1. Critical Care Inpatient Services

The attending physician of record bears ultimate responsibility for the care of patients admitted under his or her name. Junior residents work-up all patients admitted to the services to which they are assigned and report directly to the senior resident. Senior medical residents report to the fellow. The Pulmonary and Critical Care fellow reports all admissions, admission requests, and consultations to the attending. In addition, residents and fellows report problems as they arise and any member may contact the attending at any time. The attending may go with the medical resident and fellow to initially evaluate and care for the patient especially if the patient is critically ill. Otherwise, the resident and fellow first evaluate the patients and then report to the attending. Patients remain under the care of the attending physician in the Emergency Department or Hospital Service until they are accepted by the ICU team and transported to an intensive care unit. The ICU Attending then assumes responsibility for the patient’s care.

Sound medical education demands the incremental responsibility inherent in the above-described chain of command. Critical Care fellows and attendings must be available at all times. Residents write all orders on inpatients. Fellows should frequently check with the residents and come in if there is any indication that the resident needs supervision or assistance.

2. Pulmonary Consultation Service

On Pulmonary Consultation Service the resident generally sees the patient first, reports to the fellow, and then presents to the attending. In the interests of effective and timely patient care, any member of the health care team can page the fellow or attending physician at any time. Late or urgent consultations may go directly to the fellow. The ultimate responsible rests with the attending physician.

Pulmonary fellows obtain consent for procedures and generally write orders for procedures. The orders must be countersigned by the medical service resident. The pulmonary fellow should be observed obtaining consent and evaluated by the supervising attending physician.

The Pulmonary Consultation fellow may perform right heart catheterizations with a Cardiology attending, invasive radiologic procedures with a Radiology attending or thoracic procedures with a Thoracic Surgeon attending. In each case these physicians will be the direct supervisor. The pulmonary fellow must follow the direction of the supervising attending. This will often include arranging and following up on the procedure and writing orders and notes.

3. Ambulatory Settings

In the outpatient clinics, residents and fellows see patients first and report to the attending. The university outpatient clinics have only fellows. The VA has residents and fellows. The attending then evaluates the patient with the resident or fellow. The attending reads the resident’s or fellow’s note and adds an additional note that includes his or her examination and agreement or disagreement with the resident or fellow.