Many White Coats: A Patient’s Guide to Medical Education
You’re sitting in the doctor’s office, or lying in bed in the hospital. In walks a young man or woman in a white coat, who starts asking you questions.
Then along come two or three others. They ask questions, too — sometimes the same ones. Maybe they even examine you.
The last one you see actually looks old enough to be a doctor. But who were all those others? It’s a question that may have occurred to you when you received care from Einstein Medical Center Philadelphia doctors. They introduced themselves, but you’re still not sure.
The parade of white coats may be confusing, but it’s all part of the medical education process. This time-honored method is what molds medical school students and graduates into well-seasoned doctors.
Einstein is the area’s largest independent academic medical center. At any given time, more than 400 young doctors — known as interns, residents, or fellows — are receiving training here in about 30 specialties. They work in teams, supervised by hundreds of longtime doctors.
And even though Einstein doesn’t have a medical school, students from other schools also participate in these care teams as part of their training.
“The thoroughness and the repetitiveness of the process is what makes teaching hospitals special,” says Glenn Eiger, MD, Program Director of the Internal Medicine Residency program, the hospital’s largest.
“I believe medicine is practiced best in teams,” he says. “A single doctor doesn’t always know all the answers. And we, working in a highly functioning team, will often come up with something that is much greater than the sum of the individual parts.”
If you’ve ever wondered about who is providing your care, here’s your guide to medical education at Einstein.
Who are all these people in white coats?
The senior member of the team is known as the attending, a member of the medical faculty who is responsible for the work of the team. He or she probably has been in practice for some time.
“That person has been through medical school and residency training and, for some specialties, maybe a specialty fellowship,” says Merle Carter, MD, Assistant Vice President of Graduate Medical Education, who oversees all of Einstein’s residency and fellowship programs. “The attending is the person who is in charge of your care.”
The attending will delegate some responsibility to the residents. They are medical school graduates, with an MD or DO degree, who are getting training in their specialty. These residency programs last from three to five years.
“Senior” residents, those who are nearing the end of their training, help to supervise the interns (first-year residents). You can find out more about the experience of one intern in our podcast series, “A Resident’s Journey.”
If you’re getting care from a specialist in, say, arthritis (rheumatology), you’re likely to see another type of doctor in training, a fellow. Fellows have been through a basic residency program and are getting more advanced training in a sub-specialty area of expertise.
Medical students are supervised and taught by everyone else on the team. Typically, they are in their third or fourth year of medical school.
Students do multi-week “rotations” through different specialties, from internal medicine and pediatrics to the community clinic, emergency room and surgery. At Einstein, they are the ones wearing the short white coats.
All these team members wear name tags that list their roles. They also should introduce themselves and describe their role in your care as a member of the team, Dr. Carter says.
What do they do?
Let’s say you’re in the hospital. You’ll probably see people in all these roles, but especially in the morning on something called rounds.
“It’s the time where all members of the team get together to review all aspects of care. We review and analyze the data,” such as vital signs and test results, Dr. Eiger says. “We will talk to the patient, examine the patient and then decide what are the next steps in care.”
But before you see the team, you might see a medical student first. “The student might get a set of vital signs from overnight, ask you how you are doing, examine you, and find out from the nurses how the you did overnight, and if there were any events the team should know about,” says Dr. Carter.
The student checks on any new test results and does an exam that he or she will present to the team during rounds. The students and interns probably will have the most time to spend with you.
Next comes the intern, who may ask the same things the student did, but in more depth.
Depending on the specialty area, the “day-to-day care of the patient is often in the hands of interns, who will be spending the most time talking with the patients, finding out how they’re progressing, what needs they may have,” Dr. Eiger says. “Patients on their patient list are their responsibility, everything that happens to them while they’re in the hospital — with supervision, of course, from more senior physicians.”
The senior residents supervise the interns and students. “They will often confirm or change some of the plan by coming around and also talking with the patient and examining them,” Dr. Eiger says. If your care is focused on a specialty, such as cardiology, a fellow in that specialty also may come to see you.
When the attending and the rest of the team come through on rounds, it’s the student or intern who “presents” the patient to the others, summarizing what’s new that day.
“That presentation has to be organized, succinct and complete,” Dr. Eiger says. “That’s a skill they need to develop, how to tell the team everything that needs to be told and leave out all the things that are unnecessary.”
At this point, the attending will talk with and examine the patient and confirm the care plan for the day. The residents also will consult the attending later for any major changes.
If you’re an office or clinic patient, again you’re likely to see a student or intern first. In the emergency room, Dr. Carter says, students also see patients but are more highly supervised because of the severe illness and trauma seen there. In the ER, interns and residents will be directly involved in your care. They will be supervised one-on-one by an attending.
