Hierarchical Structure in Medical Education, Implications and Optimization Strategies: A Review

Abstract

Background: Hierarchy means the classification of individuals based on power and organizational status, which plays a fundamental role in health systems and medical education. Given the pervasive presence of this structure and its direct impact on lower-level learners, especially students, the present study aimed to identify the dimensions, effects and strategies for adjusting the hierarchical structure in medical education. Methods: This study includes a review study that was conducted in 2023. A search of sources was conducted in reputable scientific databases, including PubMed, Google Scholar and Elsevier, using keywords extracted from the mesh and related terms. The inclusion criteria included qualitative and quantitative studies related to hierarchy in clinical settings. Findings: Hierarchy as part of the hidden curriculum, on the one hand, promotes team coordination and goal pursuit, and on the other hand, it has negative consequences such as restrictions on expressing views, moral distress, increased misconduct, burnout, damage to professional identity, and reduced empathy. Also, the inability of subordinates to report errors of higher-ranking individuals due to fear of the system seriously jeopardizes patient safety. Conclusion: Although the existence of hierarchy is essential for organizing high-pressure medical environments, its traditional and rigid approach can be destructive. The realistic solution is not to completely negate this concept, but to focus on optimization strategies such as creating psychological safety, modifying educational feedback, and strengthening moral courage in learners. © 2026, null. All rights reserved.