Hierarchy of Care

As a Nurse Practitioner for a busy neurosurgical service in a large medical center, I am frequently questioned by patients and family members about the team members with whom they interact. In addition, I have had patients say that “someone in a white coat was in here at 6 AM this morning, when I was still half asleep, and told me I am going home today. Who was that?

Although we all work together in the hospital with a single goal, sometimes there are so many people it becomes confusing for patients and their advocates to know who is who. I have put together a general list, below, to help clarify who some of the staff members are and what they do. Always remember that you can ask people again and again to introduce themselves and tell you what they are there for. We all know there are a lot of us and it can be overwhelming.

The Doctors

In a medical center, there are many different kinds of doctors. They frequently work together on teams or “services”. 

Primary Care Provider (PCP): That’s your own doctor, if you have one, who manages your everyday medical problems. That person can have an MD (Medical Doctor) degree or a DO (Doctor of Osteopathic Medicine) degree. Sometimes a Primary Care Provider is a Nurse Practitioner or PA who works independently, but with an MD for backup. Some primary doctors were trained in General Medicine, some in Internal Medicine and some in Family Medicine.

Attending Physician: When you are in the hospital, especially in a medical center with a medical school, the head doctor or surgeon responsible for your care is called the Attending Physician. An Attending Physician has completed all of the training and licensing to be managing your care and teaching and directing others to do the same.

Resident: A resident is a doctor who has graduated medical school and is now training in a specific medical area, like pediatrics or internal medicine, or in a specific surgical specialty. Doctors spend from 3 to 7 years in residency training, depending on the area of specialty, before taking examinations to receive board certification in their specialty. Residents providing care are supervised by Attending Physicians who must approve their decisions. An intern is a person who has graduated from medical school and is now in their first year of residency in the hospital. They usually work in several different specialty areas while they learn more practical patient care.

Fellow: A Fellow is a doctor who has already completed a 3-to-7-year residency and is completing another year or more of very specialized training.

Medical student: This one is pretty clear. Medical school lasts for 4 years and the first 2 years are spent in the classroom and the third and fourth years are spent in hospitals and offices learning to apply all that book-learning to patient care. 

Some other doctors you might see in the hospital are consultants, who help the Attending and the Primary Team manage complex problems. A few of these consultants are listed below:

Hospitalist: A Hospitalist is an Attending Physician who specializes in managing the general medical needs of patients within the hospital. Some Primary Care Physicians turn the responsibility for the care of their hospitalized patients over to the Hospitalist. Hospitalists usually don’t have clinic offices for patient care, so after discharge, you will return to the care of a PCP.

Specialist: A Specialist is an attending physician who has extra training in different techniques or medical care in a certain body system. For example, Pulmonologists specialize in care of the lungs. Cardiologists are heart specialists. Gastroenterologists specialize in the stomach and intestines.

Neurologist: A neurologist is an MD who specializes in the nervous system, the brain and spinal cord, and their connections to the body.  A neurologist completes a 3-year residency after medical school.  Neurologists can be generalists, who care for all neurology patients or can specialize in various areas of neurology such as epilepsy, stroke and vascular disorders, movement disorders such as Parkinson’s disease, multiple sclerosis or neurocritical care.  

Neurosurgeon: A neurosurgeon is an MD who specializes in operating on the nervous system.  Neurosurgeons complete a seven-year residency after medical school. During this residency they learn all the different areas of neurosurgery, but many then specialize in operating on such diseases as tumors, pediatric diseases, aneurysms and vascular malformations, spinal nerve problems, surgical treatment of movement disorders, relieving pain or compression of nerves in the trunk, arms or legs.  

Vascular Neurosurgeon: A vascular neurosurgeon has specialized in treating aneurysms, vascular malformations, and conditions involving insufficient blood flow to the brain.  A vascular neurosurgeon has typically studied another year or two, after the 7-year residency, in a vascular Fellowship program.  Some vascular neurosurgeons do more open surgeries that involve treating these diseases from the outside through a craniotomy (opening the skull).  Others specialize in treating the problems from the inside using catheters and stents.  Comprehensive Stroke Centers or Centers of Excellence have a vascular neurosurgeon available 24/7.

