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The Teaching Hospital Hierarchy: Who Are All These Doctors?

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Have you ever wondered why you were seen by so many doctors at your last clinic visit or hospital stay?  Terms such as intern, resident and fellow can be confusing to someone who does not have a background in medicine.  Most people have a general understanding of the teaching hierarchy in the field of medicine probably from television shows such as Grey's Anatomy or House.  However, you may still find yourself asking 'Who are all these doctors?'

If you interacted with a medical student, intern, resident or fellow physician at your last doctor's appointment then chances are you were seen at a teaching hospital. These types of hospitals provide medical care to patients while doing so much more.  Many people working at these institutions are conducting medical research, which provides the perfect environment for training future physicians, nurses, therapists and other clinical personnel.  Unlike smaller community hospitals that make up the majority, teaching hospitals can provide more advanced care. 

Although teachings hospitals are necessary to train future clinicians, receiving care at such an institution may be confusing due to all the individuals who you may interact with. Understanding the role of each individual within this medical hierarchy will hopefully provide the clarification needed to navigate all these doctors.


Medical Students - The Neophytes of Medical Care

The first doctor, or more correctly stated, student-doctor that you may meet in a teaching hospital is the medical student.  Just as the title implies, the medical student is currently enrolled in medical school and is working at the hospital as part of his or her curriculum.  Most students will introduce themselves as student-doctor or student-physician.  

The role of the medical student is to gather information so the majority of the medical history will be obtained at this point.  Since medical students have just learned how to interview a patient, they may ask many questions that may or may not be relevant to your symptoms.  Just practice some patience!  It can be difficult to learn how to talk to people about such intimate medical problems.  Additionally, the medical student may conduct a physical exam, which is usually quite thorough.  

Intern Physicians - Fresh Out of Medical School

An intern is a physician that has successfully completed medical school and is in his or her first year of post graduate medical training otherwise known as a residency.  Your initial encounter may be with an intern physician if a medical student is not available.  In this setting the role of the intern mirrors that of the medical student as a gatherer of information from your medical history, physical exam, laboratory work up and imaging.  

Alternatively, the intern may supervise the medical student.  In this scenario, the medical student presents all of your information to the intern who attempts to assess the data and possibly come up with a plan.  

Due to the relative lack of experience early in post graduate medical training, the plan created by the intern usually undergoes revision once it is presented to senior residents.  However, having the intern start the plan for further diagnostic work up or treatment is crucial for learning as mistakes are caught early prior to being implemented in your care.

Resident Physicians - Medical Training in Full Swing

A resident is a physician who is beyond the first year of post graduate training but is still training nonetheless. Each specialty in medicine has its own residency and varies in duration.  These doctors have more experience in clinical care and medical decision making than the intern or medical student.  Again, the initial encounter of a clinical visit may be with a resident if there are no interns or medical students on the medical service.  

The resident is usually more capable of assessing the clinical information that you provide and may develop a reasonable treatment plan.  Feel free to ask questions about your care when dealing with residents.  They are usually quite capable of answering less complex medical questions. However, many questions may still be deferred to senior residents, fellows or attendings (described below).  

A senior resident describes a physician who is within the last two years of his or her residency.  Senior residents usually have greater responsibility and autonomy in the care of patients.  You may also hear the term 'chief resident.'  This is a resident who has demonstrated some form of outstanding leadership ability and usually plays both a clinical and an administrative role.

Fellow Physicians - Seekers of Specialty or Sub-Specialty Training

Fellow physicians or "fellows" for short are doctors that have graduated from residency but are seeking additional training (i.e. a fellowship) in a medical specialty or subspecialty.  These physicians are usually board-certified meaning that an independent entity has verified their qualifications to practice within that field.  Fellows are highly capable of independent patient care and are granted more autonomy than residents.  They may supervise residents, interns or medical students.  However, they continue to require supervision from an attending physician and cannot practice independently.  You are more likely to encounter fellows if you are seeking sub-specialized care.

Attending Physicians - The Supervisors

Ultimately, the doctor who is responsible for your care is referred to as the attending physician.  This physician is board-certified and is able to practice independently without any supervision.   The attending physician will usually be the last doctor that you will see when you are in the hospital or clinic.  Depending on the hospital, some attending physicians have been known to introduce themselves as the supervising physician or the physician in-charge.

The final decision regarding your care is made by the attending physician.  Therefore, any concerns or questions that were not fully addressed by the fellow, resident, intern or medical student should be presented to the attending at this point.  If fact, the attending should provide the most thorough and credible answers to your questions.  Make sure that all your questions are answered and that you are satisfied with your treatment plan before the attending leaves.  This may be your last chance to get all your symptoms looked at!



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