Intern, Resident, Registrar. The Doctor Hierarchy in Australia.

Do you have aspirations to be a doctor but are only familiar with the one title – that being “doctor”? Or maybe you have previously been admitted to the hospital and befuddled by the myriad of busy staff members you’ve come across who have been part of your care? Or you might be part of the allied health workforce and can’t seem to get your head around the difference between a resident and a registrar?

Whatever the reason might be, understanding the medical system and the doctor hierarchy in Australian hospitals can be very difficult and this blog post will aim to clear up a few common misunderstandings about the different job titles that doctors have and hopefully some other helpful information about their roles.

At its simplest form the doctor hierarchy for a medical team usually comprises one or more intern doctors as the most junior doctor in the team, followed by one or more resident doctors, then registrars, and finally consultant doctors as the most senior doctor/s in charge.

This explanation is however a very simplified one. And the actual composition of teams can vary considerably according to whichever State or Territory you are in, the hospital you are working in and the area of specialty. Some other common terms for doctor job titles include JMO, which stands for “junior medical officer”, which may refer to an intern or interns or residents and occasionally even more senior doctors; house officers, which are generally alternative titles for residents; career medical officers, who are generally quite experienced doctors, almost at the level of consultant; and staff specialist and visiting medical officers, which are two common titles for consultant staff.

Currently, I’m in the final year of my medical degree and this topic is something that confused me for a large part of my first clinical year in the hospital. 

Alongside my studies, I am actually working as what is called an Assistant in Medicine, which means that I have been able to gain first-hand experience of how medical teams in Australian hospitals work and who works in them.

So, whilst this topic isn’t necessarily something you get taught specifically in medical school, it’s one that has been of keen interest to me lately. And hopefully, you will also find this blog will help you to feel a bit more comfortable when you are in hospital and words like registrar, BPT, or fellow are being thrown around!

The Basics of the Doctor Hierarchy in Australia

So let’s get started by breaking it down a little bit. The foundations of the hierarchy can best be shown with the following basic diagram:

At its simplest form the doctor hierarchy for a medical team usually comprises one or more intern doctors as the most junior doctor in the team, followed by one or more resident doctors, then registrars, and finally consultant doctors as the most senior doctor/s in charge.

The diagram above however is a very simplified version of the doctor hierarchy in Australia. Whilst it breaks down the doctor hierarchy quite nicely if working in the medical field is something you’re interested in then this level of information becomes too basic quite quickly.

You’ll soon be exposed to terms such as principal house officer, career medical officer, fellow, advanced trainee etc. and things get much more complicated. For example, below is a more complex diagram illustrating the various doctor roles from the State of Queensland.

Read on further as I go through each of these job titles, their variations, what they do and how they form the medical team, and how they interact with patients and the rest of the hospital staff.

The Medical Team

An important concept that can sometimes be a bit confusing is the medical team. So before explaining each individual role, let’s see how they fit together as a team.

Medical teams or teams of doctors are normally split into different medical specialities such as cardiology, emergency, paediatrics, psychiatry and orthopaedics.

The basic structure of a medical team is, ideally, at least one of each of the following individuals – intern, resident, registrar, and consultant (in order of least to most seniority).

The consultant is in charge of the team and all patients are under their care. The rest of the team supports the consultant in taking care of patients by doing the majority of the grunt work which eventually gets reported to the consultant. This allows the consultant to take on multiple patients and prioritize their time to the most important tasks.

Depending on how many patients the team has (and therefore how busy they are) or sometimes on consultant preference, the number of junior staff (i.e. interns, residents, and registrars) may change.

For example on a busy team, there may be 2 interns assigned to one team whilst less busy teams may only have an intern, a registrar, and a consultant. 

The Roles of Individual Doctor Team Members

Now to let’s look at each individual team member and understand their role. Luckily there is some logic behind it all and we can work off the basic diagram to slowly add more pieces to the puzzle. However, before adding more, let’s start by tackling some of the basic roles and titles.

The Intern Doctor

So what does internship even mean? Well, an internship is a period of work experience for students or new graduates.

Originally this term was used mainly in the medical field, however, these days it’s seen in a wide range of professions such as business, law firms, and government agencies. For some professions, internships can be voluntary positions, solely for the purpose of gaining work experience.

This is especially the case for students undertaking an internship. However, in the medical profession, an internship is always a paid position. Yet it still serves as a period of work experience.

