The Medical Hierarchy


For two years, RxCreative founder Jonathan Kohler was a blogger for the Health Dialog Care Compass, a patient education site. Their blog has recently stopped publishing new content and may soon be taken down entirely, so we’ll be republishing his posts here. Look for the tag “care compass”.

A Brief Introduction to the Medical Hierarchy

So there you are, lying in your hospital bed, trying to get some sleep, when someone in a short white coat shows up to poke and prod and ask you a bunch of questions. He or she is followed by another group of slightly older-looking doctors, who ask the same questions again, then disappear back into the pre-dawn darkness. And you can’t help but think: Who are all these people?

If you or a friend or family member is in the hospital or have a surgery planned, it helps to understand and prepare for the early morning schedule. As a starting point, it’s useful to understand the surgical hierarchy at an academic medical center, and the typical schedule of your surgery team. Let’s review:

Why So Early?

Surgeons’ days are determined by the operating room (OR) schedule, and operating rooms generally start working at 7:30 every morning. The number of patients that a surgery team has to see before going to the OR for the day varies tremendously, but in my experience it can be anywhere from 1 to 50 patients. Seeing any number of patients, even at the fast pace surgeons are famous (and infamous) for, means starting the day very early. The practice of seeing hospitalized patients is called “making rounds.”

Who’s Who on Rounds:

•  Medical students: If you’re in an academic hospital, you may have medical students looking in on you before anyone else.  This is called “pre-rounding,” and is a way for the medical students to prepare to present your case to the whole team on rounds. The medical students on your surgical team are probably in their 3rd or 4th years of medical school – the equivalent of juniors and seniors. If you have specific questions you’d like the team to answer, telling the medical students can be a great way to make sure the doctors on your team have an answer for you when they arrive a few minutes later.

•  Interns: Interns in surgery are actually just first-year resident doctors. They’ve graduated from medical school and are starting the 5- to 7-year process of surgical training. They’re the workhorses of the surgical team, and will probably be the members of your team you see the most. Interns manage many of the minute-to-minute details of your hospital stay.

•  Residents: Residents are surgeons in training – they’ve graduated from medical school, but are still training in surgery. They may range in experience from interns (1st year residents) to chief residents (they’ve had 5-7 years of training and are almost ready to practice on their own.) The residents report to your attending surgeon to make a plan for your care every day that you’re in the hospital, and they’re responsible for making sure that plan gets implemented.

•  Attendings: The bosses. These are surgeons who have completed their training. They usually don’t accompany the surgery team on morning rounds, but do check on their patients later in the day, between cases in the operating room.  All the residents report to the attending, who is ultimately responsible for your care. Of course, if you’re in a community hospital, rather than an academic medical center, your attending surgeon may be a surgery team of one.

How You Can Make the Morning Wake Ups Work Best for You

Here are some tips to make the most of morning rounds and visits from the team:

  • Most teams will do more informal rounds in the afternoon, often with the attending surgeon, when the operating room and clinics are done for the day. Afternoon rounds can be a great time to ask questions and have longer conversations with the team, and are usually a much more convenient time for your family to be at your bedside to have their questions answered. If you want to be sure someone from the team comes back to see you later in the day when you’re more awake, just ask.
  • Keep a list of questions for your team. They’ll be moving fast and you may be a little fuzzy-headed. If you have a list of questions ready, it will be easier to get good answers. Remember that the team is racing the clock in the morning, though, so if you have lots of questions you’ll probably get better answers when they come back later in the day.
  • Try to get to know the interns and medical students. Though they’re on the bottom of the medical totem pole, the medical students also have the fewest responsibilities and will be able to spend the most time with you and your family. They know a lot, and know how to get answers if they’re over their heads. Likewise, the interns spend more time on the wards than the more senior surgeons, and will be responsible for the details of your day-to-day care.
  • Attendings can get busy, and may not see you every day if everything is going well. If you want to see your attending surgeon, feel free to ask the team to specifically ask him or her to come by.
  • Don’t hesitate to ask your team if they washed their hands before they examine you. It’s a simple, important act that gets missed about 10% of the time.

Being woken up early is no fun, but it’s a necessary evil in the modern hospital. By understanding what your medical team members do and knowing what to expect, you can be better prepared and get the information you need.

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