Policy for Gynecologic Oncology Fellow Supervision and Duty Hours
The University of Iowa Gynecologic Oncology Fellowship Program ensures that it provides appropriate supervision for all fellows, as well as a duty hour schedule and a work environment that optimizes quality patient care, fortifies the educational trajectory of fellows, 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 term "fellow" used in this policy shall refer to fellow physicians at all levels.)
The clinical activities of all fellows are supervised by teaching staff in such a way as to ensure that fellows assume progressively increasing responsibility according to each fellow’s level of education, ability and experience. The teaching staff determines the level of responsibility accorded to each fellow. On-call schedules for teaching staff are structured to ensure supervision is readily available to those on duty. Each fellow, regardless of level of training, is directly supervised by the attending teaching staff.
The following guidelines have been established to assure the appropriate supervision of fellows:
Inpatient Gynecologic Oncology Service
All patients admitted to the Gynecologic Oncology inpatient service are assigned an attending gynecologic oncology staff. This assignment is made at the time of admission, regardless of the time of day. The fellow is instructed to notify the attending staff of every admission to the service and make the staff aware of the condition of all seriously ill patients on the service. The attending staff is notified of the admission of stable patients soon after the fellow develops a working diagnosis and treatment plan. The timeliness of the notification of the attending depends upon the urgency of the problem.
Daily attending rounds are made by the faculty who remains actively involved in directing patient care. The fellow is given progressively increasing responsibility in clinical care and in the supervision of the general OB/GYN residents on the service, while continuously remaining under faculty supervision. The daily census is typically between 10 and 20 patients. The fellow who is on call for any given day will assume responsibility for the care of these patients, at a level appropriate for the fellow’s learning, with the help of the 2 or 3 OB/GYN residents on the service, and under the direct supervision of the attending staff. There is an attending staff available 24 hours a day for consultation and to be physically present if required. The fellows know which gynecologic attending is on call and how to reach the attending at any time via the pager system or the hospital operator.
Operating Room Service
All patients who undergo inpatient or outpatient surgical procedures are assigned to a gynecologic oncology attending staff physician. The attending is responsible for the patient’s surgical care, and will determine the appropriate level of involvement in the procedure by the fellow, based on the fellow’s experience and level of training. The attending physician is physically in the operating room for all the key portions of the procedure, and is immediately available at all times during the procedure.
Faculty members from the Division of Gynecologic Oncology are assigned to staff the gynecologic oncology clinic on a daily basis. Each fellow participates in one day of clinic per week. The fellows can do the initial evaluation of new and return patients. They then present this to the attending physician who examines the patient with the fellow and formulates a management plan. All decisions with respect to recommendations for treatment and management are ultimately made by the attending staff. Fellows can do office procedures as directed by the attending physician, with the staff physically present or immediately available.
Fellows may be called to the Emergency Treatment Center (ETC) to evaluate patients. The gynecology oncology staff physician on call provides supervision, and is available to evaluate the patient in the ETC if necessary.
Each fellow spends one month in the Radiation Oncology Department, and one month in the Surgical Intensive Care Unit. The care of patients during these rotations is directly supervised by the attending physician staff of these departments.
The Gynecologic Oncology Fellowship Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every gynecologic oncology patient has an attending staff physician assigned who is responsible to assure the excellence of medical care and to supervise and teach the fellows involved in the care of that patient. The 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 is physically present with the fellow and the patient
- Indirect Supervision:
- with direct supervision immediately available – The supervising physician is physically present within the hospital or other site of patient care, and is immediately available to provide direct supervision
- with direct supervision available – The supervising 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
During the first year fellows are supervised either directly or indirectly with direct supervision immediately available while they acquire basic knowledge and skills specific to the specialty. Activities of second year and above fellows are supervised by any level of supervision, as appropriate to the patient situation and fellow 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 fellows. These supervision standards encompass the concepts of graded authority, responsibility and conditional independence that are the foundation of delegation of authority to more senior fellows. For further information or assistance the fellows should contact the appropriate gynecologic oncology attending physician. All major treatment decisions especially involving surgery, chemotherapy, radiation therapy or transition to palliative care and DNR orders must be communicated with the attending staff.
Fellows work hours are monitored by the Program Director by means of a work hour record that fellows are expected to complete weekly, preferably into the electronic information system https://uiowa.medhub.com. The work hours are designed such that hours worked will fall within the ACGME rules for work hours: no more than 80 hours per week when averaged over 4 weeks; one day off in seven when averaged over 4 weeks; there is no in-house night call for fellows. Fellows taking at-home call will be provided with one day out of seven completely free from all educational and clinical responsibilities, averaged over a four-week period. When fellows are called into the hospital from home, the hours the fellow spent in-house are counted toward the 80- hour limit.
The fellows will report any concerns about hours directly to the Program Director.
Specific duty hour requirements are as follows:
Maximum Hours of Work Per Week
The duty hours of any fellow must be limited to 80 hours per week when averaged over a 4-week period; it is noted that there are no in-house call activities and that there is no moonlighting. Any time spent in the UIHC or at another institution for clinical and academic purposes, related to the 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 fellow 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
- For the fellows, 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 fellow accept a new patient (any patient for whom the fellow has not previously provided care) during this 4-hour extension period.
- Fellows must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
- In unusual circumstances, the fellows, 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. Fellows must appropriately hand over the care of all other patients to the team responsible for their continuing care.
- Any fellow exceeding maximum duty period lengths will document their justification in the institution’s resident management system (i.e. MedHub).
- The number of hand-offs is minimized and occurs through direct communication between fellows. The process is facilitated by the use of a patient care summary and hand-off template available on EPIC.
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
Fellows do not participate in in-house night float.
Mandatory Time Free of Duty
Fellows 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 fellow 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 fellow, there are identified levels of time off between scheduled duty periods.
- First year fellows – should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.
- Second year and above fellows (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.
- The Program Director monitors time off between scheduled duty periods.
Fellows 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 fellow.
- Fellows 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 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. To avoid conflicts with the ability of the fellows to achieve the goals and objectives of the Gynecologic Oncology Fellowship Program, moonlighting is not allowed.
The Gynecologic Oncology Fellowship 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 as well as by the Gynecologic Oncology Program at the time of orientation. The Gynecologic Oncology Fellowship Program 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