Medical Hierarchy

[himom]

Would someone be kind enough to explain to me who is who amongst a lineup of doctors?

For instance, I realize an intern is still a student. I assume they are students that have not yet graduated from medical school yet.

But what is a resident, an attending, a chief, etc? (I know there are more titles but I can't remember) Who has more experience? Who is usually in charge?

We've got a hospital stay coming up and I'm a little curious. The titles were flying fast and furious last time and I never did get it sorted out.

TIA!

[JoyNChrist]

Okay, the majority of my medical knowledge comes from watching ER, so you might want to take this with a grain of salt. :-)

Residents are doctors who have graduated from medical school but haven't completed their formal training (unless I'm mistaken, you can't go into practice straight from med school - I think you have to be a resident first). They complete their 3 or 4 years of residency in order to receive special "hands-on" training in their chosen specialty. I don't think they still go to classes (or at least not as many as they did while in medical school), but they do attend conferences and do research and stuff like that. In the hospital, residents work under the supervision of attending physicians, and seem to be often given the "crappier" jobs. The "chief resident" is chosen from the most advanced group of residents and is basically the resident in charge, who reports to the attending. The attending has completed medical school and residency, and is usually in charge of the residents. The chief of staff is the most experienced and is over everyone, both residents and attending physicians.

Okay, like I said, I'm not 100% sure that I've got all that right, but I think it's the basic hierarchy.

[mommyoftwo]

Yeah, you are on the right track. Once you graduate from medical school you need at least one year of additional experience to open your own practice, work independently at a hospital etc. Residency is actually not required (just the additional one year called the intern year) but in reality doesn't really happen any more. The purpose of residency is to have additional training in the speciality of your choice (internal medicine, surgery, pediatrics etc).General practitions are those who only did the one year and then started practicing on their own. There are still a good number of GP's out there but they are the older docs who began practicing medicine when residency was much more of a rarity. Interns are first year residents. They have graduated from medical school and have earned the MD behind their name but are just starting residency. Chief residents are residents in their last year of residency. If it's a small residency program than the cheir residents are automatically the residents finishing up. Otherwise, it is an earned position that the best resident(s) get. They are in charge of things like the call schedule, assigning vacations, trying to solve problems before they are brought to the attention of the attendings etc. and they also have the best call schedules. All residents work with the attending physicians but there is a chain of command. So if an intern has a question, they ask the intermediate residents and if they can't solve the issue, then a chief resident is called who in turn will go to the attending. All residents have to report to the attending who signs off on their orders so they are always being supervised. Dept chairmen/chief of staff is the head of the department (ie surgery, ob etc). I hope that clears things up for you. Let me know if something I said was confusing. I went to medical schoo and my husband is a resident now so I can answer any questions you have.

[VClute]

Reading between the lines here, I hope you're not worried about being cared for by a resident. They have a lot more people checking behind them than your typical non-teaching hospital. I see residents at our family practice and before they do anything, they'll say, "Let me check with my colleagues," which is code for, "Let me ask my attending if he agrees with my plan." I kind of dig that.

Amy in NC
mom to Dixon, born 2/14/05
...and let the shopping begin!

A GIRL (!!) Due 3/30/07

[table4three]

Yup - PP's are correct

Attending (finished residency, board certified, now working in their field)
Fellow (finished residency, got board certified in their field, now doing a more specialized residency program - for instance, already an internist, now training in cardiology)
Chief Resident (last year of residency OR in larger programs, often a position that the most qualified residents are offered to stay an extra year to be the chief)
Resident (during the years of residency)
Intern (finished medical school, now in the first year of residency)
Medical Students

HTH

[pb&j]

Interns are MD's and have graduated from medical school, and are in their first year of post-graduate medical training.

Residents are in post-graduate medical training. Some specialties require shorter residencies than others, but most are at least 4 years.

Fellows are done with residency, but are doing additional specialized training.

Attendings are full-fledged docs, done with residency.


-Ry,
mom to Max the one year old
and my girl in heaven

http://www.windsorpeak.com/dc/user_files/37124.gif

[Lovingliv]

I agree Amy, I like when the residents are around. They always go over me with a fine tooth comb and I like that. They never rush either. When I was working in the hospital, they were always waiting for me to get to the ICU to see what "my plan" was for a patient. Then they implemented it because "you are the expert in your field." I really enjoy the residents!

