I think they know. The problem is the doctor that about all of the work gets paid as much as the others that do his and their own.

My wife got a position at a teaching hospital and the director was making about 2.5x her salary. When the administration figured out he was completely unqualified to be the director, they made him a faculty and her the director. Now he still made 2.5x her salary and proceeded to just sit in his office and not do any of the work. He was tenured and so it took 4 years to force him out of the school. He of course quit and got a job elsewhere just before being fired.

Some people are just lazy and worthless, but are able to study hard enough to learn how to pass the tests. Then they try and coast thru life because of how hard they worked to get there.