Policy for Pediatric Cardiology Fellow Supervision and Duty Hours
University of Iowa Children’s Hospital, Pediatric Cardiology Fellowship Training 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
address 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 “fellow” or “house staff
member” used in this policy shall refer to fellow and fellow physicians at all house staff levels.)
activities of all fellows
are supervised by teaching staff 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 accorded to each fellow. On-call schedules 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. All fellow call is from home.
The following guidelines have been established to
assure the appropriate supervision of house staff:
All patients admitted to the cardiology
inpatient service are assigned an attending.
The assignment to this pediatrician is made at the time of admission,
regardless of the time of day. Faculty
are notified of all admissions and work with the fellows
to develop a working diagnosis and
treatment plan to encourage the fellows' independent diagnostic and
management plans. The timeliness of the
notification of the attending depends upon the unit and 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, while continuously
maintained under faculty supervision.
Cardiology Faculty staff the outpatient
clinic on a daily basis. Each fellow
is assigned a clinic one half day per week that rotates every six months to
ensure teaching and exposure to the range of faculty and sub-subspecialties.
All patients are evaluated and cared for by the Faculty are involved in the
evaluation and care of all outpatients. Gradated levels of involvement and
decision making are given to fellows through their training.
Catheterization, Electrophysiology, and Echocardiography Laboratories
Fellows rotate in the cardiology
subspecialty laboratories. Faculty staff the laboratories at all times, are
present for all interventional procedures and are involved in the care and data
interpretation for all patients. Graduated levels of involvement, data analysis
and decision making are given to fellows through their training.
Pediatric 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
pediatrician assigned who is responsible to assure the excellence of medical
care and to supervise and teach pediatric house staff involved in the care of
that patient. Each clinical service is continuously covered by a faculty member
who is accessible at any time by means of the pager system. 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 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
1st year fellows are supervised either directly or indirectly
with direct supervision immediately available while they acquire basic
knowledge and skills specific to the specialty. Activities of 2nd year fellows and above are
supervised as appropriate to the patient situation and fellow capability. Supervision does not equate merely to the
presence of more senior physicians nor with the absence of independent decision
making on the part of 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 further assistance or information, they
can contact the faculty on call.
Fellows work hours are monitored by the
Program Director/Associate Program Directors and Program Coordinator by means
of a work hour record on MedHub that are expected to be completed monthly by the
fellow. All call is from home. All
rotations are designed such that hours worked will fall within the ACGME rules
for fellow work hours: no more than 80 hours per
week when averaged over 4 weeks; one day off in seven when averaged over 4
weeks; post call, and at least a 10 hour period free of clinical duty between scheduled
All fellows will report any concerns about fellow
hours directly to the Program Director/Associate Program Directors or via
rotational evaluations solicited at the end of every rotation.
Specific duty hour requirements are as follows:
Hours of Work per Week: The
duty hours of any 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 fellowship program, both
inpatient and outpatient, counts toward the weekly maximum. Additionally, the weekly maximum includes
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 fellow 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
Duty Period Length:
No schedule exceeds 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 does the fellow accept a new patient (any patient for
whom the fellow has not
previously provided care) during this 4-hour extension period.
must not be assigned additional clinical responsibilities after 24 hours of
continuous in-house duty.
In unusual circumstances, fellows, 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.
appropriately hand over the care of all other patients to the team responsible
for their continuing care.
Any fellow exceeding maximum duty period lengths will document their
justification in the institution’s fellow management system (i.e., MedHub).
The Cardiology Fellowship Program has minimized the
number of handoffs, and has an inpatient data sheet to ensure the best possible
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. All call is from home.
4. Maximum Frequency of In-House Night
must not be scheduled for more than six consecutive nights of night float or as
specified further by the program’s RRC, as applicable. Night float is not a
component of the Pediatric Cardiology Fellowship Program.
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 does not include home call nor is the fellow is required to carry a
pager. A day is defined as 24
6. Minimum Time Off between Scheduled
The Program Director monitors time off between
scheduled duty periods.
in the Pediatric Cardiology Fellowship Program are all PGY4 or beyond. Fellows
have 10 hours free of duty between scheduled duty periods, but there may be
circumstances where fellows must stay on duty to care for their patients or return
to the hospital after shorter intervals.
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
Home call activities must not be so frequent as
to preclude rest and reasonable personal time for each fellow.
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
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 pediatric fellows wishing to moonlight:
A. Each fellow
wishing to moonlight must submit a single request in writing to the 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 Program Director. The
PD and Head will evaluate and respond to such requests on an individual fellow
basis. Approval can be for no longer
than one year and may be revoked during the course of the year pursuant to the
must have a permanent physician's license to moonlight outside of the
institution. The "resident physician"
license issued by the state is not valid for professional activity
outside the training program.
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
allowed in a pediatric setting only. (Chief Fellows
are technically faculty or fellows and, as such, may also request
permission to moonlight.)
E. 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 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
elective rotations in the PL3 year.
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
The fellow must obtain permission of his/her 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
Pediatric 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
with the GME employment contract. The Pediatric Fellowship also distributes this policy at the time of
interview and orientation. The
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.