Interventional Neuroradiologist: An interventional neuroradiologist is an MD who has completed a 4-5-year residency in “diagnostic radiology” or reading scans and X-rays to diagnose problems.  Neuroradiologists study an extra two years in a Fellowship program that focuses on diagnosing diseases in the brain and spinal cord.  Interventional or endovascular neuroradiologists complete a two-year Fellowship after radiology training to learn techniques for diagnosing and treating diseases from inside the blood vessels.  In addition to treatments like coiling aneurysms or embolizing (blocking off with materials like coils or glue) vascular malformations, they can collect blood samples and measure pressures in distant tiny arteries. 

Intensivist: An Intensivist is an Attending Physician who specializes and works in Critical Care. If either you or your family member are in an Intensive Care Unit, you will probably see an Intensivist as well as your Attending Physician. 

Anesthesiologist: An anesthesiologist is a doctor who works in the operating room and administers anesthesia. Many intensivists have backgrounds in anesthesiology.

Allied Healthcare Providers (AHP): These are people with advanced degrees and certification who function, in many ways, similarly to medical doctors. Some of these are:

Nurse Practitioner (NP): A nurse practitioner is a nurse who has additional training in a particular area, such as family practice, pediatrics, critical care or gerontology. NPs often take the medical history, do the initial physical exam, perform some tests and procedures, write prescriptions, and treat acute or chronic illnesses and injuries. Many NPs serve as Primary Healthcare Providers. NPs have a masters degree, board certification in their specialty, and a state license.

Clinical Nurse Specialist (CNS): A clinical nurse specialist provides a wide range of care in hospitals, clinics, nursing homes, private offices, and community health centers. A CNS has been licensed in nursing, has a master’s degree, and often works in administration, education, or research.

Certified Registered Nurse Anesthetist (CRNA): CRNAs specialize in giving and monitoring anesthesia. They prepare patients before procedures, administer anesthesia, and oversee recovery from anesthesia. CRNAs receive 2 to 3 years of training in this area.

Physician Assistant (PA): PAs are medical professionals who diagnose illness, develop and manage treatment plans, prescribe medications, and often serve as a patient’s principal healthcare provider. PAs are generally required to be associated with a medical doctor. PAs have a Master’s Degree, board certification and a state license.

The Nursing Team

Registered Nurse (RN): A registered nurse gives medication, performs procedures such as drawing blood and managing IV fluids, and closely monitors and manages the day to day care of patients. RNs have graduated from a nursing program and have a state license.

Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN): LPNs and LVNs provide basic care and assistance to patients with tasks like bathing, changing wound dressings, and taking vital signs. An LPN has at least 1 year of training in this kind of care.

Nursing Assistant (also called Patient Care Technologist or Patient Care Assistant): An unlicensed care provider who assists the bedside nurse in providing every day care such as bathing, ambulating and eating.

Other Care Providers

Dietitian: A dietitian plans meals for patients based on their medical condition and needs. A dietitian also might provide dietary guidance for people to help them after they leave the hospital.

Occupational Therapist (OT): An occupational therapist works with patients to improve coordination, motor skills, and skills needed to accomplish all our routine activities of daily living. Occupational therapists are usually more concerned with activities done with the hands and arms than with the larger muscles like the legs. Occupational therapists can also help train people with new vision loss issues.

Physical Therapist: (PT): A physical therapist uses exercises, stretches, and other techniques to improve balance and mobility, decrease pain, and reduce any disability related to illness or injury. People might need physical therapy after surgery or as a result of strokes, brain tumors, injuries, or long hospitalizations.

Speech-Language Therapist (ST): A speech-language therapist can work with patients who have problems speaking or swallowing. Most are also trained in doing cognitive evaluations and helping to maximize recovery of intellectual functioning after injury.

Respiratory Therapist (RT): A respiratory therapist evaluates, treats, and cares for people with breathing problems and heart problems that also affect the lungs.

Social Worker: A social worker at a hospital focuses on improving the emotional well-being of patients and their families, and helps coordinate health care. In addition to offering emotional support, a social worker can help the family meet a person’s needs at school or at home.

Case Manager: Frequently also the hospital’s Discharge Planner, a case manager helps to find the right care and coordinate any needs during the transition from hospital to rehabilitation or home.

Some role information adapted from the parents’ handout Kids Health by Nemours


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