Supervision & Duty Hours
University of Iowa Hospitals
Gastroenterology fellow Supervision and
The pediatric gastroenterology fellowship program ensures that it
provides appropriate supervision for all fellows, as well as a duty hour
schedule and a work environment that optimizes quality patient care, fortifies
the educational trajectory of house staff members, and addresses all applicable
program requirements. On-call duties are necessary components of the UIHC
clinical care systems and educational programs; these duties are managed to
ensure adequate periods of rest with appropriate levels of supervision to
deliver safe, effective patient care.(The terms “resident” or “house staff
member” used in this policy shall refer to resident and fellow physicians and
dentists at all house staff levels.)
clinical activities of all fellows are supervised by teaching staff and/or more
advanced house staff members in such a way as to ensure that fellows assume
progressively increasing responsibility according to each fellow’s level of
education, ability and experience. The
teaching staff determines the level of responsibility according to each fellow.
On-call schedules for teaching staff and more advanced house staff members are
structured to ensure supervision is readily available to those on duty. Call is
no more frequent than that approved by the Pediatric RRC of the ACGME.
following guidelines have been established to assure the appropriate
supervision of house staff:
1. Inpatient Pediatric Gastroenterology Service
All patients admitted to the pediatric
gastroenterology inpatient service are assigned an attending pediatric
gastroenterologist. The assignment to
this pediatric gastroenterologist is made at the time of admission, regardless
of the time of day. The house staff is
instructed to notify the attending pediatric gastroenterologist of every
admission to the service and make the attending physician aware of the condition
of all seriously ill children on the service.
Attending pediatric gastroenterologists are notified of the admission of
stable patients soon after the house staff (including fellows) develop a
working diagnosis and treatment plan to encourage the fellow's independent
diagnostic and management plans. The
timeliness of the notification of the attending depends upon the urgency of the
Daily attending rounds are made by the
faculty who remains actively involved in directing patient care. The fellows are given progressively
increasing responsibility in leading inpatient rounds, suggesting and
implementing management plans, while continuously maintained under faculty
2. Outpatient Pediatric Gastroenterology Clinic
Faculty members from the Pediatric
Gastroenterology Division are assigned to staff the pediatric Gastroenterology
outpatient clinic on a daily basis. When
assigned to outpatient clinics, fellows initially evaluate scheduled patients
(new and follow-up) and then staff them by the faculty from the Pediatric
Gastroenterology Division. Each fellow
is assigned a panel of patients that he or she follows in a continuity fashion
with a variety of gastrointestinal disorders for one half-day a week for their
3 years of training. The care of patients is supervised by faculty in all
3. Pediatric Gastroenterology procedures
members from the Pediatric Gastroenterology Division are assigned to perform
endoscopic and other gastrointestinal procedures on inpatients and/or
outpatients. When assigned to procedure days, fellows will perform scheduled
procedures under direct faculty supervision.
fellow will be supervised by a research faculty mentor to learn and conduct
basic, translational and/or clinical research activities.
The pediatric gastroenterology fellowship program demonstrates that the
appropriate level of supervision is in place for all patients cared for by all
fellows. Every pediatric patient has
an attending pediatric gastroenterologist assigned who is responsible to assure
the excellence of medical care and to supervise and teach pediatric house staff
(residents and fellows) involved in the care of that patient. These levels of supervision include:
Direct Supervision – The supervising
physician is physically present with the fellow and patient.
i) with direct supervision immediately
available – The supervising physician is physically present within the hospital
or other site of patient care, and is immediately available to provide direct
ii) with direct supervision available – The
supervising physician is not physically present within the hospital or other
site of patient care, but is immediately available by means of telephonic
and/or electronic modalities, and is available to provide direct supervision.
PGY 1 residents are supervised either directly or indirectly with direct
supervision immediately available while they acquire basic knowledge and skills
specific to the specialty. Activities of PGY 2 residents and above (including
fellows) are supervised by any level of supervision, as appropriate to the
patient situation and the capacity of the resident or fellow. Supervision does
not equate merely to the presence of more senior physicians nor with the
absence of independent decision making on the part of residents and fellows.
