Policy for Obstetrics and Gynecology Resident Supervision and Duty Hours
The University of Iowa Hospitals and Clinics, Obstetrics and Gynecology 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 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.)
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 Obstetrics and Gynecology RRC of the ACGME. Faculty members are assigned to supervise all resident clinics. Faculty members are assigned to supervise all inpatient services. A supervising faculty physician is in-house twenty-four hours a day, every day of the year. A backup call system from home ensures that additional faculty physicians are always available should additional supervising physicians be needed for patient care.
The following guidelines exist to assure the appropriate supervision of house staff:
- Inpatient Obstetrics and Gynecology Service
All patients admitted to an obstetrics and gynecology inpatient service are assigned an attending general or subspecialty obstetrician/gynecologist. The assignment to this physician is made at the time of admission. The resident physician notifies the attending obstetrician/gynecologist of every admission in a timely manner and provides a clinical summary and plan of management. The attending obstetrician/gynecologist is notified urgently when urgent issues are present.
The attending obstetrician/gynecologist makes daily rounds on each inpatient and remains actively involved in directing patient care. Residents are given progressively increasing responsibility while remaining continuously under faculty supervision.
- Outpatient Obstetrics and Gynecology Service
Faculty obstetrician/gynecologists are assigned to each Obstetrics and Gynecology teaching clinic. The resident continuity of care clinic is staffed by members of the General Obstetrics and Gynecology Division, as is the Colposcopy Clinic, Outpatient Procedures Clinic, and Vulvar Vaginal Disorders Clinic. Scheduled patients are seen by the resident and then staffed by the faculty physician. Subspecialty clinics function in the same fashion with every patient being seen in consultation with a faculty member.
- Emergency Medicine Rotation
Each R1 has a rotation through the Emergency Treatment Center (ETC) at the University of Iowa Hospitals and Clinics. The evaluation and treatment of patients in the ETC is directly supervised by the Emergency Medicine faculty.
- Elective Rotations
R3s and R4s pursue elective rotations which may be at UIHC or elsewhere. All electives must be approved by the Program Director and have specified learning objectives, learning activities, a specific preceptor physician, and evaluation. All electives must meet requirements as set forth by the UIHC GME office. The resident is responsible for obtaining appropriate medical malpractice/professional liability coverage for any electives away from UIHC.
The Obstetrics and Gynecology Residency Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every patient, inpatient or outpatient, has an attending faculty member assigned whose responsibility is to supervise and teach residents involved in that patient’s care and to ensure excellent, appropriate, and evidence-based care. These levels of supervision include:
- Direct Supervision – The supervising physician or dentist is physically present with the resident and patient.
- Indirect Supervision
i) with direct supervision immediately available – The supervising physician or dentist 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 or dentist 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 are supervised by any level of supervision, as appropriate to the patient situation and resident capability. Supervision does not equate merely to the presence of more senior physicians or dentists 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 desire further assistance, guidance or input regarding any patient’s care, s/he may contact a senior resident and/or the faculty member on call.
Resident work hours are monitored by the Program Director/Associate Program Directors, and Program Coordinator by means of a work hour record on MedHub which each resident is expected to complete weekly. Work hours on all rotations are designed such that hours worked will fall within the ACGME requirements as specifically delineated below. In unusual circumstances, residents on their own initiative may remain beyond their scheduled period of duty to continue to provide care to a singles patient. Such unusual circumstances are limited to 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 patient’s family. Any such unusual circumstances are monitored by the Program Director/Associate Program Directors and Program Coordinator.
Residents will report any concerns about resident duty hours directly to the Program Director/Associate Program Directors.
Specific duty hour requirements are as follows:
- Maximum Hours of Work Per Week: The duty hours of any resident 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.
- 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 management system (i.e. MedHub).
- The Obstetrics and Gynecology residency has minimized the number of handovers of patient care in order to ensure continuity of care and patient safety. Handover of patients on labor and delivery is carried out each morning and evening at a specific time. The entire provider team attends, including the staff physician coming on duty. Handover is direct and is accompanied by a printed handover tool as well as utilization of the labor and delivery whiteboard. Each weekday evening, the senior resident from each inpatient team provides an in person handover of all inpatients to the night float chief resident which includes a printed handover tool developed specifically for this purpose. The following morning, the night float chief resident provides handover back to the senior resident on the inpatient team. The same process is carried out on weekends and holidays between the senior resident on each inpatient team and the chief resident on call.
- 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.
- Maximum Frequency of In-House Night Float: Residents must not be scheduled for more than five consecutive nights of night float or as specified further by the program’s RRC, as applicable.
- Mandatory Time Free of Duty: Residents 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 resident be required to carry a pager. A day is defined as 24 consecutive hours.
- 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 (PGY2s, 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 (PG 3 and 4s 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.
- 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.
- Home call activities must not be 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."
- 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. The OB/GYN training program allows moonlighting, but it is rare for a resident in this program to pursue moonlighting. It should be noted:
- Moonlighting is never required and must not interfere with the ability of an OB/GYN resident to achieve the goals and objectives of this educational program.
- PGY 1 residents are not permitted to moonlight.
- The resident must obtain permission of the OB/GYN Program Director prior to the beginning of such activities. All approved requests must be filed with the GME Office.
- The resident must obtain appropriate medical malpractice-professional liability coverage for the moonlighting activities before the approval is granted. The professional insurance protection provided by the State Tort Claims Act does not protect the resident when s/he is engaged in clinical practice outside the scope of the training program.
- Residents must have a permanent physician’s license to moonlight outside of the institution.
- Time spent by residents in 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.
The Obstetrics and Gynecology Residency 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 Obstetrics and Gynecology Residency distributes this policy at the time of interview and orientation. An electronic copy is available on Med Hub. The Obstetrics and Gynecology Residency monitors resident duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.