Residency application season has arrived, and as fourth-year medical students, many of us are carefully considering where to apply. One of the most important, and most frequently cited, factors is program culture.
A big contributor to program culture, I’ve noticed, is geography. One of the classic stereotypes goes something like this: the “formal, hierarchical East Coast” versus the “chill, laid-back West Coast.” Before I go further, I want to acknowledge that I am well aware that there is far more to the U.S. than its coastal regions. But these are the places where I have spent almost all of my time, and in one op-ed, I can only tackle so many concepts. So, I decided to delve deeper into this particular coastal divide.
Another reason I felt compelled to write this piece was my own effort to navigate culture, especially in the professional and clinical environment, more intentionally. In Iran, where I grew up and went to college, many people actively pushed back against unjust systems and harmful policies. However, that also meant that there was an urge to resist structures and rules, even if they were logical and sensible; there was this deeply entrenched culture of not trusting anything from “above.” By contrast, in the U.S., I noticed that people were often more willing to operate within rather reasonable existing structures. This difference made me more attentive to how I might adapt, rather than instinctively challenging everything, in my new professional environment. I also realized that as an immigrant, or really anyone who has traveled a distance, figuratively or literally, to improve their lives, there is sometimes a tendency to idealize the new environment. After all that effort, you want to believe you have landed somewhere excellent. So I was determined to maintain a balanced, critical perspective on the culture around me.
When it comes to medical culture, how exactly does this “formal versus laid-back” narrative play out? Regardless of location, what do people really mean when they describe a program as hierarchical? There does not appear to be any rigorous, peer-reviewed research directly addressing these broad claims about East versus West Coast medical culture. Much of what I encountered came from informal sources, conversations, Reddit threads, discussion boards, and occasional blogs or videos. One description that stayed with me characterized the East Coast as a place where people assume you are not capable until you prove otherwise, while on the West Coast, people assume you are capable until you show them otherwise. This perspective reflects what some describe as a “pay your dues” or “old boy network” culture. I also came across the observation that on the East Coast, feedback tends to be more blunt and unfiltered, whereas on the West Coast, people may be more conflict averse and less inclined to share direct criticism. On one hand, these are clear concepts; on the other, understandably, medicine everywhere relies on hierarchy and structured feedback, so can it really vary that much?
Some of those ideas resonated once I saw them in practice. I once found myself in a situation where a senior resident claimed first authorship on a manuscript to which they had not contributed but was very relevant to their subspecialty area of interest, despite the fact that I had led the project for a year and a half. When I raised my concerns, another co-author — also a resident — told me that this was how things worked, and I had to pay my dues until I became one of them. That moment made the word hierarchical very real to me. It especially stood out since this was out of the clinical realm, and such hierarchy was not natural or necessary.
At the same period of time, there was an attending physician very early in my core clinical rotations who sat me down in his office after a week of working together and told me, quite directly, that I really needed to improve my communication skills. He then gave me specific strategies to sound less anxious and more confident. His honesty horrified some of my friends whom I recounted this feedback session to, but as a direct person myself, I actually appreciated it.
As I travel for away rotations and speak with people who have trained on both coasts, nearly everyone agrees that while there may be some regional tendencies, culture is ultimately program dependent. One resident, who had completed medical school in the northeast like me, and was now training in California, shared a useful strategy for gauging a program’s culture: asking who their ideal trainee would be. If the answer focused on qualities like being coachable (this is a term I heard a lot in this context), emphasized group cohesion, and de-emphasized baseline capability or any skill you bring to the table, that often pointed to an environment where trainees are expected to adapt or to an extent defer to the existing culture and shape their professional identity accordingly. A potential advantage of this approach could be providing structured mentorship and clearer expectations for growth. If the response highlighted someone who is motivated, “gets the job done,” and is passionate about the field, it suggested a culture that valued autonomy and self-direction, though it could also place greater responsibility on the trainee to hit the ground running.
She, along with others I spoke to, emphasized that every program ultimately develops its own microculture, regardless of location, and keeping an open mind is essential. I especially appreciated this piece of insight while comparing two programs on the same coast, within less than three hours drive of each other. When I asked who their ideal trainee was, the response at one program revolved around authenticity and aiming to make a change, and the other around being adaptable, safe, and easy to train. While all these are among the many positive and essential qualities of a physician in training, I believe that when asked this question — on the spot — what the responders choose to focus on says a lot about the dominant mindset.
These observations might seem straightforward, but they challenged my assumptions in meaningful ways. Before medical school, I believed that as long as a program offered excellent training, the rest would not matter, that a shared commitment to patients and science would override any cultural friction. What I did not fully appreciate was that culture, even when subtle, shapes who is allowed to belong, who is supported, and who is left to figure things out alone. Perhaps what is most revealing about the East versus West Coast conversation is not whether one style is better, but why these narratives persist in the first place. They endure because they offer a mental shortcut to predict the unspoken social rules of a place, who holds power, who gets second chances, and who is expected to adapt. Those rules still shape how people move through medical training, even in a profession that claims to value merit above all else.
So while it is tempting to dismiss these stereotypes or hidden curricula as something trainees just have to put up with, they can serve as an entry point to ask deeper, more uncomfortable questions about any training environment: Who is genuinely welcomed here, beyond the polished brochure or social media images? How are differences in background or communication style accommodated or quietly penalized? Does the culture invest in helping people belong, or does it only reward those who already know how to play by its rules?
Helia is a fourth-year medical student at Yale School of Medicine. When not learning medicine, she can be found sketching, collecting rare books, and bouldering. She was a 2024–2025 Doximity Op-Med Fellow.
Collage by Jennifer Bogartz
