Beyond Collaboration: The Quiet Rivalries of Medicine 

Amr Ihab reflects on their experience of medical training and how cultures of competition and rivalries among medical professionals can be challenged through the medical humanities.

Medicine is often described as a profession built on care, empathy, and collaboration. From the outside, medicine is usually presented to students and the public as a profession primarily centered around helping patients. Although many voices within patient advocacy, disability activism and anti-psychiatry movements have long challenged the realities of medical culture and power, inside medical training another reality exists which is less visible, rarely discussed, and often misunderstood.  

During my medical training in Egypt and KSA, I noticed that comparison started almost immediately and slowly became normalized within everyday student life. 

Students compare grades, rankings, and opportunities. 

Who answered better in rounds. 

Who impressed the consultant. 

Who got selected. 

At first, this feels normal, even motivating. But over time, comparison stops being occasional. It becomes constant and eventually automatic. You no longer need a scoreboard. You start measuring yourself against others without thinking. Indeed, medicine teaches teamwork. However, rewards are often individual. One student gets the top mark. One resident gets the recommendation. One name is remembered. This creates a quiet tension because while you are expected to support your peers, you are also competing with them – for recognition, opportunities or future positions. No one explains how to reconcile these two expectations. So, you learn to navigate both at once, carefully. 

A System Built on Limited Opportunity

Scarcity is a significant component of competition as the number of fellowships, surgical cases, and authorship positions are limited. According to a Financial Times’s report, in 2025 33,100 doctors applied for 12,800 specialist training posts in the UK (El-Qushayri, 2026; Rana, 2025). This scarcity therefore makes doctors see colleagues as economic rivals. 

Another unspoken rule is the expectation of strength. You are expected to cope, to adapt, and to perform, regardless of how you feel. Fatigue is normalized. Stress is expected. Doubt is rarely expressed openly. Because showing vulnerability can be misinterpreted as weakness or as lack of competence. That is why many physicians complain from burnout (Amoafo, Hanbali, Patel, & Singh, 2015). So, most people learn to hide it. They continue working, even when they are overwhelmed. 

Over time, silence becomes a strategy. You notice things, behaviors, attitudes and decisions. But you do not always comment. Not because you agree. But because you understand the structure. 

Hierarchy matters. 

Timing matters. 

Position matters. 

So, you learn when to speak, and when not to. This is not formally taught. But it is quickly understood. Medicine is deeply hierarchical. This is not unique to medicine. But in clinical environments, hierarchy influences daily interactions.  

Who asks questions. 

Who answers. 

Who makes decisions. 

Who challenges them. 

In fact, this is critical since you are dealing with patients’ lives, one simple error can change the patient’s live and/or their family forever. 

As a trainee, you learn how to move within this structure, how to present information, how to respond and how to avoid conflict. This learning is not written in textbooks. But it shapes behaviors as much as clinical knowledge. 

At some point, learning begins to feel like performance. You are not just trying to understand, you are trying to demonstrate understanding in front of others. Ward rounds, case discussions, presentations, each becomes an opportunity to be evaluated. Not always formally, but constantly. 

This changes how you engage. You start thinking not only about the answer, but about how it will be perceived. Being evaluated continuously has consequences. It sharpens awareness. But it also increases pressure. You become more cautious, more self-aware, and sometimes more anxious because mistakes are not just learning opportunities. They are visible and sometimes remembered. This does not stop learning. But it changes how it feels. 

Friendships in medicine are real. But they exist within a structure of competition and this creates complexity. You celebrate each other, but you are also aware of differences, in performance, in recognition, and in opportunities. 

Most of the time, this remains unspoken, but it is understood.  

Over time, success becomes less clear.  

Is it academic achievement?  

Clinical skill?  

Recognition? 

Balance? 

Different people define it differently, but the system often emphasizes measurable outcomes, scores, positions, or achievements.  

This can shift focus, away from personal meaning, towards external validation. One of the most significant shifts is internal. External expectations gradually become internal ones. You begin to expect more from yourself, to perform better, to know more or to make fewer mistakes. Even without external pressure, the internal standard remains high, sometimes higher, but it can also increase stress. 

Despite how common these experiences are, they are rarely discussed openly. 

Not in lectures. 

Not in formal teaching. 

Sometimes not even among peers. 

Because everyone assumes others are managing. 

This creates a perception that struggle is individual, rather than shared. 

Challenging Competition through the Medical Humanities 

When I wrote The Hidden War in Medicine (2026), my intention was not to criticize medicine itself. The book examines how professional hierarchies and competitive pressures shape everyday experiences in medicine. It argues that these dynamics can significantly affect relationships between colleagues, contribute to emotional distress, and influence the culture in which doctors train and work. I believe medicine remains one of the most meaningful professions a person can pursue. But every profession has truths that are difficult to discuss. 

