Who's Who in Your Health Care, Part 1: In the Hospital - What Your Doctor Is Saying - Harvard Commentaries

Several years ago, our hospital decided to install white marker boards in every hospital room. The boards were installed so that all the health care professionals’ names could be listed along with their role. Even when health care professionals introduce themselves and tell patients why they are there, few patients can keep them straight.

Whenever I enter a patient’s room and remind them who I am — and then ask if they remember me — it’s common for the response to be, “I’m sorry I don’t remember your name, I’ve seen so many doctors … and why are you here, again?” For people in the hospital, each day seems to bring in a fresh battalion of doctors, nurses, physical therapists, dieticians and others. Some are dressed in hospital scrubs, some in short white coats, some in long white coats, and some look too young to drive. When the white boards went up, many of us thought it was a great idea and one that had come none too soon.

The same thing can happen in a doctor’s office – there may be an office assistant or receptionist, a nurse, nurse practitioner, or trainees at various stages of learning, in addition to your “regular” doctor.

Whether in a doctor’s office or in the hospital, you may have wondered who’s who. It happened to me when I went to see a highly respected hand specialist for some minor surgery. After my examination, I remember being amazed at how young he was, especially given his reputation. Soon I realized I had not yet met the physician with whom I had the appointment. His “fellow,” a physician training in the subspecialty of hand surgery, had performed the initial examination and failed to introduce himself.

If you’ve ever been confused about all the people coming in and out of the doctor’s examination or hospital room, here’s a quick rundown of who's who.

Medical student — Sometimes called “student doctors,” medical students have not yet earned their medical degree (M.D.); these trainees have generally completed an undergraduate college or university degree and are in the midst of a four-year medical training program. During the fourth and final year, they may be called a “subintern” because in a matter of months they will graduate medical school and become interns. During some final medical school “rotations” (one or more months spent in one area of the hospital), they take on the workload and responsibilities of an intern. All orders, recommendations and other professional activities of medical students must be approved by their supervisors, who include interns, residents and attendings (see below).

House officer — This generic term refers to interns and residents, trainees who have completed medical school (they have their M.D.) but must complete residency training for three or more years as part of licensure requirements. Depending on the trainee’s chosen area of interest, medical students apply in one of several fields, including internal medicine, radiology, surgery, pediatrics, psychiatry, neurology, obstetrics and gynecology, dermatology and anesthesia.
- Intern — A trainee in the first year of residency, just after graduation from medical school. Also called “first-year residents,” these physicians tend to have the longest hours. In the past, it was not unusual for them to work 100 hours or more per week and spend every third or fourth night in the hospital. In U.S. training programs, the number of hours per week has only recently been reduced to 80 hours. The internship year is also called “PGY-1,” meaning “post-graduate year 1.” Under direct supervision by a number of senior physicians, interns are expected to know nearly everything about the patients assigned to them; they are the first persons called by nurses and generally write all orders for all medications, tests and consultations.
- Junior resident, or PGY-2 — Physician trainees in the second year of residency; they supervise interns, teach medical students and interns, and are themselves learning and becoming more independent.
- Senior resident — A physician trainee in his or her third year of residency, also called a PGY-3. They supervise interns and medical students, have an increasingly important teaching role, and are preparing themselves for independent practice, which follows this year of training for many. In some fields, such as surgery, residency continues beyond three years; in the fourth year, for example, the physician might simply be called a fourth-year surgical resident, or PGY-4.
- Chief resident — One or more residents are invited to become chief residents. They play a key teaching role within the residency program, and serve as an intermediary between the more senior physicians, hospital administration, the teaching program and the house officers.
Fellow — For physicians who have completed the three or more years of residency and choose to pursue subspecialty training, fellowship is the next step. If you are hospitalized with a heart problem, the first cardiologist you see may actually be a “cardiology fellow.”

Attending — These are physicians who have completed their training and practice medicine independently, without required supervision. This term applies to medical doctors (M.D.s) who practice internal medicine, surgery, psychiatry or any other field of medicine. Because they have completed a residency program, they are “board eligible” and if they have passed the qualifying examination, they are “board certified.”

