Supervision & Duty Hours

University of Iowa Hospitals and Clinics

Policy

FOR

Pediatric Gastroenterology fellow Supervision and Duty Hours


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.)

SUPERVISION

The 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.

The 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 problem.

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 supervision. 

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 clinics.

3. Pediatric Gastroenterology procedures

Faculty 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.

4. Research

Each 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.

·         Indirect Supervision

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 supervision.

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.

 

DUTY HOURS

Fellow 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.

All fellows will report any concerns about work hours directly to the Fellowship Program Director.

Specific duty hour requirements are as follows:

1.            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.

2.         Maximum 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 duty.

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.

3.         Maximum 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.

4.         Maximum 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 duties.

5.         Mandatory 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.

6.         Minimum Time Off between Scheduled Duty Periods:  Based on the level of the resident, there are identified levels of time off between scheduled duty periods.

·         PGY 1 residents – should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.

·         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.

7.         Home 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 weeks.

·         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 only.

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 noted:

·         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 GME Office. 

·         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.

Sincerely,
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
riad-rahhal@uiowa.edu

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