Policy for Maternal Fetal Medicine Fellow Supervision and Duty Hours

The University of Iowa Maternal-Fetal Medicine 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.)

Supervision

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.

Program should describe how its house staff members across all levels are supervised during regular rotations, clinical assignments and on-call (in-house/home call) schedules.

Supervision of Maternal-Fetal Medicine (MFM) Fellows:

  • All patient care must be supervised by MFM faculty when cases are high risk and relate to fellowship training requirements. For all clinical assignments, the fellows are always directly supervised by an appropriate attending. This includes duties in our outpatient clinics and our inpatient units.
  • Faculty schedules must be structured to provide fellows with continuous supervision and consultation.
  1. Inpatient Services
    Labor & Delivery Suite – When our fellows are scheduled on the service/labor and delivery rotation, there is always a MFM physician also on service. Both the staff and the fellow will attend patient rounds together each morning. While on labor and delivery, the MFM fellows are responsible for supervising the OB/GYN residents. In turn, the MFM fellows are supervised by the MFM physicians.
  2. Outpatient Clinics
    Fetal Diagnosis & Treatment Unit – Dr. Asha Rijhsinghani is the Director of the AIUM accredited UIHC Fetal Diagnosis and Treatment Unit. This clinic is staffed by 6 registered sonographers, 3 registered nurses, 1 certified genetic counselor and 5 Maternal-Fetal Medicine physicians. The Maternal-Fetal Medicine fellows are responsible for the management and clinical care of patients in this highly specialized clinic under the direct supervision of the MFM physicians. The registered sonographers and qualified physicians will work with the fellow to ensure competence in performing ultrasound evaluation and interpretation at an advanced level. The fellow will be required to explain ultrasound findings to patients, their families, and the referring physicians.
    High-Risk OB Clinic – This clinic is for high-risk obstetrical patients primarily followed at the UIHC as well as those referred for consultation or antepartum care. The OB/GYN residents directly manage the patients in this clinic. The Maternal-Fetal Medicine fellows are responsible for supervising the residents and in turn, the MFM fellows are directly supervised by the MFM physician staffing the clinic.
    Fellows’ High-Risk Continuity of Care Clinic – In this clinic, the fellows have direct management of select high-risk patients with MFM staff supervising them. The high-risk obstetrical patients seen in this clinic are chosen to maximize fellow education and are seen with MFM staff supervision. The fellows are expected to attain training to allow them to become an independent MFM consultant to general OB/GYNS, other specialists, and subspecialists.
  3. On-Call
    The MFM fellows participate in general Maternal-Fetal Medicine night and weekend call. During the first year of fellowship, the fellow is on call along with a MFM physician.
    Within 6 months to 1 year, under the discretion of the MFM Division, the fellow may choose to continue to take call with the MFM faculty or obtain privileges to take general OB call without a MFM faculty in-house, but with continued high-risk back up by the MFM physicians.

The Maternal-Fetal Medicine Fellowship Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents.

All patients seen by MFM fellows have an attending MFM physician supervising and overseeing their care. This physician is responsible in assuring that all patients are receiving excellent medical care and to also teach and supervise the fellow. The level of supervision should be commensurate with the amount of independent function that is designated at each fellow level. Faculty schedules are constructed to provide fellows with continuous supervision and consultation.

These levels of supervision include:

  • Direct Supervision - The supervising physician or dentist is physically present with the resident and patient.
  • Indirect Supervision - Supervision 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.

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.

Insert program’s guidelines for circumstances/events in which residents must communicate with appropriate supervising faculty members.

Fellows in MFM are required to discuss the management of all patients with obstetrical complications with their assigned attending.

Duty Hours

Program identifies/defines how tracks and monitors compliance of duty hours; include how a program tracks/monitors/intervenes when a house staff members needs to stay longer for a single patient’s needs.

All scheduling for fellows, including moonlighting inside and outside the institution, is done by the departmental personnel or the program director’s secretary. The work hours for day and night (on-call) on all rotations are designed such that hours worked will fall within the ACGME rules for resident work hours. Thus, all fellow duty hours can be monitored in real time. Fellows enter their work hours into the MedHub system and the hours are reported and tracked by the program director and/or coordinator.

The fellows are asked to report any concerns about their hours to the Program Director, Dr. Stephen K. Hunter.

Specific duty hour requirements are as follows:

  1. 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.
  2. Maximum Duty Length Period
    • 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).
    Hand-offs occur at the change of shifts. On Labor and Delivery, all hand-offs occur at a team meeting at 7:30 AM and 6:00 PM.
  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.
  4. 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.
  5. 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.
  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.
    • 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 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.
    • 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.”
     
  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.
    Program identifies if any moonlighting is allowed or not during training.
    The Maternal-Fetal Medicine fellows may be approved to moonlight as long as they follow the departmental policy.
    1. Any fellow wishing to obtain moonlighting privileges must first meet with the Program Director and his/her research mentor for permission. Permission for moonlighting is given on an individual basis and will be renewed/reviewed quarterly to semi-annually by the research mentor and the Program Director.
    2. The fellow must have completed a minimum of 6 months of the fellowship.
    3. Because fellowship education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the fellow to achieve the goals and objectives of the educational program. The fellow must demonstrate that he/she is attaining the required clinical skills on a timetable which will enable he/she to acquire all competencies prior to the completion of the fellowship. The fellow’s performance will be monitored for the effect of these activities upon performance and that adverse effects may lead to withdrawal of permission.
    4. The fellow must demonstrate that he/she is on schedule in his/her research project.
    5. The fellow must demonstrate the ability to continue to publish papers and/or presentations at regional and national meetings.
    6. The fellow must demonstrate that the moonlighting commitment will not affect the ability to responsibly carry out all clinical assignments and to attend scheduled conference, meetings, etc.
    7. 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 ABOG/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 and externally counts toward the 80 hour work week.
    8. Moonlighting does not count towards the 10% of time devoted to non-subspecialty or non-research activities.
    9. To comply with the 80 hour work week and to meet all scheduling requirements in the MFM fellowship, external moonlighting will need to be done during the fellows’ scheduled research month.
    10. The fellow must adhere to the department’s moonlighting policy as well as the UIHC policy, including completion of all of the necessary paperwork for each and filing all requests with the UIHC GME Office. The signed paperwork is also kept in each fellow’s permanent file.
     

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 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.

The Maternal-Fetal Medicine Fellowship 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.

The Maternal-Fetal Medicine Fellowship distributes this policy at the time of the incoming fellow’s orientation. The rules and guidelines are also in the fellows’ Policy and Procedure Manual, which is updated yearly and given to each fellow in July. The Maternal-Fetal Medicine Fellowship 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.

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