These supervision standards encompass the concepts of graded authority,
responsibility and conditional independence that are the foundation of
delegation of authority to more senior house staff members. Should a fellow
ever need assistance or information, they can contact the faculty on call.
work hours are monitored by the Fellowship Program Director and Fellowship
Coordinator by means of a work hour record on MedHub that fellows are expected
to complete weekly. The pediatric gastroenterology fellowship training program
does not include in-house overnight call. The work hours are designed such that
hours worked will fall within the ACGME rules for resident/fellow work hours:
no more than 80 hours per week when averaged over 4 weeks and one day off in
seven when averaged over 4 weeks.
fellows will report any concerns about work hours directly to the Fellowship
Specific duty hour requirements are as follows:
Maximum Hours of Work per
Week: The duty hours of any resident
or fellow must be limited to 80 hours per week (or other applicable limit as
specified by the appropriate Residency Review Committee (RRC), when averaged
over a 4-week period, inclusive of all in-house call activities and any
moonlighting activities. Any time spent in the UIHC or at another institution
for clinical and academic purposes, related to the residency or fellowship
program, both inpatient and outpatient, shall count toward the weekly maximum. Additionally, the weekly maximum shall
include time spent for administrative duties related to patient care, the
transfer of patient care, scheduled academic activities such as conferences,
research related to the program, and any time the resident spends on-site after
being called in to the hospital. Not
included in the weekly maximum is time spent outside of UIHC (or outside
another institution related to the program’s academic purposes) for academic
preparation, reading, and studying.
Duty Period Length:
PGY 1 residents– scheduled duty periods must not
exceed 16 hours in duration.
PGY 2 and above residents – no schedule shall
exceed a maximum of 24 hours of continuous duty in the hospital, with no more
than 4 additional hours used for any transitional activities (i.e. maintaining
continuity of medical and surgical care, transferring patient care, or
attending educational sessions).
In no event shall the PGY 2 or above resident
accept a new patient (any patient for whom the resident has not previously
provided care) during this 4-hour extension period.
PGY 2 or above residents must not be assigned
additional clinical responsibilities after 24 hours of continuous in-house
In unusual circumstances, PGY 2 and above
residents, on their own initiative, may remain beyond their scheduled period of
duty to continue to provide care to a single patient. Justifications for
such extensions of duty are limited to reasons of required continuity for a
severely ill or unstable patient, academic importance of the events transpiring
or humanistic attention to the needs of a patient or family. Residents must
appropriately hand over the care of all other patients to the team responsible
for their continuing care.
Any resident exceeding maximum duty period lengths
will document their justification in the institution’s resident/fellow
management system (i.e. MedHub).
To facilitate handoffs, the Pediatric
Gastroenterology fellowship program has created a hand off
inpatient/consultation list located on EPIC (under patient lists) to ensure the
best possible patient care.
Frequency of Over-Night In-House On-Call Duties: In-house call must
not be scheduled more frequently than every third night when averaged over a
4-week period however this is not applicable to our fellowship training program
as fellow responsibilities do not include over-night in-house on-call duties.
Frequency of In-House Night Float: Residents must not be scheduled for more
than six consecutive nights of night float or as specified further by the
program’s RRC, as applicable, however this is not applicable to our fellowship
training program as fellow responsibilities do not include in-house night float
Time Free of Duty: Fellows must be scheduled for a
minimum of one day free of duty every week (when averaged over four
weeks). This day off shall not include
home call nor shall the fellow be required to carry a pager. A day is defined
as 24 consecutive hours.
Time Off between Scheduled Duty Periods:
Based on the level of the resident, there are identified levels of time
off between scheduled duty periods.
– should have 10 hours, and must have 8 hours, free of duty between scheduled
Intermediate level residents (as defined by the
program’s RRC) – should have 10 hours, and must have 8 hours between scheduled
duty periods. They must have at least 14 hours free of duty after 24 continuous
hours of in-house duty.
