Even after being hospitalized for an entire week, my friend Aidan never got an answer to a major question: Who is my doctor?
As a healthy 26-year-old, he didn’t know much about the hospital—a place that I work every day. He learned a lot after a lung infection forced him into the infirmary for seven long nights.
Aidan now knows the excruciating pain of having plastic hoses inserted into the chest to drain pus from around the lungs; the definition of an empyema (which he still refers to as his lung empanadas); the violation of dignity that occurs when physicians probe into your personal life; how disorienting and lonely the hospital can be.
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He called me from his hospital bed with updates and a series of queries. But he had one question that never got answered: Who, in fact, was his doctor?
Despite a steady march of white-coated figures in and out of his room—sometimes at 5 A.M., seldom introducing themselves—he never found out. They would often face each other instead of addressing him, and use only technical language when pulling back blankets to examine his body.
During these months of pandemic fear, friends, old classmates, previous professors and even strangers have reached out to me because of my role as an emergency medicine physician. With loved ones in or about to be in the hospital, they send a flurry of questions to my inbox. How do they get in contact with their loved one? What questions should they know to ask? What does this test result mean? Is it safe to go home? Who is my doctor?
Though staying overnight in the hospital can be one of the most frightening, dizzying and unpleasant life experiences, admission rarely comes with an orientation packet. It’s a confusing place with an uncountable number of moving parts, roles and features, and when patients are whisked from one place to another by busy people who already know the system well, a clear explanation of what to expect often falls between the cracks.
Communication is even more limited with the visitor limitations COVID-19 has forced into place. The advocates that patients usually have around them—worried parents, frightened children, concerned friends—aren’t there to process information as it comes in spurts. Important family decisions are reduced to Zoom calls on propped-up tablets. It takes a clear head to sift through medical jargon, but we expect patients to interpret this new language in the height of discomfort, in a new environment and often with pain, anxiety and illness clouding their ability to ask questions about their care.
Aidan is a smart guy. He’s Ivy League–educated, with friends in the medical system he can call on at a moment’s notice, but he still felt immensely uninformed and unequipped to process what exactly was going on with his care on a day-to-day basis. He, like a number of other people in this pandemic, had never had reason to interface with the hospital and was forced into the steep learning curve of illness without warning or preparation. Aidan can’t imagine how much worse the process would have been if he, like so many of our patients, didn’t possess impeccable English, above-average health literacy, and family support.
Getting Aidan’s call reminded me how muddled and opaque a hospital stay can be. Though the following is by no means comprehensive, I’m hoping that by offering a short glossary of physician roles and a brief summary of the hospital stay process, people who are experiencing hospitalization or sending care to hospitalized loved ones will have a better understanding of what to expect.
ADMISSION
Most patients get admitted to the hospital after being seen and stabilized in the emergency department. Sometimes it can be frustrating to repeat your story about what is happening multiple times, but generally it’s because there are several steps that happen to make sure a patient is being appropriately placed and evaluated in the emergency room. Often, patients will undergo a brief triage evaluation, wait in the waiting room, then undergo an initial nursing evaluation that is sometimes conducted in parallel to a medical resident physician evaluation. The resident will then present the clinical history and findings to the senior/attending physician (simply “attending,” in hospital jargon), who will often perform their own formal evaluation as well.
In almost every case, care in the emergency department is a team sport that takes a number of different people to help the process run smoothly. Because shift changes don’t always align for attending physicians, resident physicians, medical students and nurses, this means a patient in the emergency room can be cared for by several different people during their stay. When there are shift changes, major facts of each patient case and plan are communicated from the original care provider to the incoming team in a process we call “sign out.”
If a patient is admitted overnight to the hospital for care and monitoring, the admitting physician from the wards (the “inpatient” side of the hospital) will reevaluate the individual to come up with a medical assessment and plan for the patient’s stay. (This includes, for example, ordering medications that the patient has previously been prescribed, deciding on further necessary tests and calling specialists for consultation.)
In the morning, new labs (blood work) are drawn for updated clinical information. Residents usually arrive in the morning before their attendings in order to “pre-round,” or complete a fresh physical exam and assessment of each patient. Sometimes, medical students, interns and senior residents will all “pre-round” on patients, which can result in multiple people in white coats coming in and out of a room. What’s more, if a patient is being followed by consulting teams, each team will also do their own exam.
