to do so and are staffed accordingly. As Arthur Jones of Proctor & Gamble famously remarked, “All organizations are perfectly designed to get the results they get.”

Putting pressure on individuals to do everything—deliver excellent clinical care, teach/mentor students/trainees, and contribute to high-impact research—fails to acknowledge the reality on the ground that doing high-end work in any of these dimensions is hard. Without dedicated time and sufficient support, doing anything successfully for very long is a challenge. Trying to work toward impossible expectations (even self-imposed ones) is a big contributor to burnout. At least a veneer of control, self-determination, and respect are prerequisites–not luxuries–for a successful “knowledge worker”-type career. We could more reasonably expect people in every role to excel at one role, be competent at another, and largely ignore the third.

Hospitals and large academic institutions are not filled by flat teams of equals working on a common mission, they are occupied by layers of committees and bureaucracy. Rising stars often contribute more to their superior’s careers than their own. Progress, change, and new initiatives are choked by a spinning-wheels-grind of proposals, SOPs, committees (and subcommittees), amassing nebulous “stakeholders,” and every other trick in the large organization toolbox that isn’t bad in theory but should never be implemented universally and thoughtlessly. It’s all leadership in the I-attended-a-leadership-conference sense without any true leadership.

Physicians who focus on producing excellent care are derided as “worker bees” while those who believe in education are labeled “doesn’t like research.” And the managers rise to the level of their incompetence and perpetuate the hierarchy.

Meanwhile, the consultants and nonphysician leadership consolidate power outside of the traditional hierarchy. And how can we stop them, when we do such a bad job ourselves?

Ben White is a practicing neuroradiologist in Texas, independent blogger, editor, and author. His free book, Medical Student Loans: A Comprehensive Guide, was written to help students and doctors combat the crippling physician debt crisis. This post originally appeared here.

3 replies »

  1. I think we never every kind of combination. I like the idea of the three-legged stool, just that we can’t expect a functioning department of real-life people to actually contain only people who do all three or that it’s a productive outlook to consider only one of the three legs as meaningful. I’d argue more chairs should be powerhouse clinicians or educators and fewer prolific researchers.

  2. One other point, Ben. Some teachers have to do research so that the youth, as they leave training, have a snapshot of the latest knowledge. I can’t think of any other way to insure that this happens. Even this, of course, is going to leave large gaps in au courant science knowledge, but people doing research sort of know what other research is going on in that discipline.

  3. Ben, you laid it all out there very accurately. How can we disagree? I would look at it from another angle too. If you are not having a little fun in life then something must be amiss. On the theory that ”the purpose of life is to help others and have fun”, when the bureaucracy starts wearing us down we should just stop….stop going to useless meetings; don’t show…stop filling in the endless forms and documentation, don’t do it …don’t show, don’t comply. When we wear out and get sick we commit these absentias anyway, don’t we?, but often at the point of actual illness and post-traumatic stress. After all, the communal and bureaucratic brain has to know when it is dealing with the tolerable edges of human work behavior. It needs this feed-back. We don’t need to march beyond these limits as they did in Japan with all those guys killing themselves from overwork and stress in that Karoshi thing. We can Learn, can’t we? I realize that this is easier said than done and that careers are on the line. But they are also on the line from PTSD. Pick one.