The term “attending” is usually used in the hospital, referring to the physician of record, the one person who is ultimately responsible for a particular patient’s care. But the term also applies to others who have completed their training. Examples of attending physicians include:
- Internist — Not to be confused with “intern,” an internist is a physician who has completed a residency in internal medicine and provides medical care to adults. Often called “general doctors” or “regular doctors,” they may or may not have completed additional specialty training. Internists are often “primary-care doctors,” or PCPs (see below).
- Specialist — These attending physicians have already completed a residency and have additional training in a specialty fellowship program. They may have passed a specialty certification examination (making them “board certified” in that specialty). Examples of attendings who are medical specialists include:
  - Allergist (allergic disease)
  - Cardiologist (heart disease)
  - Endocrinologist (hormonal disorders)
  - Gastroenterologist (digestive disease)
  - Hematologist (blood disease)
  - Infectious-disease specialist
  - Oncologist (cancer)
  - Otolaryngologist (ear, nose and throat disease)
  - Nephrologist (kidney disease)
  - Neurologist (nervous system disease)
  - Pulmonologist (lung disease)
  - Rheumatologist (joint disease)
  Other fields have their own subspecialties. For example, graduates of a surgical residency may choose additional training in hand surgery or cosmetic surgery; obstetricians may choose high-risk pregnancy training; and dermatologists may choose to learn more about skin-cancer treatment well beyond what is covered in their residency training.

During your office visit or hospital stay you may meet a number of other health care professionals who are not physicians. These include physician assistants, nurses, nurse practitioners, nurse specialists, physical therapists, dieticians, transporters (who help move people around the hospital in wheelchairs or gurneys; previously called “orderlies”), phlebotomists (people who take samples of blood), and receptionists. Their roles will usually be clear, especially if they have introduced themselves. However, in some situations, it can be confusing, especially when their dress and behavior are similar to a physician's or medical trainee's. For example, a nurse practitioner may do many of the same things in a routine office visit that a doctor does; a nurse anesthetist may be hard to tell apart from the anesthesiologist. However, in those situations there is a clear supervisory role for the physician who is ultimately responsible for the care delivered. And the more complicated evaluations and decisions are generally made by the physicians.

One other distinction that may be confusing is the “primary-care physician,” or PCP. While some insurance plans allow (and some patients prefer) seeing only specialists, many HMOs require you to have a PCP — one physician who oversees the “big picture,” performs the initial evaluation for most conditions and approves referrals to specialists. The distinction between specialist and PCP is not always clear because some specialists also provide primary care while others practice only their specialty. Many people seek out a PCP with a specialty that is relevant to their medical problems. For example, if you have arthritis, having a rheumatologist who also provides primary care might be particularly convenient. If you are in an HMO or other insurance plan that requires you to “sign up” with a PCP, the insurance company can provide you with a list of approved providers.

Ideally, anyone you meet at the doctor’s office or during a hospital stay will introduce themselves the first time and remind you later who they are. In addition, they should be wearing nametags. But if you are sick, you may not recall any of it. I remember a seriously ill elderly woman who spent a week in the intensive care unit. Her intern was a woman who had spent four years at a top medical school, graduating just six months earlier, and had spent many hours in the middle of the night successfully reviving the elderly woman. When she was finally well enough to be moved to a regular bed in the hospital, the patient looked up at the intern and said, “thanks so much, you’re the best nurse anyone could ask for” — this patient had spent an entire week thinking the female physician in the scrubs was her nurse rather than her doctor. In fact, in an intensive care unit, it can be particularly difficult to figure out who is who — patients are very sick, the pace is fast and everyone seems to be wearing scrubs.

As confusing as it is, there is a clear structure, hierarchy and rationale behind the seemingly endless number of people who see you in the hospital. Your doctor’s office may be easier, but still, with staffing changes and ever-changing trainees (if your doctor also teaches), unfamiliar faces may be the rule rather than the exception.

In the end, good communication goes a long way toward sorting out who’s who. If you are not sure, just ask. No one involved in health care should be offended by a patient asking who they are and what their role is. If you are in the hospital, write down the names of the people caring for you — or make sure they “sign in” on the white marker board.

In a future column I will discuss some of the people you may encounter in health care who are not M.D.s.

Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.