LDAP: Respecting the Hierarchy
By Lincoln D. Stein
Respect the hierarchy! So said my department chairman, speaking on that nervous day when I sat with the other first-year medical residents in the dimly lit conference room, listening to our new masters set down the rules of the road. I don't remember most of the other things the chairman told us to do -- something about working hard, and something else about saving time to attend enriching cultural events. But I clearly recall the words about respecting the hospital hierarchy, that byzantine structure that governs the life of the medical staff. Over the next months I learned how to respect the hierarchy: when to refer a problem to the fellow, when not to bother the chief of service, and where to turn when an attending physician turned out to be less than fully attentive.
The hospital hierarchy is based on the delegation of authority. The chief of service delegates to the attending physicians, the attendings delegate to the fellows, the fellows to the senior residents, and so on down the line. You can often judge where a doctor is on the totem pole by looking at the length of his or her lab coat. The longer the coat the greater the authority. Medical students, with the least authority of all, wear lab coats that barely reach their belts. The godlike attendings wear lab coats that reach their knees.
As frustrating and inequitable as the system sometimes seemed, I appreciated its role in keeping the wheels of medicine turning smoothly. Only by carefully delegating authority can medical teams keep up with the myriad details of taking care of the seriously ill patient.