During internship, you are provisionally registered by the Medical Board of Australia and at the end of the mandatory 12 months, you are eligible for general medical registration. 

There are multiple different conditions to fulfil before becoming eligible for an internship in Australia, however, the most basic requirement is that you must be a graduate of an Australian or New Zealand Medical school that has been accredited by the Australian Medical Council.

Interns in Australia must complete at least one term in each of Medicine, Surgery, and Emergency Medicine to progress to residency and full registration with the Medical Board.

In explaining the basics of the medical team – we already know that interns are the most junior team members, hence their official title being Junior Medical Officer (JMO).

Interestingly, despite being called Junior Medical Officers, you may find this term to be slightly misleading too. With many universities moving to a post-graduate medical degree, medical students are a bit older and additionally, there are always mature age students, some of whom have had successful careers in other fields!

So whilst the term JMO is accurate in terms of experience in the hospital, it doesn’t account for one’s maturity and worldly experience!

Also, the term JMO can often be used by some to refer to residents as well as interns. And some hospital managers may even use this term to refer to all the trainee medical staff, i.e. everyone other than the consultants.

What Does an Intern Do?

Interns are in essence the backbone of the team, doing much of the grunt work.

A good example of this is seen during ward rounds. As an intern, an important aspect of your job is to ensure that the ward rounds go smoothly and efficiently. To do this, interns will often come in a bit earlier to print off a list of the patients under the care of their team.

During the ward round they will find the correct patient files and take notes whilst the consultant and registrar talk to the patient and conduct any relevant physical examination.

The intern will also be the doctor asked to organise any investigations (e.g. blood tests, scans) or medications that the consultant would like. If a consultant would like to see letters from the patient’s GP or notes from previous hospital admissions, it is the intern’s job to find such documents. So in a way, the intern role is very much a secretarial role. 

Now after reading the last paragraph, you might be a little put off by the role of the intern, especially if like me you are a medical student. After all, when you think of being a doctor, secretarial work isn’t the first thing that necessarily comes to mind!

This is quite a common thought, even for medical students who are in the latter part of their studies. You may expect to be making the big medical decisions as soon as you graduate but realistically that is not the case.

Despite having studied for up to 6 years, making the big decisions is not something you can expect to be doing – this requires experience, experience, and more experience! This is why the road to becoming a consultant is more often than not, a long and time-consuming process.

Internship, residency, and your years as a registrar are all about gaining experience and finding a field that you want to specialise in. Some may find the role of an intern degrading; however, it should really be seen as a time where you are being paid to learn!

For example, taking notes during ward rounds is a great way to see how your consultant and registrar think about the medical problem at hand and gives you first-hand experience to use when you eventually are in their position. 

Since an intern’s role has a lot of non-medical aspects to it, you will find many interns and residents enjoy doing after-hours work.

On after-hours shifts, as an intern, you get to do more “pure” medicine such as taking a history and doing a physical exam which is largely what you’ve been training to do throughout your medical degree. It’s the time where you actually feel like a doctor instead of a secretary or assistant.

And to make things even better, you are well supported during after-hours shifts as there will be a registrar, who is more experienced, that can provide support whenever there are times you are unsure. 

The Official Role of an Intern Explained

Here is an official statement found in a Western Australia internship Job Description Form outlining the key responsibilities:

“To provide a high-quality clinical service to all hospital patients under the supervision of Clinical Supervisors (including Consultants and Registrars) and within a multidisciplinary team. To work within your ability and according to the hospital’s core values. To expand your knowledge and skills through the available learning opportunities. To perform satisfactorily under supervision in a range of accredited terms and complete the mandatory experience required to be granted general registration with the Medical Board of Australia under the registration standard “Granting general registration as a medical practitioner to Australian and New Zealand medical graduates on completion of intern training”

C/- Western Australia Health

This is quite a succinct and clear description of the role of an intern however to break it down further and explain some of the key elements here is a summary of some of the critical points:

1. Providing high-quality service under the supervision of a clinical supervisor and within the multidisciplinary team (MDT)

• This is an important point and there are a few different aspects to it. Firstly, as discussed above, as an intern, you are working under the supervision of senior staff members (i.e. registrars and consultants). You will often find patients asking questions which you are unable to answer, and this is completely acceptable. You should be very comfortable in saying you will need to double check with your consultant or registrar.
• Secondly, it’s very important that you remember the other members of your team. Whilst doctors play a critical role in the functioning of a hospital, without the rest of the MDT, the whole system would fall apart very quickly. So, familiarising yourself with the MDT, which includes the nursing staff, physiotherapists, occupational therapists, social workers, pharmacists, discharge planners and a range of other professionals is vital. You’ll find how much easier your life becomes when everyone comes together as a team so be sure to use every asset available to you!