Final year residents (as defined by the program’s
RRC) – can participate in transition to practice activities when they are
preparing to care for patients over irregular or extended periods. It is still
desirable that these residents have 8 hours free of duty between scheduled duty
periods, but there may be circumstances where residents must stay on duty to
care for their patients or return to the hospital after shorter intervals.
The Program Director monitors time off between
scheduled duty periods.
call: Fellows returning to the
hospital from home call must count their time spent in the hospital towards the
80-hour maximum weekly hour limit. The frequency of home call is not subject to
the every-third-night limitation but must satisfy the requirement for 1 day in
7 free of duty, when averaged over 4
Home call activities must not be so frequent as to
preclude rest and reasonable personal time for each fellow.
Fellows are permitted to return to the hospital
while on home call to care for new or established patients. Each episode of
this type of care, while it must be included in the 80-hour weekly maximum,
will not initiate a new “off-duty period.”
8. Moonlighting: Moonlighting
is governed by the Moonlighting Policy and Procedures for House Staff
Physicians and Dentists. All
requirements of that policy must also be followed, including visa and license
requirements. In order to ensure against any adverse effects on the
fellow's educational or clinical program, the following departmental policy has
been established for fellows wishing to moonlight:
A. Each fellow wishing to moonlight must submit a
single request in writing to the Fellowship Program Director and the Department
Head. The request will set forth the circumstances necessitating moonlighting.
The form for making such a request may be obtained from the Fellowship Program
Director. The Fellowship Program Director and Department Head will evaluate and
respond to such requests on an individual basis.
B. Fellows must have a permanent physician's
license to moonlight outside of the institution.
C. Fellows must possess adequate professional
liability insurance. The professional
insurance protection provided by the State Tort Claims Act does not protect the
fellow when he or she is engaged in clinical practice outside of the scope of
the training program. The house staff
member is responsible for obtaining appropriate medical
malpractice/professional liability coverage for moonlighting activities. Evidence of such insurance is required before
approval is granted.
D. Moonlighting is limited to times when fellows
are not on the inpatient clinical rotation (allowed during research rotations)
E. Moonlighting is allowed in a pediatric setting
F. Total hours worked, including those hours
worked as part of the training program and those hours devoted to moonlighting,
must not exceed the standard set by the Pediatric Residency Review
Committee/ACGME. These standards state
that each resident/fellow should have a monthly average of one day out of seven
without clinical responsibilities and work no more than 80 hours per week on
average, when averaged over four weeks. Moonlighting at UIHC counts toward the
80 hour work week. Because of this
requirement, moonlighting is allowed only during research rotations.
G. Any fellow wishing to moonlight must have
passed the American Board of Pediatrics Exam or obtained scores on the American
Board of Pediatrics In-Training Examination which indicate the likelihood of
passing the board exam after training is completed (currently: PL2 exam score ≥ 300; PL3 exam score ≥ 360).
It should be
Moonlighting is never required and must not
interfere with the ability of the fellow to achieve the goals and objectives of
the educational program.
The fellow must obtain permission of his/her
Fellowship Program Director prior to the beginning of such activities. All approved requests must be filed with the
Time spent by fellows in internal and external
moonlighting must be counted toward the 80-hour maximum weekly hour limit.
Failure to completely document all time in moonlighting activities will result
in suspension of the moonlighting privilege.
PGY 1 residents are not permitted to moonlight.
The pediatric gastroenterology fellowship program meets the requirements
of this policy as well as any applicable standard set by the ACGME, the
appropriate RRC, or other accrediting or certifying body. This
policy is distributed by the GME Office to all GME contract holders. The program also distributes
this policy at the time of orientation. The pediatric gastroenterology
fellowship program monitors fellow duty hours with a frequency sufficient to
ensure compliance with this policy and the ACGME/RRC/other accrediting or
certifying body’s rules.
Riad Rahhal, MD
Clinical Assistant Professor
University of Iowa Children's Hospital
Department of Pediatrics
Division of Gastroenterology
200 Hawkins Dr, 2868 JPP
Iowa City, Iowa 52242
Tel: 319 356 2950
Fax: 319 353 8967