Wednesday, January 25, 2012

Who's who in the medical training world

In my last post, I alluded to different levels of medical training.  As I thought about the post later, I remembered that many of the patients I've interacted with over the years are confused about what those terms mean, and perhaps some of my lay readers are, too.

So, today I present the Singing Pen's guide to medical seniority:

Medical student = has completed a bachelor's (college) degree and is in a 4 year medical school program.  Medical students cannot independently provide any patient care; their patient notes and orders must be co-signed by a licensed physician (can be a resident or an attending).

Resident = has graduated from medical school and is training in his or her medical specialty of choice.  Residents must have medical licenses to practice and train, and a resident is rightfully referred to as "Doctor."  Graduating from medical school does not confer enough knowledge to practice independently in this day and age, though.*  Specialty training programs thus follow medical school for virtually all US med school grads; those programs are called "residencies" because, in the old days, residents actually lived (resided) in the hospital.

Intern = a first year resident.  This term is falling out of favor in some circles, as some residents and their teachers worry that it has developed a demeaning connotation.  The label persists partially because it's convenient (interns require the most supervision of all residents, given that they're fresh out of medical school) and partially because some medical specialties require a generic ("transitional") intern year program before joining their residency program (ophthalmology and physical med & rehab are two examples).

Fellow = a post-residency trainee.  Most residents go directly into independent practice after completing their residency, but some medical career paths require yet more training.  Many of the internal medicine specialities require fellowships: cardiology, endocrinology, nephrology, rheumatology, as do some of the surgical subspecialties.  Some fellowships focus less on patient care and more on academic training; I did a two-year faculty development fellowship following my family medicine residency to build my teaching and research skills.

Attending = done with training (but certainly never done with learning)!  Attendings bear the final responsibility for the trainees working with them.  Many attendings don't teach at all and just work independently, but those of us in academia work with students, residents, and fellows on a regular basis.

So, from the last educational level to the earliest:
Medical student

Each level has responsibility to the levels below.  So, residents supervise medical students and attendings supervise residents' supervision of the medical students. As residency takes 3-6 years, depending on the specialty, higher-year (or "senior") residents often supervise newer residents ("junior" residents and/or interns, depending how each residency program labels its residents).

Some residency programs designate one, some, or all of their final-year residents as "chief residents" with varying levels of responsibility - from scheduling to teaching to representation - for their resident peers.  In many programs, being a chief resident is an elected honor.

Each year of medical school and then residency confers more responsibility and autonomy, ideally with the attending safety net always easily accessible.  Good attendings unobtrusively know everything that's going on with both the patients and their learners.  They gently guide the plan of care in the right direction, liberally sprinkle in teaching points, and avoid micro-managing every little detail.

I don't want to suggest, however, that the learning only moves in one direction. The constant challenge of keeping up with the latest evidence and studies is an energizing part of the job for many of us.  I learn more from the ideas and perspectives of the residents and students I am privileged to work with than I could ever teach them back.  This two-way learning makes academic medicine a very interesting place to be.

I consider myself one fortunate doc to get to teach every day, that's for sure.

* "General practice" as it used to be known in the US is no more.  Many family docs and internal med docs are frankly offended when people refer to them as a "general practitioner" or "g.p.," as these terms imply that their medical training ended after medical school (which used to be the case decades ago).  The vast majority of primary care docs in the US are board-certified "specialists" who have completed residencies in either family medicine, internal medicine, or pediatrics.


  1. Thank you for this summary of who's who in the medical world. I've been reflecting on your post and I have to say that these titles make no intuitive sense to me.

    Resident- where are they 'residing'?
    Attending- what are they attending to?
    Fellow - "for he's a jolly good..." ??

    I wonder if clarity for patients might be improved if titles corresponded with ideas of seniority that most people can relate to?

    Instead of Attending, using "in charge"- clearly states who's boss!

    Residents could be: "Level 1, 2, 3, 4"- also clear

    Medical students might be: "Junior, sophomore, senior"- Americans might understand these terms, (Canadians don't use these, at least that I know of)

    BTW...can a Fellow be an Attending?

    Thanks again for adding some clarity to these titles...It would be great if a Canadian could chime in and tell us if there are any differences in our system. I know that Family Practice is a specialty here which I believe roughly replaces the old concept of GP.

  2. Edit to the above post...I meant to say that Primary Care has replaced Family Medicine...need more coffee before I post!

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