[writermama]

Ok, this one always confused me. Do I finally have it right?

An intern is a "doctor in training" as discussed up thread.
An internIST is a specialist in Internal Medicine -- so not just a doc, but a board certified extra special kind of doc. That's a big difference from one suffix.

Is that right?

[Sillygirl]

You are correct. Internal Medicine is a specialty with board certification and its practitioners are called internists. Most people don't know what that is, though, so there are some other colloquial terms tossed around which are not specific. Usually a patient looks at me blankly if I ask who their internist is, but they can name their "family doctor" or "primary doctor." The American College of Physicians, one of the big associations of internists, started a "Doctors for Adults" PR campaign a few years ago, but it doesn't seem to have caught on.

[tarahsolazy]

You got it all from all these nice ladies. Takes a long time to get through all that training, too! I got my first real job at 32.

I teach residents and med students, and have been one in my day, and I love having them involved in my and my family's care. (As long as its not someone I've trained doing my pelvic, etc). A chief resident did all my maternity care with DS, and delivered him by c-section. If I have another c-section this time, it will also be performed by a senior resident. My new baby will probably have a pediatric resident for a doctor, too. So don't be one of those people who assume that having residents means you are being experimented on or something! On my team in the NICU, I have two interns, a senior resident, a fellow, and me, the attending, to care for the patients. Five brains are better than one, IMO. (I do oversee all care and make all important decisions, though, residents really have a lot of supervision)

[shilo]

i'm gonna just ditto what amy and rachel are saying. this is one of those areas in life where the old cliche "don't judge a book by it's cover" couldn't be more true. i'm not saying that's what the OP is doing, just adding my 2 cents on this topic in general... working with hundreds of drs. in my career, the actual 'title' matters the least sometimes in the quality of care you're receiving from the individual. you will run into some first year interns who are amazingly thourough, excellent communicators who could teach their attendings a thing or two, and who have exemplary diagnostic, clinical and bedside skills. you will run into some chief residents who are worthless. you will run into some attendings who you love, and others who do nothing but rub you the wrong way. like in every profession i can think of, IME, the individual doctor in question is absolutely what determines the quality of care.

with my own DS's specialist care i'm always willing to see the resident or fellow first. we are at the children's hospital at stanford and i have run into exactly one resident and one attending that i've requested not to see again. on one service, my favorite doc to see is a fellow - i'd see her over any of the attendings on the service. on the other service, we see the service chief because that's who our case got assigned to, but i have let her know that i am totally ok with working with her residents on things she thinks are appropriate.

when we are seeing residents/fellows, if i'm not getting my questions answered to my satisfaction, or if i'm not feeling entirely confident in their assessment or explanation, i speak up - politely of course - and ask to speak with the attending myself. often, i get a similar if not the same set of answers from the attending, but sometimes not.

in my own care, i love my OB, but i think the sun rises and sets around her nurse practioner. i ask to see the NP whenever i can and as much as i love my OB, if her NP delivered babies, i'd have her as the primary for my care - she's just that good.

hth, lori
Sam 5/19/05 How lucky I am that you chose me.

[himom]

Thanks for the clarification, ladies! I think I get it now.

As for whether or not I'll be asking not to be treated by students, the truth is I haven't decided yet. This will be my second time giving birth. The first time around I was really okay with a slew of people "practicing," since they were mostly alright. I was really uncomfortable with one of the residents, but that's just because she was rude and gave off an attitude of wishing she were anywhere else on earth.

The major problem I had last time was with an intern I got stuck with in what the hospital calls "triage." When you first come in as a patient in labor they stick you in this bed while they monitor you and ask questions. On our maternity tour, we were told that if we were truly in labor, then we would be in this room for a few minutes while they prepared our LDR room, etc. I got there and I was 5 cm and contractions 3-4 minutes apart. I'd spent a peaceful day at home in labor, working on focusing, breathing through contractions, etc. I was actually feeling great.

