The Medical Meritocracy: Boon or Burden to Human Flourishing?

I emerged from Osler’s crucible 36 months after plunging into the art and science of healing, and I hung my residency years on a nail that I drove through my own forehead. I, like many residents, spent my free time dredging medical records for retrospective studies, planning PDSA (plan-do-study-act) cycles to improve patient care, and stepping into leadership roles. I reasoned that such grinding would eventually pay off with an admission to an illustrious fellowship. Though I was one of the lucky ones, I also couldn’t shake the thought that surely there were others more qualified and more deserving than me. I had 4 or 5 failed attempts or false starts for every line on my CV, and I was convinced that my accomplishments were attributable to the “blind squirrel” phenomenon. My migrainous feelings of fraudulence also got me wondering about the origin of my self-doubt: Why, despite my fevered striving, was I still not good enough?

Just as it is not straightforward to explain why seeing a ripe, juicy apple is more than just photons on the retina, the complexities of resident well-being are difficult to capture and characterize. “Flourishing” is a concept that attempts to expand the language of residency experience by integrating physical and mental health with other important facets: happiness and life satisfaction, meaning and purpose, character and virtue, close social relationships, and financial and material stability. Two metrics, the Flourish Index (FI) and the Secure Flourish Index (SFI), assess these domains (1). In a letter published in Annals of Internal Medicine, Vermette and colleagues report a survey of 14 residency programs in the United States using the FI, the SFI, and a custom Likert-type scale to ask about various aspects of residency (2). Residents who were flourishing (that is, those with higher SFI scores) were more likely to be more resilient, view medicine as a calling, have an improved quality of life and better work–life balance, and report higher feelings of community among their co-residents. Residents who had low scores were more likely to report emotional exhaustion and feelings of depersonalization. The authors suggest interventions (like mindfulness-based stress reduction, among others) as strategies to increase flourishing. They also emphasize that program leadership should foster a supportive environment and sense of community, encourage camaraderie, and articulate a clear mission. This brief report from Vermette and coauthors is important—creation and standardization of resident-reported outcome measures are useful not only for cross-sectional assessment of resident well-being but also for longitudinal assessments, particularly in the context of wellness interventions. The study expands on currently available measures of resident well-being to paint a clearer picture of the various facets of residents’ experience and identify some factors that may help residents flourish.

One factor in residency well-being that hasn’t gotten as much attention is meritocracy—the notion that individuals should be rewarded based on their abilities and hard work rather than allocating rewards according to prejudice, birthright, nepotism, luck, or some other criterion (3). The meritocracy of medical training is grounded in the alluring principles that we are the masters of our own destinies, and that if everyone has an equal chance to compete, then we will get what we deserve according to our merit. But this system also has a corrosive effect on early career physicians. The more we view ourselves as self-made, the more we moralize our success as just desert for our efforts. We become blind to the fact that we are indebted for our achievements; things like a fortunate starting point in life, loving parents, the support of teachers and mentors, and many other advantageous circumstances are all happy accidents for which we can take no credit. We also become callous and view the failures of others as personal shortcomings, deficiencies of character, or simply not having the talent or drive to succeed. Exalting individual responsibility also deflates medical trainees who fail, providing fertile ground for self-contempt and imposter syndrome, as well as resentment for those who land on top. These sentiments erode solidarity among physicians and promote a culture that valorizes the “lone healer,” an autonomous, commanding, and controlling decision maker fixated on their own performance but handicapped in their ability to collaborate (4, 5). The side effects of the medical meritocracy undermine the teamwork necessary to provide the highest-quality care to patients in a health care system that, like the patients themselves, is increasingly complex.

The remedy? It’s a bitter pill, but we must eschew triumphalism by acknowledging the contingency of our fates, and that meritocracy is not a perfect alternative to other systems that allocate resources. Understanding these things may lessen the self-aggrandizement of the winners, the self-deprecation of the losers, and the mutual disdain of both groups to unburden us all so that we might truly flourish.

References

1. VanderWeele TJ. On the promotion of human flourishing. Proc Natl Acad Sci U S A. 2017;114:8148-8156. [PMID: 28705870] doi:10.1073/pnas.1702996114
2. Vermette D, Hanson C, Pennarola A, et al. Flourishing among internal medicine residents. A cross-sectional, multi-institutional study [Letter]. Ann Intern Med. 2024;177:106-108. [PMID: 38109735] doi:10.7326/M23-2233
3. Markovits D. The Meritocracy Trap. Penguin; 2019.
4. Lee TH. Turning doctors into leaders. Harv Bus Rev. 2010;88:50-8. [PMID: 20402055]
5. Stoller JK. The clinician as leader: why, how, and when. Ann Am Thorac Soc. 2017;14:1622-1626. [PMID: 28771027] doi:10.1513/AnnalsATS.201706-494PS

Taylor R. Brooks, MD

Taylor is a new junior faculty member and lymphoma specialist in the Department of Hematology and Oncology at the Cleveland Clinic in Cleveland, Ohio, where he recently completed his fellowship after internal medicine training at Wake Forest Baptist Medical Center in Winston Salem, North Carolina. He was an Annals editorial fellow for the 2023–2024 academic year.