Policy for Neurology Resident Supervision and Duty Hours
The University of Iowa Hospitals and Clinics, 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 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 “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 a 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.
The Neurology Residency program demonstrates that the appropriate
level of supervision is in place for all patients cared for by all
residents. Every neurology patient has an attending neurologist assigned
who is responsible to assure the excellence of medical care and to
supervise and teach 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 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
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 ever need
further assistance or information, they can contact the senior resident or
faculty on call.
All residents will report any concerns about resident hours directly to
the Program Director/Associate Program Directors or via rotational
evaluation solicited at the end of every rotation.
Residents work hours are monitored by the Program Director/Associate
Program Directors, and Program Coordinator by means of a work hour record
on MedHub that residents is expected to be completed 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 noon 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
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
- 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).
- Neurology residents at the end of the workday who are members
of the stroke and 2BT teams (and if necessary, the VA and UIHC
consult team, as well) should page you to check out. Sign out should
not occur before 5pm on weekdays and should not occur prior to the
work being completed on weekends. The ACGME requires that physician
handoff be done verbally or in person. The Sign-out feature on Epic allows
for a brief amount of information to be entered, both things for the
on-call resident to do, and for the on-call resident to let the team
know what happened overnight. Significant events should be recorded
in a progress note, and conveyed verbally to the team in the
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 six 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
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
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. In order to ensure against any
adverse effects on the resident’s educational or clinical program,
the following departmental policy has been established for Neurology
residents wishing to moonlight:
Moonlighting is never required and must not interfere with the ability
of the resident to achieve the goals and objectives of the educational
- 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 Office.
- 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 1 residents are not permitted to moonlight.
- 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 training program.
- 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 for 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
The Neurology 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 with the GME employment contract. The Neurology Residency also
distributes this policy at the time of orientation. The Neurology
Residency program 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.