Updated August 18, 2014.
Throughout my time in medical training, one of the most common questions I was asked by friends and family couldn't be answered in any of the books I'd read, even though within the world of medicine it defined me professionally. What was my job title, and what did it mean?
I've heard that people in medical school learn as many words as someone who moves to another country to learn another language.
While this wouldn't surprise me, the shift in culture deserves similar emphasis.
Academic medicine has a unique culture that includes a distinct, almost militaristic hierarchy. This first becomes apparent in medical school, and the hierarchy continues from there on. While I will focus on neurology, since it was my own training, the structure is similar throughout most of medicine, with some slight variations around the theme.
Keep in mind that an American medical student has completed at least four years of challenging college education including physics, chemistry, biology, and the humanities. They are among the best and brightest students-- it is challenging to enter medical school with less than a 3.5 grade point average, and most schools only accept higher. Still, in the hospital, medical students are the bottom of the totem pole.
In many academic institutions, the status of a medical student is displayed by a short white coat as opposed to the longer lab coats worn by physicians.
Other medical personnel occasionally wear these coats as well, but not physicians as this would symbolize a kind of demotion.
Even among medical students, however, there are different positions. First and second year medical students generally have limited access to patients, with an emphasis on traditional coursework. The third year is a transition in training where most learning occurs in clinics and hospitals, as the students learn and work with teams of physicians, becoming directly involved with patient care.
All medical students are required to spend time, usually a month or more, in different fields of medicine. Each time is called a rotation. All medical students, for example, do at least one rotation in internal medicine. These required rotations are generally performed during the third year.
When a student is particularly interested in one field of medicine, as I was in neurology, they can do what is called a "sub-internship" in that specialty. The sub-intern, or "Sub-I," is a senior medical student who is generally looking to learn as much as possible during that rotation.
When someone graduates medical school, they have earned the title of doctor. They can prescribe medications, order tests, even do surgery. In the United States, however, this isn't usually considered enough to practice independently.
The next step is to enter residency, where young doctors perform medicine under the close guidance of senior physicians. The length of a residency varies by specialty, and usually runs from between three to five years or more.
The first year of residency again involves rotations in various specialties of medicine, and is known as an internship. Those who will practice surgery, for example, rotate in several different areas of surgery. An aspiring neurosurgeon may well spend a month taking care of people with appendicitis. Similarly, although I was going to be a neurologist, I spent a month learning about hematology and oncology. While some of this training may feel superfluous, it allows for a breadth of understanding, and also facilitates communication between different specialists.
After a year as an intern, things change more dramatically between subspecialties. Many professions serve an additional two years in internal medicine before going on to do a fellowship in their field of interest. Others, including neurology and radiology, go on within residency to focus solely on areas within their field of interest. In neurology, the remaining residency is three years, for a total of four years of residency training after medical school.
During the last year of residency, some residents may be selected as chief residents. This selection process usually depends on input from various physicians with whom the resident has worked. To be selected as a chief resident is an honor, but also comes with various additional responsibilities, such as arranging academic talks or maintaining schedules on the floor. Still, the experience is considered valuable enough that some residency programs extend the residency by one year for the chief residents, making them uniquely senior to other residents in the program.
After residency, a physician can not only call themselves a doctor, but also state their field of practice. I, for example, could call myself a neurologist following my residency training.
The field of neurology, though, is vast and complicated enough to narrow one's focus further. About 70 percent of neurologists, however, choose to continue their training by focusing in one particular area of neurology. This is known as sub-specialization.
There are several different fellowships even within just the field of neurology. The American Academy of Neurology's Directory for Fellowship Positions offers 29 different categories now, and that is far from all-inclusive and the categorization is imperfect, permitting some overlap. Examples of some fellowships within neurology include epilepsy, neuro-oncology, vascular neurology, movement disorders, behavioral neurology, neurorehabilitation, sleep medicine, neuro-otology and more.
A fellowship usually last just one or two years. After a fellowship's completion, a physician may choose to do additional fellowships, or they may go on to serve as an attending physician or leave academics.
An attending physician is the doctor to whom these various trainees report. During "rounds," the team of doctors will meet, discuss, and visit with the patients, working together to form a plan for the best approach to medical management.
At each stage of training, the number of patients overseen goes up, but so does the number of people who are helping. For example, an attending in the hospital may oversee thirty different patients, but is actually working with three residents who are overseeing ten patients each, collecting most of the information about the patient, writing notes and orders, and otherwise directing care. It would be much more difficult for the attending to do all of this without such assistance, but more dangerous for the residents to do this without the attending's feedback.
Residents, in turn, may be working with some medical students, each of which is involved in the care of one or two patients. The residents are expected to teach the students in return.
It should be mentioned that there are two major models of how attendings work in a hospital setting. Some attendings are sub-specialists themselves who only serve in the hospital a few weeks every year. Others are hospitalists, meaning they do nothing but work in the hospital. While there are some arguments to be made for either structure, many academic institutions are moving towards the hospitalist model.
In denoting the hierarchy of medicine, I hope I do not unintentionally mislead some readers to believe that "bigger is better" under all circumstances. While often it may be useful to work directly with an attending-level physician, there are trade-offs in doing so, and in some cases insisting on working directly with the attending would actually be detrimental.
A classic example is when a patient insists that only the most senior physician, the attending, should do a procedure such as a lumbar puncture. If the attending is a sub-specialist who generally doesn't do lumbar punctures in their more everyday practice, it may in fact have been several years since they last performed the procedure, whereas the resident may have done a dozen lumbar punctures in the last week. Asking for the most senior physician in that case guarantees less chance of success.
Similarly, because attendings oversee more patients than the junior staff, they often do not know minute details about each case. Medical students, on the other hand, may have only one patient to focus on, and will be expected to know every potentially pertinent facet about that patient. Refusing to work with a medical student out of fear of their inexperience, then, may actually limit the thoroughness of your evaluation, even while ensuring that only more highly trained people are involved in your care.
As I've said, the structure of medical hierarchies vary somewhat between specialties and between institutions, but what I've described is relatively common. While there are risk in placing your health in the hands of people who are in the beginning stages of their medical training, there are often unanticipated benefits as well.
AAN Resident Survey Summary Report [Internet] Minneapolis, MN: American Academy of Neurology; 2011