Power Distance in Healthcare: Why Nobody Questions the Senior Doctor

I spoke to a GP recently who told me about his time in an emergency department. The department ran on junior doctors, and a great many of them had trained overseas.

What stood out to him most was that nobody questioned him.

Whatever he concluded, they accepted. Whatever he decided, they went along with. He was not used to it. He had worked with Australian-trained juniors who would say something if they thought he had it wrong, and he had come to rely on that, because he knew perfectly well that he could make mistakes. So he started telling them to speak up. Then he told them again. He kept telling them.

He said it concerned him, because he needed their support so that he did not make a mistake.

Sit with that for a moment, because it is the opposite of the story we usually tell. This is not a senior doctor guarding his authority. This is a senior doctor asking to be argued with and getting silence back.

The deference was offered as respect. It was received as risk.

What power distance means in a clinical team

I had a conversation with a pilot not long before that one, and he gave me the language for it.

In aviation they call it the cockpit gradient, and they are trained on it explicitly, as a safety matter. He said it comes up in his work all the time. What struck me was how carefully he described the balance. The gradient must not be too steep, or the first officer will not raise the concern. But it must not be flat either, because the captain still has to hold the responsibility and make the final call. There is an optimum somewhere in between, and finding it is part of the job.

The social scientists call the same thing power distance. Geert Hofstede defined it as the extent to which the less powerful members of an organisation “accept and expect that power is distributed unequally”, and he made a point that matters here: it is defined from below, not from above.¹ The gradient is not only what the person at the top does. It is what the person at the bottom expects.

In healthcare the term is authority gradient, and it carries a formal definition in the patient safety literature: “the balance of decision-making power or the steepness of command hierarchy in a given situation”. A shallower gradient, the same source notes, “encourages trainees to clarify instructions, challenge decisions and voice concerns”.²

Three different fields, three names, one thing. How far is it from the bottom of this team to the top, and can anyone climb it in a hurry?

The gradient that matters is the one in the room

Here is where most discussions of this go wrong, so let me take the strongest possible case.

On 27 March 1977, at an airport in Tenerife, a KLM Boeing 747 began its take-off roll while a Pan Am Boeing 747 was still on the runway in front of it. Five hundred and eighty-three people died. It is still the worst accident in aviation history.

Seconds before the collision, the flight engineer, who knew the other aircraft’s position was uncertain, asked the captain a question.

“Is he not clear, that Pan American?”

The captain answered: “Oh, yes.”

The flight engineer did not ask again.³

Now, the part that should stop us all. That crew was Dutch. On Hofstede’s own index the Netherlands sits near the bottom for power distance, well down among the flat, informal, egalitarian countries.⁴ Australia sits in the same band. If steep hierarchy were a foreign import, Tenerife could not have happened.

But the gradient in that cockpit was never national. It was local. The captain was KLM’s chief flight instructor, the man who trained and tested the airline’s other pilots. That is the gradient the flight engineer was looking up at, and it was quite steep enough.

The research says the same thing, less dramatically. A team of Harvard and Japanese researchers surveyed 240 medical residents in the United States and Japan about what stopped them challenging a senior. If national culture were the driver, this is where you would see it. They found differences in some beliefs about the workplace, but on the thing that actually counts, the threshold at which a resident will challenge their senior, there was no statistical difference between the two countries at all. What did predict it was “the relationships and perceived response of the superiors”. Their conclusion was blunt: “Changes in organizational and professional culture may be as important, if not more so, than national culture to encourage speaking up.”⁵

This is the point. What decides whether a junior clinician speaks is not the country on their qualification. It is what they expect the senior in front of them to do about it.

So why does it turn up in the emergency department?

Because two things are happening at once, and we usually only talk about the first.

The first is real. Medical training is not delivered the same way everywhere. An Australian systematic review of the issues facing clinicians who supervise internationally trained doctors put it plainly: in many systems the teacher holds great esteem and the student is not encouraged to question or challenge, and a student is expected not to appear to know too much. The same review found that a reluctance to answer questions or offer opinions in Australian teaching sessions “can be misinterpreted as a lack of knowledge”.⁶

It also captured the detail I think about most. Internationally trained registrars often do not ask for help directly. They hint at the problem instead, and expect the supervisor to notice and step in. The supervisor, interpreting that through an Australian lens where asking for help means asking, hears a passing remark and moves on.⁶

That is not silence. That is a request for help, delivered in a register the listener was never taught to hear, and then missed because of an assumption nobody noticed making.

A larger review across 47 studies found the same pattern internationally. Clinicians trained elsewhere frequently arrive from systems where the relationship with senior colleagues and with patients was more vertical, and describe the flatter Australian arrangement as something they have to learn.⁷

None of that is a deficit. A doctor who does not contradict a consultant in front of the team is following a rule that was correct, and often explicitly taught, in the system that trained them. They did not arrive with a flaw. They arrived fluent in a different set of manners.