Then they stuck me in that stupid room, told me I had to lie down on my back, and started asking questions. For almost an hour. Did I have a history of diabetes? Heart disease? Asthma? Family history? First baby? Any complications in your OB visits? Blah blah blah. Keep in mind I already filled all that out in my pre-registration. They already had all this information. Apparently, this dude was trying to get up on all this as part of his learning experience. And he typed slower than Fred Flinstone. So instead of working on my labor like I wanted to, I was instead trying to breathe through a contraction while he inquired about my Hep B status -- which I didn't remember but which was RIGHT THERE ON THE DAMN CHART. (Sorry -- apparently I'm still bitter) If I was struggling with a contraction he'd just stare at me until it subsided then repeat the question. Anyway, my labor slowed down considerably and the torture went on until I sent my husband to go get a nurse and insist on moving me to a room. After I finally got to walk around again I got things moving and all went well after that.

So....this time I'm thinking that if they throw a student at me I'm throwing them back. I realized they need to learn sometime, but I don't need to be a guinea pig in the middle of my freaking labor. I just want to be left alone for a nice, quiet, birth.

I'm sure this was a very nice man. He came to see me the next morning (to ask more questions) and he congratulated me on doing a great job. I was very nice to him, even during the inquisition, but still not too happy with how things worked out.

And I've definitely decided that if I'm in that triage place more than 15 minutes next time I'm immediately walking out and finding the OB nurses myself.

ETA: Oh! I almost forgot! When DS was 11 months old he caught a horrible virus. We had houseguests, and they were throwing up for two days straight, then I was, then DS was. We knew he had it, we knew where it came from, we knew all the symptoms, etc. But DS didn't handle it well. We had already contacted our ped about it and she told us what to watch for, etc. DS seemed okay but I started to worry because his diapers weren't wet as much as they should have been and he was getting really floppy....so tired and wiped out...lethargic. So -- off to the ER. I wanted him checked for dehydration, which was what I was mainly worried about.

The ER doc was a student (wearing a University of Hawaii medical student tag) and he was just awful. He decided DS needed an MRI or a CT scan (I'm blanking on which one, I think it was MRI) because all the puking was a sign of bowel torsion or obstruction and it needed to be ruled out. Being a first time Mommy I of course wanted to just make sure baby was ok. But I also knew that throwing up was par for the course with this illness, and I told him so. FOUR other people in the household are throwing up the exact same way. Did we all have bowel obstructions??

Anyway, I mentioned that our ped had told us that the throwing up was normal but we needed to watch out for dehydration. He asked who our ped was. When I told him, he did this name dropping speech, "Well, I KNOW so-and-so, your pediatrician, very well. And I'm absolutely confident she would agree with my assessment." At this point my husband stepped in with his cell phone and dialed our ped, who proceeded to spank this guy verbally over the phone for trying to force an 11 month old into an unnecessary (and apparently expensive??) procedure. Then she asked about the dehydration, and it turns out even after I told him about the lethargy and the dry diapers he hadn't even bothered to check yet. We could actually hear her yelling, and I swear this woman is the most laid-back, sweetest person ever. DS threw up a few more times, slept for 15 minutes in my arms, woke up to nurse, and was completely fine after that, trying to run around the ER and pull all the cords he could reach. It was a little weird -- the sound of the doctor yelling seemed to get rid of the lethargy!

So if you've made it this far, you can see why I'm a bit leery of students. I've also known some who I thought were pretty good. So again...I'm torn.

I do appreciate all the advice!

ETA second, much longer story!

[MonicaH]

Most medical students are not that clueless and/or arrogant. You can always let them try to do the interview/exam but ask (or insist) to see their supervising physician if you don't like how things are going. I hope you meet some more clued-in ones next time!

Monica

[VClute]

Don't forget that you could get "stuck" in triage just waiting for a bed to open up on L&D. It could very well be that he (and the nursing staff, etc) was stalling because there wasn't a clean room to take you to. I was in triage for a half hour and walked the hall for 20 minutes before getting to my room - It had just been vacated and needed to be cleaned.

Then again, I go to a VERY high-volume hospital.

Amy in NC
mom to Dixon, born 2/14/05
...and let the shopping begin!

A GIRL (!!) Due 3/30/07

[himom]

I did actually think of that. Stalling is one thing, but forcing me to lie there and answer questions was what irritated me. Why couldn't I walk around and wait for the stupid room????

You might be right though, this place is also pretty high-volume.