This can mean multiple examinations happen very early in the morning, often before 6 or 7 A.M. It’s not pleasant to be woken before the sun rises by hands that usually push and inspect exactly where it hurts most. It’s definitely not enjoyable to have rest and privacy disrupted, or to be jarred into the day by freezing stethoscopes and slamming doors. But these exams and new laboratory results are used to discuss each patient’s developments or improvements during “rounds” with the attending later in the morning. During “rounds,” most major scheduling and clinical decisions for the day are made with the whole team present, though discussions involving specialty care can be completed later during the day.
Overall, and unfortunately, these processes favor a system where communication about new information and decision-making about patient care happens chiefly among physicians, instead of between patients and doctors. Though providers should introduce themselves and explain their clinical role clearly, this rarely happens. It can be helpful to keep a notebook and pen around to keep track of questions, notes and physicians. If possible, make sure someone you trust is being updated with medical decisions and plans each day. It’s always good to have a second set of ears listening in and clarifying any confusing points. Most importantly, ask questions. It’s important that you as a patient understand and are on-board with your own medical plan.
WHO DOES WHAT
Medical Students: Third- and fourth-year medical students working towards their M.D. participate in four- to-12-week rotations in the hospital, where they are involved with patient care as part of their education. Their main role is to learn, not work, and as novices they usually “carry” (are responsible for) a fewer number of patients. Because of this, they have more time to spend on each patient and can be important sources of advocacy and communication. They can put in orders for medications and procedures with the supervision of senior physicians.
Interns/Residents: Residents are graduated and practicing doctors in the middle of residency—a three-to-seven-year specialty training program required to become an independent, licensed physician. Interns are simply physicians in the first year of residency. Residents and interns are responsible for evaluating patients and placing medication and procedure orders, under supervision of the attending physician. Often, residents and interns are the physicians with whom patients are in most contact and communication, since they remain on the wards for the entirety of the day and night and are the first call for any arising medical issues or questions.
Attending: The attending physician is the senior and supervising doctor of the team. Major medical decisions are made by the attending, who also supervises residents during medical procedures and rounds. Many attendings are scheduled to be “on service” for inpatient wards for one to two weeks at a time. This means, depending on scheduling and duration of stay (often, attendings switch on and off service on Sundays or Mondays), patients may be under the primary care of multiple or different attending physicians from week to week.
Primary Team: The primary team is responsible for a patient’s overall care and makes final clinical decisions, sometimes with the input of Consulting Teams or Consultants who have special expertise in, for example, pulmonology, geriatrics, psychiatry, orthopedics. When called, consulting physicians will evaluate patients and offer recommendations on specialty care through written notes and discussions with primary team members.
Fellow: Fellows are in between residents and attendings in seniority, as they are physicians who have graduated from medical residency and are pursuing extra training in a subspecialty (For example, infectious disease, critical care, cardiology, endocrinology, trauma). They can work within a primary or consulting team. Sometimes, and especially in large academic medical centers, fellows and residents on rotation operate as the arm of a consulting team and will do an initial evaluation/daily examinations before reporting back to the specialty attending and communicating recommendations to the primary team.
Aidan’s experience is not unique, and it is a reminder that taking the time to communicate compassionately is a major part of patient care, comfort and well-being. I imagine that, in the emergency department, it is awful to see your doctor walk out the door with their bag and coat without giving you warning or further explanation. While sign-out is often a rushed time, I am trying harder to introduce myself, my role on the team, the next steps of the medical process and who I am taking over for to every patient whose care is transferred into my hands.
The hospital is a terrifying place even without a novel pandemic. Tell your patients who you are before you touch them. Know that everyone is hungry for answers; be generous with information. Many people who come to the hospital are understandably distracted by pain, discomfort, suffering and fear, which makes it ever more important to help them process difficult and technical information and to take the time to communicate with family, who are often waiting anxiously across phone lines for updates on their loved ones. We must recognize these small actions as integral to ethical and appropriate patient care. Everyone is busy, but it is necessary to make time for this.
As the poet Marge Piercy tells us as a bracing reminder: The work of the world is common as mud.