Here is the second thing, and we talk about it far less because it is ours.

A scoping review of internationally qualified nurses in the Australian healthcare system found they are frequently treated as less competent regardless of their experience, that workplace hierarchies fail to recognise their previous qualifications and roles, and that they are excluded from clinical discussions and social networks in ways that leave them, in the authors’ word, disempowered.⁸ The Australian review of medical supervision found the same mechanism from the education side, and it can start with something as ordinary as an accent. A doctor may handle medical English confidently and still find everyday conversational English harder going, and an Australian ear may struggle with an unfamiliar accent in a fast, informal discussion. So the registrar offers something in a teaching session and is asked to say it again. Then again. The review found that once that has happened enough times, they become increasingly reluctant to take part at all.⁶

So before we settle on the idea that these clinicians came to us too quiet, we should be honest about our share. Some of that gradient came in the suitcase. A good deal of it we built here, and then we complained about the result.

Australia is not doing this at a small scale. In the 2024/25 year alone, 26,703 internationally qualified practitioners gained registration to practise here.⁹ That is not a diversity statistic. If even a fraction of those people are standing at the bottom of a gradient nobody has named, it is a patient safety exposure, and it is national.

Why telling people to speak up does not work

The GP did the obvious thing. He told them. Then he told them again.

I understand exactly why, and I also think it was never going to work, because of what the researchers Detert and Edmondson call implicit voice theories. These are the taken-for-granted rules people carry about when it is dangerous to speak to someone above them. Their study named five, and every one of them is self-protective, resting on the assumption that speaking up to authority at work is risky. Two of them are almost the whole story here: do not bypass the boss upward, and do not embarrass the boss in public.¹⁰

The finding that matters is where these rules come from and how stubborn they are. They are not picked up from the current job. They are formed early, in families, in schools, in whatever hierarchical institutions a person passed through on the way here, and they hold even when the present workplace is actively saying the opposite. One respondent’s beliefs survived management “always stimulating that you should speak up”.¹⁰

The study records a moment I have not been able to shake. A research associate stayed quiet about a mistake her boss made in a meeting, because you do not embarrass the boss in public. She told him afterwards, in private. He said:

“Oh, you should have said so at the meeting.”

That is the GP’s emergency department in one line. He is standing there asking for challenge. They are following a rule they do not know they are following. An instruction cannot undo a belief laid down twenty years earlier in a classroom, and repeating the instruction only makes the person more anxious about a rule they cannot explain.

You do not fix this by asking for more courage. You fix it by lowering what courage costs.

What actually works

The senior clinician is the intervention

When two researchers went looking for studies on how senior clinicians experience being spoken up to, they asked exactly the right questions. Are senior clinicians aware of how hard it is for junior staff to speak up to them? How do they feel when a junior points out an error? Then they reported the result: in contrast to the many studies and interventions aimed at junior staff, “we were unable to find studies specifically focusing on senior staff”.¹¹

Read that again with the GP in mind. He identified the problem himself, he was willing to be challenged, and there was nothing built for him. Almost every speaking-up programme trains the person at the bottom of the gradient. That is the equivalent of responding to Tenerife by sending the flight engineer on an assertiveness course.

What does work is unglamorous and it belongs to the senior person. Research across neonatal intensive care units found that leader inclusiveness, meaning the words and deeds by which a leader invites and appreciates other people’s contributions, predicts whether a team feels safe enough to speak. The effect is strongest for the lowest-status person in the room, because they have the least experience of anyone asking.¹²

Which means the most valuable thing a consultant can do on a shift is ask the newest, quietest, most recently arrived person in the room what they think, by name, out loud, in front of everyone. It will do more good there than anywhere else, precisely because it has never happened to them before.

Give people a licence, not a personality transplant

The most practical finding I have read on this came out of a synthesis of eighteen studies on why staff fail to escalate a deteriorating patient. Staff described the early warning score as a licence to escalate, a tool that let them push care across hierarchical and occupational boundaries “without having to seek permission”.¹³

That is the whole idea. The number on the chart does the work that courage used to have to do. The junior clinician no longer has to decide whether they are senior enough, or certain enough, or Australian enough to raise it. The chart says escalate, so they escalate, and the gradient stops being the deciding factor.

We already believe this in Australia, for patients. Queensland built Ryan’s Rule so that a patient or a family member can escalate over the treating clinician’s head, without asking anyone’s permission first. We accepted that families needed a formal licence rather than more nerve, because we knew that a patient who is trying to be considerate will go quiet at exactly the wrong moment. We have been much slower to build the same thing for a junior clinician who trained somewhere the teacher is never questioned.

