Policy and Procedure on Resident Supervision

This policy and procedure delineates the mechanisms for acceptable supervision of neurosurgical residents at the University of Iowa.

It is the policy of the Department of Neurosurgery at the University of Iowa, that all neurosurgical residents, regardless of level of training, be supervised by a faculty member for all clinical activities. Residents are supervised by teaching staff 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.

The philosophy of the Iowa Department of Neurosurgery is that all patients on the neurosurgical service, either inpatient or outpatient, will be assigned an attending surgeon who is responsible for that patient. The attending surgeon has both an ethical and legal responsibility for the overall care of the patient, and for the supervision of the residents involved in the care of that patient.

Proper supervision provides for the safe care of the patient, as well as training of the resident towards independent decision making. The degree of supervision will vary with the clinical circumstances and the training level of the resident. These judgments will be based on the attending neurosurgeon’s direct observation and knowledge of each resident’s skills and abilities. For those instances where the attending neurosurgeon is not in-house, the resident team is instructed on how to contact attending surgeons if needed. Initial supervision is conducted by the team’s Chief Residents.

All neurosurgeons are available by pager. The page operator has available an up to date call schedule with attending pager numbers, home and emergency phone numbers. If a resident at any PGY level finds that there is not a rapid, reliable system for communicating with an attending neurosurgeon, this should be immediately reported to the Program Director or Department Chair.

Overview

Two of our department's core missions are to provide outstanding patient care and train neurosurgery residents. Residents learn to become competent neurosurgeons by participating actively in patient care directed by faculty neurosurgeons. A critical aspect of this learning process involves residents gradually, and systematically assuming more responsibility for the care of patients on the neurosurgery service. The intent of this policy statement is to clarify how this concept is to be implemented in practice.

Attending Neurosurgeon

The staff neurosurgeon is ultimately responsible for the clinical care of all patients on his service. It is the staff surgeon's responsibility to delegate clinical responsibilities to residents in a manner consistent with patient safety and the concept of graded increases in clinical responsibility for residents. Decisions regarding the level of resident participation in an individual patient's care are the responsibility and prerogative of the staff neurosurgeon.

Chief Resident and VA Resident

The most senior residents on University and VA services are responsible for having a comprehensive understanding of all patients on their service. They must understand the indications for all surgical procedures, the rationale for the particular procedure to be carried out, and the plan for perioperative management. The senior residents must be engaged in all clinical decision making for the patients on their service. With the exception of unusual emergency situations, when seeing patients prior to the staff neurosurgeon encounter, the senior resident should formulate his/her own management plan prior to consulting the staff neurosurgeon.

Senior residents must communicate with the appropriate staff neurosurgeon to insure that a clear understanding exists between the senior resident and the staff neurosurgeon regarding clinical management plans, including the role residents will play in the actual clinical care delivered to the patient. The staff neurosurgeon will determine whether the senior resident will function as the primary or assistant neurosurgeon for a given operative case.

Junior Residents

Junior residents are assigned specific duties as the primary physician providing peri-operative medical care to patients on the neurosurgery service. Junior residents are directly supervised by the Chief Resident. The Chief Resident assigns the junior resident graded responsibility for patient care. The individual staff neurosurgeon and Department Head oversee the integrated resident team, and ensure appropriate levels and quality of clinical supervision. For each patient, ultimate responsibility and management prerogatives are those of the staff neurosurgeon.

PGY 7: Fellow Associate Year (2 six-month blocks)

General Neurosurgery Block

Six months of the PGY 7 year are devoted to managing a large general neurosurgery practice. This is an opportunity for the fellow associate (FA) to hone his general neurosurgical skills and make the transition to independent surgery in a maximally supportive setting. The FA member spends one day per week in the outpatient clinic under the supervision of the Department Head and carries out independent elective surgery on all other days.

The FA provides attending/chief resident level coverage for the patients he and the Department Head have admitted to the service. The FA directly supervises junior neurosurgery residents caring for his patients. He has no night call obligations during the week, except under circumstances when a Chief Resident is unavailable to take call. Among his administrative responsibilities, the FA is responsible for the optimal organization and implementation of the departmental teaching conferences.

Subspecialty Neurosurgery Block

Six months are devoted to the pursuit of concentrated subspecialty training. In consultation with the Department Head, the FA is free to arrange a "mini-fellowship" with the University of Iowa attending of his choice or arrange for extramural subspecialty training elsewhere in the United States or overseas. The FA has no call obligations during this time period.

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