The United States relies on international and osteopathic medical graduates (“non-USMDs”) to fill one third of residency positions because of a shortage of American MD graduates (“USMDs”). Non-USMDs are often informally excluded from top residency positions, while USMDs tend to fill the most prestigious residencies. Little is known, however, about whether the training in these different settings is comparable or how it impacts patients. Drawing on 23 months of ethnographic fieldwork and 123 interviews, I compare training at two internal medicine programs: a community hospital staffing 90% non-USMDs and a university hospital staffing 99% USMDs. The community program’s structure lent itself to a hands-off approach resulting in “inconsistent autonomy.” In contrast, the university hospital supervised its residents much more regularly, resulting in “supported autonomy.” I conclude that medicine may be stratified in unexpected ways between USMDs and non-USMDs and that stratification may matter for patients.