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The Medical Hierarchy – Defining Medical Team Members

November 1st, 2014

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The Medical Hierarchy – Defining Medical Team Members

The following definitions summarize the responsibilities of the members of the physician team and the roles different doctors may play in your care. While not every level of physicians – especially resident physicians and medical students – are present in every institution, the chain of authority is similar in most hospitals.

Please review the following chart outlining the physician hierarchy. Corresponding definitions follow:

THE MEDICAL HIERARCHY – DOCTORS1

↓  Medical director

↓  Head of department

↓  Attending physician or hospitalist

↓  Fellow

↓  Chief resident

↓  Senior resident (usually third year resident)

↓  Junior resident (usually second year resident)

↓  Intern (first year resident)

↓  Medical student

 
MEDICAL DIRECTORS are physician leaders who oversee all the staff physicians on staff. Medical directors coordinate all aspects of both inpatient and outpatient care in hospitals and work to establish institutional policies and practices that will ensure high quality care to patients.  All of your physicians ultimately answer to the medical director.

Your attending is the doctor ultimately responsible for your treatment plan.  If you cannot get the help you need from the attending you can ask to speak to the HEAD OF THE DEPARTMENT he is associated with, such as orthopedics, cardiology, etc.

ATTENDING PHYSICIANS are the most senior doctors directly responsible for your medical decision-making and treatment while you are in the hospital. Attending physicians are fully trained doctors who have completed a minimum of three years of residency training and who may have passed a board examination in a specialty. Collectively, the attending physicians treating patients at a hospital are called the Medical Staff.

HOSPITALISTS are physicians who focus solely on the care of hospitalized patients. They are usually employed either by the hospital or by a medical group that contracts with the hospital. In some hospitals, hospitalists take over responsibility from your regular doctor when you enter the hospital and function as your attending physician. In others, they serve as a backup to your attending physician. You should inquire if your hospital employs hospitalists so you will know what to expect if you are admitted. Call the patient relations department or the admitting office to obtain this information.

House Staff is a generalized term used by hospitals to cover doctors- in-training, or residents, who may range from interns just out of medical school to fellows with years of experience.  In teaching hospitals, house staff will direct a great deal of your medical treatments. Find out if your local hospital is a teaching hospital so you will be prepared to interact with residents. The following are different levels of house staff you may encounter.

  • FELLOWS operate at a level of responsibility just below attending physicians. They are physicians who have completed their primary residency and have chosen to pursue advanced training (a fellowship) in a particular specialty. Fellows may have little direct patient contact and it may not be obvious that a fellow is participating in your treatment. Be sure to ask, since fellows, like other residents, can write orders in your chart and make decisions about your treatment plan.
  • RESIDENTS have graduated from medical or osteopathic school and passed a national licensing exam. A resident is a licensed “MD” (osteopaths are called “DO”) but he cannot work without supervision until he has completed a minimum of three years of hands-on training (the primary residency). The CHIEF RESIDENT is a senior resident who directs the activities of other residents and functions as their immediate “boss.” Just below the Chief Resident is the SENIOR RESIDENT (usually a third year resident) and below them are JUNIOR RESIDENTS (usually in their second year). These are the basic categories – some residency programs in specialty fields can be as long as eight years.
  • INTERNS are doctors who have completed medical school and are in their first year of residency training.  Some hospitals do not use the term “intern” and instead refer to interns as first year residents,  R-1’s or PGY-1’s (for Postgraduate year 1). Regardless of the name used, interns have a medical degree but are not yet licensed to practice medicine on their own, which requires them to be supervised by senior MDs or DOs.

MEDICAL STUDENTS are still studying to become doctors and do not have a medical degree. Medical students do hospital rotations and follow the course of hospital patients as part of their training. They are given varying degrees of authority and in some hospitals they may take and review your medical history and even write orders in your chart, which need to be reviewed and signed by a licensed doctor.

 

Your Turn

Before we move on to the nurses, let’s take a break and ask you to answer a couple of questions about the physician hierarchy.

Q:  Residents in their primary residency are licensed doctors but they cannot yet practice medicine without supervision

True            False

Answer: True.
Residents have completed medical school, passed a licensing exam and have their medical degrees (MD or DO) but they cannot practice medicine without supervision.
Q: The term “House Staff” refers to:

A. Hospital administrators and attending physicians
B. Housekeeping staff and other custodial workers
C. Doctors-in-training, such as interns or other residents
D. Bedside nurses

Answer:  C.
House staff is a general term that refers to all doctors-in-training in the hospital. Administrators, housekeeping staff, and nurses are not members of the medical training program.
 
1.   Hallisy, JA, Haskell, HW. The Empowered Patient Guide to Hospital Care for Patients and Families. San Francisco, CA: The Empowered Patient Coalition; 2008.


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