Supervision and Duty Hours
UNIVERSITY OF IOWA HOSPITALS AND CLINICS
PEDIATRIC NEPHROLOGY FELLOWSHIP PROGRAM
RESIDENT SUPERVISION AND DUTY HOURS
The University of Iowa Children's Hospital Pediatric Nephrology Fellowship Program ensures that it provides appropriate supervision for all fellows as well as a d 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 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 and are structured to ensure supervision is readily available to those on duty. Call is no more frequent than that approved by the Pediatric RRC of the ACGME. Call-free months are also built into the program. The following guidelines have been established to assure the appropriate supervision of fellows.
1. Inpatient and Consultative Services
The fellows are expected to make early morning rounds with the pediatric residents assigned to the inpatient services. Any change in status is to be reported directly to the attending nephrologist. The fellow and nephrology faculty will meet during regularly scheduled rounding time with the entire ward team. The fellow will be given increasing degrees of responsibility with the advancement through the three years of training. The fellow will assist the attending in management decisions. Consultations will be initially obtained by the fellow and the information then presented to the attending. The attending will complete their assessment and discuss any differences in findings with the fellow as part of the educational process. The fellow is encouraged to provide input into assessment and medical management.
2. Outpatient Clinic
Fellows are expected to attend their weekly continuity clinic. The exception to this policy is during inpatient service when other clinical obligation precludes attendance. The fellow will initially meet with the patient and family, obtain a complete history and conduct a thorough physical examination. After they have formulated their impression they will meet with the nephrology faculty assigned to the clinic for that day. The information will be presented to the attending and the fellow will be expected to determine appropriate additional tests and complete a management plan.
The fellows act as liaisons between the nephrology attending, medical students and the pediatric and family medicine residents assigned to the inpatient or outpatient rotations. They are to be an immediate source of information and education for the residents and students. In addition to bedside teaching they will be expected to provide didactic lectures on relevant case material.
Nephrology fellows will take night call averaging every 3rd or 4th weekday night and every 3rd or 4th weekend. The call for pediatric nephrology fellows is based from home. They are required to come back to the hospital to see new admissions to the service or to evaluate and assist in the management of any patient who has a change in clinical status. They provide consultative call service to the pediatric intensive care unit, neonatal intensive care unit and other inpatient services. They supervise the resident team assigned to the nephrology service. Fellows are under direct supervision of the inpatient attending assigned to the inpatient nephrology service for weekday or weekend call. The fellow is expected to notify the attending regarding any new admission or change in status of a patient.
The Pediatric Nephrology Fellowship Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every pediatric patient has an attending pediatrician assigned who is responsible to assure the excellence of medical care and to supervise and teach pediatric 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 physically present with the resident and patient.
- Indirect Supervision
i) 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.
ii) 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.
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.
Pediatric Nephrology fellows are expected to notify the attending regarding any new admission or change in status of a patient.
Fellow’s work hours are monitored by the Program Director/Associate Program Director, and Program Coordinator by means of a work hour record on MedHub that the fellow is expected to complete weekly. The work hours for all rotations are designed such that hours worked will fall within the ACGME rules for fellow work hours: no more than 80 hours per week when averaged over 4 weeks; one day off in seven when averaged over 4 weeks and there is at least a 10 hour period free of clinical duty between shifts.
All residents will report any concerns about resident hours directly to the Program Director/Associate Program Directors or via rotational evaluations solicited at the end of every rotation.
Specific duty hour requirements are as follows:
1. Maximum Hours of Work per Week: The duty hours of any fellow 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 Period Length:
- 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 resident has not previously provided care) during this 4-hour extension period.
- In unusual circumstances the fellow, 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 Pediatric Nephrology fellow will handoff care of the patients to the pediatric nephrology staff physician on-call.
3. Maximum Frequency of Over-Night In-House On-Call Duties: There is no in-house call for pediatric nephrology fellows.
4. 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 resident be required to carry a pager. A day is defined as 24 consecutive hours.
5. Minimum Time Off between Scheduled Duty Periods:
- Fellows (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.
6. Home call: 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 resident.
- 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.”
7. 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 fellow’s educational or clinical program, the following policy has been established for fellows wishing to moonlight:
A. Each fellow wishing to moonlight must submit a single request in writing to the Program Director and the Department Head. The request will set forth the circumstances necessitating moonlighting. The form for making such a request may be obtained from the Program Director. The PD and Head will evaluate and respond to such requests on an individual resident basis. Approval can be for no longer than one year and may be revoked during the course of the year pursuant to the program's policy.
B. Fellows 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.
C. Fellows 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 of the scope of the training program. The fellow member is responsible for obtaining appropriate medical malpractice/professional liability coverage for moonlighting activities. Evidence of such insurance is required before approval is granted.
D. Moonlighting is allowed in a pediatric setting only.
E. 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 the Pediatric Residency Review Committee/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 counts toward the 80 hour work week.
It should be noted:
- Moonlighting is never required and must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program.
- The fellow 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 fellows 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 Pediatric Nephrology 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 to all GME contract holders as well as distributed to the fellow at orientation. The Pediatric Nephrology Fellowship program monitors fellowship duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.