Bringing awareness to these dynamics does not eliminate them. But it changes how they are experienced. It allows space for reflection, for conversation, and for support. It makes the implicit more visible. This medical culture is also influenced by longstanding hierarchies within medical training, the pressure to demonstrate excellence, and what many scholars describe as the ‘hidden curriculum’ of medicine: the unspoken behaviors, values, and power structures that students gradually absorb during training (Hafferty, 1998).  

Over the past decades, the medical humanities has emerged as an interdisciplinary field concerned with the human, cultural, and social dimensions of medicine. In addition to exploring patient experiences, the field has increasingly examined the values, assumptions, and power structures that shape medical education and professional life. Medical humanities scholars have long examined how medical training and professional culture shape the identities, behaviors, and emotional lives of healthcare professionals (Bleakley, 2015; Macnaughton, 2011). This work encourages clinicians to look beyond biomedical knowledge alone and to consider how hierarchy, institutional norms, and cultural expectations influence everyday experiences within medicine. From this perspective, competition is not simply an individual trait but part of a broader professional culture that can affect how doctors relate to themselves, their colleagues, and – importantly- their patients. 

While the medical humanities has traditionally focused on patient experiences, illness narratives, empathy, ethics, and the human dimensions of healthcare, competition itself has received comparatively less attention as a lived and emotional feature of medical training and professional life. Yet for many students, trainees, and physicians, competition is not simply an occasional event or a response to limited opportunities. Rather, it becomes an enduring part of the social environment in which professional identities are formed. It shapes how individuals evaluate themselves, how they relate to colleagues, and how they understand success, failure, belonging, and worth within the profession (Bleakley, 2015; Macnaughton, 2011). 

Viewing competition through a medical humanities lens allows us to ask a different set of questions than those typically raised by educational or workforce research. Rather than focusing solely on outcomes such as examination scores, training positions, publications, or career advancement (Kumar, Makhoul, Pontell, & Drolet, 2020), the medical humanities encourages us to examine the meanings attached to these experiences and the ways they shape the emotional and cultural landscape of medicine.  
How does constant comparison influence a student’s developing sense of self? How does the pressure to perform affect the way trainees experience learning, uncertainty, or vulnerability? What happens when professional achievement becomes closely linked to personal identity? How do individuals navigate environments in which collaboration is encouraged but competition is simultaneously rewarded? 

A medical humanities perspective further invites consideration of how competition intersects with broader structures of power, hierarchy, and institutional culture. Competition does not occur in isolation; it exists within systems that determine which achievements are valued, which voices are heard, and which forms of success receive recognition.  

Importantly, exploring competition does not require rejecting excellence, ambition, or high professional standards. Medicine depends upon knowledge, competence, and continual improvement. Rather, a medical humanities approach encourages reflection on the human consequences of the environments in which these goals are pursued. It asks whether there are costs associated with cultures of constant comparison, how these costs are distributed, and how they may influence both professional development and personal wellbeing. 

Learning to navigate this environment is part of becoming a doctor, even if it is never formally taught. Recognizing this does not weaken the profession, it strengthens understanding of it. 

And perhaps, over time, opens the possibility for change.

About the author

Amr Ihab, MD is a trained medical doctor and the author of “The Hidden War in Medicine”. They currently work as an editor for PLOS ONE Journal and have published over 50 papers under the name Amr Ehab El-Qushayri.

References

Amoafo, E., Hanbali, N., Patel, A., & Singh, P. (2015). What are the significant factors associated with burnout in doctors? Occupational medicine, 65(2), 117-121.  

Bleakley, A. (2015). Medical humanities and medical education: how the medical humanities can shape better doctors: Routledge. 

El-Qushayri, A. E. (2026). The hidden culture of competition in medicine: A system-level challenge. HealthCare in Europe.  

Hafferty, F. W. (1998). Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med, 73(4), 403-407. doi:10.1097/00001888-199804000-00013 

Kumar, N. G., Makhoul, A. T., Pontell, M. E., & Drolet, B. C. (2020). Characterizing the effect of pass/fail US medical licensing examination step 1 scoring in neurosurgery: program directors’ perspectives. World Neurosurgery, 142, e440-e444.  

Macnaughton, J. (2011). Medical humanities’ challenge to medicine. Journal of evaluation in clinical practice, 17(5), 927-932.  

Rana, M. (2025). The system does not want me: why some doctors struggle to land jobs. Financial Times, November 23, 2025. https://www.ft.com/content/8b6ebcd7-67a9-4698-a5e2-1e88cde42572.