2. Working within your ability and the hospital’s values

• Working within your ability is once again a reminder that you are an intern and that there will be many things you will need to ask for help about and that this is perfectly reasonable
• Most hospitals will have a set of core values which you will be expected to abide. Whilst they are mostly common sense, and in some ways used more for the positive public image it’s a good idea to familiarise yourself with the values that your specific hospital advocates for

3. Expanding your knowledge and skills

• This is a direct reminder that as an intern, you are still training and learning. At no one point in medicine will you stop learning (even as a consultant) and its important to remember this point despite having graduated from university.  

4. Working in a range of terms/rotations to be granted general registration by the Medical Board of Australia

• There are 3 terms that are mandatory to complete before being granted general registration and becoming a resident. These three rotations are Emergency Medicine, Surgery, and Internal Medicine. Usually, you will complete 12-week rotations in each of these and the rest of your year could be in any other terms, such as psychiatry, obstetrics, and gynaecology etc. Your hospital will allocate you into your rotations (with all interns doing the three mandatory rotations at some point in the year) and depending on your hospital system you may get to preference which specialty you would like to work in

Resident or Resident Medical Officer (RMO)

So, moving on, let’s have a look at the next step up the ladder – residents.

A resident is a medical officer who has completed their internship and has been granted general registration by the medical board of Australia.

But have you ever wondered where the term resident originates from? It’s quite a funny little fact! The term arises from the fact that resident physicians would spend so much time in the hospital that they would be considered residents of the hospital. And would often actually live at the hospital!

Thankfully, however, over the years, there’s been a push towards supporting junior doctors more and more and you won’t find yourself working as much as the original residents did back in the day, not to say resident physicians have it so much easier off now. And most residents do have their own home to go to now!

Another term that you will hear is Senior Resident Medical Officer (SRMO) or Senior House Officer (SHO).

This is a doctor who has completed at least one year of residency however has not yet applied to a training program. One of the reasons you may choose to become an SRMO and extend your residency period is to gain further experience or to work in a field you haven’t worked in before to test whether or not it’s something you are interested in pursuing.

Through your internship and your first year as a resident, there’s no guarantee that you will have worked in the field you are most interested in and an extra year as an SRMO might give you that experience. It does however come with the disadvantage of delaying your training by at least a year.

Registrars

Now registrarship is where things get the most complicated! I’ll make an effort to explain as many of the different titles a registrar can have however, I’m sure there will be some that I’ll end up missing. So feel free to post a comment or a query in the comments section below.

First of all, registrars are medical officers who have enrolled in a specialty training program. By completing a specialty program, you can become a consultant in that field. However, you must first go through the training program which involves examinations, interviews, and hours and hours of work experience.

The training programs can last anywhere between 3 and 6 years however this is a minimum. Many doctors will defer their exams to allow themselves more time to study or some may have to re-sit exams/interviews if they are unable to get through the first time. In competitive specialties, it may take several years to get on the program as well.

However, throughout this period you will be a registrar, and depending on where you are along your chosen pathway, you may have other specialised terms applicable to you.

Let’s have a look at some of these specific terms and make some sense out of them:

Basic Trainee

• Some colleges, such as the Royal Australian College of Physicians, have a basic and advanced training component. Basic training is the entry point for the specialty training program and must be completed before being eligible for advanced training. In NSW you are eligible to apply for a RACP training program in your second postgraduate year (PGY2) to begin your basic training at the start of your third (PGY3). So, logically, a Basic Trainee (or sometimes referred to as a Basic Physician Trainee/BPT) is a medical officer who is in the process of completing their basic training component.
• In NSW, BPTs must complete 36 months of full-time equivalent (FTE) training before applying for advanced training

Trainee

• A trainee is similar to a Basic/Advanced trainee; however, this term is reserved for those colleges that don’t have a basic and advanced component and only have one pathway towards specialist qualification.

Unaccrediteded Trainee

• This is a medical officer who is working at the level of a trainee, i.e. a Registrar. But has yet to be formally accepted into a training program. This generally occurs in specialties where there are fewer training posts versus the number of doctors who want to train. The classic example being surgery.

