Policy for Child Neurology Resident Supervision and Duty Hours
of Iowa Children’s
Hospital, Child Neurology Residency Program ensures that it provides
appropriate supervision for all residents, 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 Child
Neurology educational program. 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 refer to resident and fellow
physicians at all house staff levels.)
The clinical activities of all residents are supervised by
teaching staff and/or more advanced house staff members in such a way as to
ensure that residents assume progressively increasing responsibility, according
to each resident’s level of education, ability and experience. The teaching staff determines the level of
responsibility accorded to each resident. 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 Neurology RRC of the ACGME.
Call-free months are also built into the program.
of Iowa Children’s
Hospital, Child Neurology Residency Program demonstrates that the appropriate level of
supervision is in place for all patients cared for by all residents. Every child neurology patient has an
attending neurologist assigned who is responsible to assure the excellence of
medical care and to supervise and teach child neurology 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
Direct Supervision – The supervising child
neurology faculty member is physically present with the resident and patient.
i) with direct supervision
immediately available – The supervising child neurology 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 child neurology 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.
All residents in the Child Neurology Residency Program at
of Iowa have already
completed at least two years of post-graduate education. This post-graduate education is typically in
pediatrics. Therefore, when they enter
the Child Neurology Residency Program, the residents are, at a minimum, at the
PGY 3 level.
Residents in their first year of training in our program
(typically PGY 3) are supervised either directly or indirectly with direct
supervision immediately available while they acquire basic knowledge and skills
specific to the specialty of neurology. Activities of PGY 4 residents and above
are supervised by more senior residents or by faculty, as appropriate to the
patient situation and resident 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 residents. 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 resident ever need further assistance or information, he or
she can contact a more senior resident or the faculty on call.
work hours are monitored by the Program Director and Program Coordinator by
means of a work hour record on MedHub that residents are expected to complete
weekly. The work hours for day and night
duty on all rotations are designed such that hours worked will fall within the
ACGME rules for resident 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, residents are excused by 1100 on the post call day if on an in-patient
service, and 0730 following check out if on an outpatient rotation, unless they
have their continuity clinic that morning.
There is at least a 10 hour period free of clinical duty between shifts.
residents report any concerns regarding resident hours directly to the Program
Director 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 resident must be limited to 80 hours per week, 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 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 that 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:
As noted above, upon entry into the
program, Child Neurology residents are, at a minimum, at the PGY 3 level. During the first year of the program
(typically PGY 3), the resident will have some rotations in which he or she
takes in-house night call. This in-house
call occurs exclusively while the resident is rotating on adult neurology
services. After the first training year,
the residents no longer take any in-house night call.
For all residents, 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
In no event does any resident who is post-call
from in-house duties accept a new patient (any patient for whom the resident
has not previously provided care) during this 4-hour extension period.
Residents are never assigned additional clinical
responsibilities after 24 hours of continuous in-house duty.
In unusual circumstances, PGY 3 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 justification in the institution’s resident management
system (i.e. MedHub).
The Child Neurology Residency program has
minimized the number of handoffs.
Handoffs between residents occur only once per week, at the end of the
resident’s one-week period on call. The
resident going off service and the resident going on service meet face-to-face
to discuss each patient’s hospital course and management plan.
Frequency of Over-Night In-House On-Call Duties: House staff in the Child Neurology Residency
Program take in-house call exclusively while rotating on the adult neurology
service. This in-house call is taken in
rotation with the other junior adult neurology residents. In-house call must not be scheduled more
frequently than every third night when averaged over a 4-week period. Typically, the in-house call occurs no more
frequently than every seventh night.
4. Maximum Frequency of In-House Night
Float: Child Neurology
residents do not participate in in-house night float.
5. Mandatory Time Free of Duty: Residents are scheduled for a minimum of one
day free of duty every week (when averaged over four weeks). During this day off, the resident does not
have in-house or home call, has no mandatory conferences, and is not 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. As noted above,
all residents in the Child Neurology Residency Program are at the PGY 3 level
Residents in the first year of the program
(usually PGY 3) should have 10 hours, and must have 8 hours, between scheduled
duty periods. They have at least 14 hours free of duty after 24 continuous
hours of in-house duty.
Residents in the final two years of the program
(usually PGY 4 and PGY 5) 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
The Program Director monitors time off between
scheduled duty periods.
7. Home call: Residents 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. Typically, while rotating on the
Child Neurology Service, the Child Neurology resident will have two weeks of
home call during a four-week rotation.
Each of these weeks of home call is typically followed by a week free of
Home call activities are never so frequent as to
preclude rest and reasonable personal time for each resident.
Residents 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 resident's educational or
clinical program, the following policy has been established for child neurology
residents wishing to moonlight:
A. Each resident wishing to moonlight must submit
a single request in writing to the Pediatric Neurology Program Director and the
Pediatrics 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
resident basis. Approval can be for no
longer than one year and may be revoked during the course of the year pursuant
to the program's policy.
B. Residents 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
C. Residents must possess adequate professional
liability insurance. The professional
insurance protection provided by the State Tort Claims Act does not protect the
resident 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 forbidden during the first
year of the training program (typically PGY 3) and is limited to the final two
years of the training program (typically PGY 4 and PGY 5 years).
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 Neurology Residency Review
Committee/ACGME. These standards state
that each resident 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 PGY 4 and PGY 5 years.
F. Any resident wishing to moonlight should
discuss the pros and cons with his/her faculty preceptor prior to initiating a
formal request to the Program Director.
It should be noted:
Moonlighting is never required and must not
interfere with the ability of the resident to achieve the goals and objectives
of the educational program.
The resident must obtain permission of his/her
Program Director prior to the beginning of such activities. All approved requests must be filed with the GME
Time spent by residents 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 3 residents are not permitted to moonlight.
The Child Neurology Residency program meets the
requirements of this policy as well as any applicable standard set by the ACGME
and the Neurology RRC. This policy is distributed by the GME
Office to all GME contract holders. In
addition, the Child Neurology Residency Program distributes the
policy at the time of interview and orientation. The
Child Neurology Residency program monitors resident duty hours with a frequency
sufficient to ensure compliance with this policy and the ACGME and Neurology RRC.