The team tools work the same way. The two-challenge rule allows any team member to stop the line, and puts a duty on the other side of the exchange: the person being challenged must acknowledge that they heard and understood the concern.¹⁴ That second half is the part that gets dropped, and it is the part that would have helped the GP, because it makes listening a procedure rather than a personality trait.

Calibrate the gradient, do not flatten it

I want to be careful here, because the easy version of this argument is that hierarchy is the problem, and it is not.

The pilot had it right. The captain still commands. In a resuscitation somebody has to be running it, and a team where everyone’s view carries identical weight in the third minute of a cardiac arrest is not a safer team, it is a slower one.

The aviation comparison has a real limit too, and the clinicians who study this are the first to say so. In a cockpit there are two pilots with the same skill set, either of whom can fly the plane, which is why the two-challenge rule can end with one taking over from the other. A nurse cannot take over a difficult airway from an anaesthetist. What transfers is not the takeover. It is the obligation on the senior to respond.¹¹

So the goal is not a flat team. It is a climbable one.

What this means if you run a service

If you employ internationally trained clinicians, and in this country you almost certainly do, the gradient in your team is not a cultural curiosity. It is sitting between a concern and the person who needs to hear it.

Train your senior clinicians first, because they set the gradient and nobody has ever taught them how. Train the whole team together rather than sending the new arrival off to a module on their own, because the misunderstanding runs in both directions and only one side of it is currently being addressed. Give people a structured licence to escalate so that raising a concern stops being an act of nerve. And check what your own workplace is teaching, because a clinician who is asked to repeat themselves until they stop volunteering has learnt to be quiet here, on your ward, whatever they arrived with.

Aviation did not solve this by telling first officers to be braver. It rebuilt the training, the language, and the procedures around the entire crew, and it did it after 583 people died. We have the advantage of not needing to wait for our own Tenerife.

The GP was right to be worried. He should not have had to fix it on his own, one repeated instruction at a time, in the middle of a shift.

If you would like your team trained to work across that gradient, both directions, that is what our workshops are built to do. And if you would rather start with one clinician than a whole team, there is a video lesson on power distance and speaking up inside Communication for Safety, and another on raising a concern respectfully inside Gender Safe Practice.

References

1. Hofstede, G. (2011). Dimensionalizing Cultures: The Hofstede Model in Context. Online Readings in Psychology and Culture, 2(1). Read the article. ↩

2. Agency for Healthcare Research and Quality (2024). Authority gradient. Patient Safety Network Glossary. Read the entry. ↩

3. Cockpit voice recorder transcript, KLM Flight 4805, 27 March 1977. Read the transcript. ↩

4. Hofstede, G., Hofstede, G. J., & Minkov, M. (2010). Cultures and Organizations: Software of the Mind (3rd ed.). New York: McGraw-Hill. ↩

5. Kobayashi, H., Pian-Smith, M., Sato, M., Sawa, R., Takeshita, T., & Raemer, D. (2006). A cross-cultural survey of residents’ perceived barriers in questioning/challenging authority. Quality & Safety in Health Care, 15(4), 277–283. Read the study. ↩

6. Pilotto, L. S., Duncan, G. F., & Anderson-Wurf, J. (2007). Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia, 187(4), 225–228. Read the review. ↩ ↩² ↩³

7. Michalski, K., Farhan, N., Motschall, E., Vach, W., & Boeker, M. (2017). Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS ONE, 12(7), e0181330. Read the study. ↩

8. Efendi, F., Pradipta, R. O., Makhfudli, M., McKenna, L., Houghty, G. S., Rahayu, F. K., & Yunita, F. C. (2025). Experiences of internationally qualified nurses in adapting to the Australian healthcare system: A scoping review. International Journal of Nursing Studies Advances, 9, 100399. Read the review. ↩

9. Australian Health Practitioner Regulation Agency (2025). Annual Report 2024/25: Registration. Read the report. ↩

10. Detert, J. R., & Edmondson, A. C. (2011). Implicit voice theories: Taken-for-granted rules of self-censorship at work. Academy of Management Journal, 54(3), 461–488. ↩ ↩²

11. Weller, J. M., & Long, J. A. (2019). Creating a climate for speaking up. British Journal of Anaesthesia, 122(6), 710–713. Read the editorial. ↩ ↩²

12. Nembhard, I. M., & Edmondson, A. C. (2006). Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior, 27(7), 941–966. ↩

13. O’Neill, S. M., Clyne, B., Bell, M., Casey, A., Leen, B., Smith, S. M., Ryan, M., & O’Neill, M. (2021). Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. BMC Emergency Medicine, 21, 15. Read the synthesis. ↩

14. Agency for Healthcare Research and Quality (2023). TeamSTEPPS 3.0 Pocket Guide. Read the guide. ↩