Advanced Trainee

• This is a medical officer who has completed their basic training component. This means they have completed the required amount of work-experience (usually about 36 months FTE) and have usually passed their basic exams. Depending on the college, advanced training is usually around 24 to36 months FTE and includes a range of assessments which differ depending on what specialty you have chosen. At the end of advanced training, you become a fellow of your respective college and can work as a consultant.

Provisional trainee

• Some colleges require a period of provisional training before entering the training program. The Australian College of Emergency Medicine is an example of a college that requires an additional year of provisional training. In most cases, this provisional training is 1 year in duration.

Provisional Fellow

• Some colleges require an addition Fellowship year before being eligible for specialist registration. It is also possible to choose to do an extra provisional year before becoming a consultant to gain further experience in your field. During this year you are given the title of Provisional Fellow

Principal House Officer

• This is a term that is used in specific states such as Queensland. It is a medical officer who has not undertaken a specialty training program. It is only eligible to those who are PGY3 and greater and is an equivalent level to a registrar

Senior Grade Doctors

There are a couple of other terms you may come across that I’ve put under the umbrella term of ‘Senior Grade Doctors’. These are doctors who don’t classify as registrars or consultants and find themselves somewhere in between.

The main term you will hear for such doctors is Career Medical Officer or Career Hospital Doctor. These are doctors who have not specialised in any one field. They can work in a variety of different fields such as obstetrics and gynaecology, emergency, or psychiatry depending on choice and their past experiences.

These doctors are usually very experienced in their area of medicine and have often completed some of the training components of the related specialty program.

Here is a list of some of the terms you may come across in relation to Senior Grade Doctors and where these terms are commonly used:

• Career Medical Officer – Tasmania, ACT, NSW
• Senior Hospital Medical Officer – NT
• Career Hospital Doctor – Qld
• Health Service Medical Practitioner/Senior Medical Officer – WA
• Senior Medical Practitioner – SA

Interestingly, there doesn’t seem to be an equivalent term in the Victorian System, at least according to the remuneration rates published by the Victorian Department of Health and Human Services.

Consultants

Finally, we come to the top of the doctor hierarchy – the consultant.

This is one of the easier roles to explain since, in reality, they are just the boss! All the major decisions are made by the consultant and at the end of the day, the buck stops with them.

Whilst their role may be easy enough to explain, there are a few different terms you will here that describe a consultant so let’s clear those up:

Staff Specialist

• This is a medical officer who has competed their training through one of the many colleges and is employed by the hospital either full-time or part-time on a salary. Most staff specialist just perform public work. But it is possible to work part-time as a staff specialist and work tyour other time in the private sector.

Visiting Medical Officer (VMO)

• A VMO is a doctor who has completed their training through their respective college and is contracted to a public hospital to care for public patients. They are not employed by the hospital and they normally have their own private practice which they work in.

Physician

• A physician is a consultant who has completed their training through the Royal Australian College of Physicians. This term could relate to any of the sub specialties within the College such as Cardiologist, Neurologist, Gastroenterologist etc.

FACEM/FRACP/FRACS etc etc etc

• Whilst they aren’t used commonly these terms can sometimes be the most confusing if you haven’t heard them before. These terms are actually a qualification, just like MD and MBBS are. They denote completion of specialty training, for example FRACS stands for Fellow of the Royal Australian College of Surgery. You will usually only see these terms written next to names however in the Emergency Department, you may here the term FACEM (pronounced “face-em”) being thrown around as many ED doctors go by this term instead of consultant/specialist

What About General Practice?

Compared to other hospital specialties, General Practice has far fewer descriptive terms and titles. So we should be able to breeze through this much quicker than the other specialties!

To be eligible to enrol into the Royal Australian College of General Practice (RACGP), you must first complete your internship and residency. After this, you can begin your training through the RACGP during which you will be known as a GP Registrar. Once you have completed all the requirements of your training you become a fellow of the RACGP and henceforth are a fully-fledged GP.

Breaking it down like this may make it seem like a simple task but it’s important to remember that the training process involves many hours of work experience, exams and interviews before you finally become a fellow of the college.

It’s important to understand that General Practitioners are specialist doctors in their own rights. And in fact, in most rural towns with hospitals, it is the GPs who are providing medical services to the hospital. Usually as Visiting Medical Officers. Often termed as GP-VMOs.

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