The chain of command is entrenched on the hospital wards, creating an obstacle to speaking up:

This new division of labor established hierarchies. On the top were the senior physicians who made rounds on the wards once or twice daily. Next were the overworked residents, who essentially lived in the hospital while training. Last were the medical students, who spent the most time with patients but were most assuredly at the bottom of the heap.

Although some senior physicians welcomed feedback from their juniors, others disdained it, either overtly or through intimidation. And students were all too easily intimidated. In a 1993 article in The New England Journal of Medicine, a Harvard medical student reported that although her resident routinely made derisive remarks about her patients on rounds, the rest of the team laughed nervously rather than confront her.