In surgery specialties, students have varying roles and responsibilities, which includes assisting with procedures, she says. Interns and residents take on larger roles in performing procedures as they gain experience, but always supervised by an attending.
Why do they all keep asking me the same questions?
The doctors know this is frustrating for you — really they do. “They may feel like we’re not listening,” Dr. Carter says. “They may feel like nothing’s moving forward because we’re just asking the same questions.”
But there are two good reasons that people on your team might repeat questions.
The first reason is all about your care. The multiple rounds of questions help to get the level of detail needed to find out what is happening with you and to plan the right course of action.
The other reason is about education. The attending (and senior residents) have a lot of experience asking questions. But the others are all learning from more senior doctors how to gather information in the most effective way.
“If you have something complex, there’s no other place that you would want to be but a teaching hospital where doctors are available in the hospital morning, noon, and night.”
— Glenn Eiger, MD
For example, the student will ask questions and then tell the resident. “The resident goes in and asks a similar series of questions, but there are nuances to some of the questions and how you ask it,” Dr. Carter says. “And there’s information that adds to the story that helps rule in or rule out things.”
Next comes the attending, who may ask questions in a new way to make sure the answers are clear. He or she may also probe to find out any deeper concerns.
The goal is to make sure you get the tests and treatments you need and not to miss any symptoms, side effects, or other issues.
What happens at night in the hospital?
At Einstein, interns and other residents can work eight to 28 hours at a stretch. But most of those in the hospital work 12-hour shifts — sometimes 14 hours for surgical residents and fellows. One group works in the day and another at night. Students generally rotate with the teams during day and night shifts. However, on internal medicine rotations the students work only in the daytime.
There’s less activity at night — fewer tests and procedures. “The interns are always here, God bless them, and mid- or senior-level residents,” Dr. Carter says. They handle the care at night, but the attending is always in charge.
But in a teaching hospital like Einstein, these young staff members are not alone.
There are also chief residents in internal medicine and other specialties in the hospital every night, Dr. Carter says. A chief resident in internal medicine is someone who has completed three years of internal medicine residency and is staying an extra year. Chief residents in other specialties are in their final (usually fourth or fifth) year of training.
In addition, there are multiple attending physicians in the emergency department every night and at least one each in surgery, anesthesia, obstetrics and neonatal intensive care, she says. Some of these doctors prefer to work nights.
Meanwhile, the other attending doctors are still in charge of their teams, and they’re available by phone if needed, Dr. Carter says. “The senior resident is required to contact the attending by phone or by beeper if there’s an admission, if there’s a change in the status, if a family member wants to speak to the attending — there’s a list of criteria that indicate when the attending must be called.
“They know that they need to come in if there’s an issue that can’t be managed by the teams that are in house, ” Dr.Carter says.
Why does medical education work this way?
Medical students, interns, and residents take classes an attend lectures throughout the week, every week, in addition to their patient care responsibilities. Sometimes they use simulators to practice procedures or patient care scenarios like cardiac arrest and traumatic injuries. They get evaluated frequently by their attendings and program directors, take tests and do research.
“But the skills of a physician, your bedside manner, your communication skills, your diagnostic skills are cultivated and expanded by immersing yourself in patients,” Dr. Eiger says. “There’s no other way.”
And yet, students, interns or residents must have supervision by the attending, “a safety net” that allows them to learn and practice as their skills grow, he says. “Learning can’t take place at the expense of the patient. The supervision and the attending’s involvement ensures that residents and students are not acting on their own right or in a non-supported, unsupervised environment.”
“It’s a very caring place. The people that have been here for a long time are here because they want to be here for the community. People also want to train here and it means something to them to be in an environment where they can make a difference.”
— Merle Carter, MD
For example, Dr. Carter says, “they have to be in a situation to learn what’s their best strategy for interviewing patients. So they try an interview technique. Then they see somebody who’s more senior to them do the same thing but maybe a little bit better, getting better and more detailed information. Then that senior says, ‘Let’s talk about how you did that and this is what I might suggest you try next time.’ “
“It’s also important that the seniors learn how to teach those who come after them,” Dr. Carter says. “That’s a part of their training. Our perspective is that you don’t know something well enough until you can teach it well.”
What does all of this mean for my care?
It means that you have many people thinking around the clock about your care.
“If you have something complex,” Dr. Eiger says, “there’s no other place that you would want to be but a teaching hospital where doctors are available in the hospital morning, noon, and night, and you’ll have numerous people providing constant inquiry and always thinking about how we can make you better.”
Einstein in particular is “a very caring place,” Dr. Carter says. “The people that have been here for a long time are here because they want to be here for the community.
“People also want to train here and it means something to them to be in an environment where they can make a difference.”