The University of Iowa Children’s Hospital, Pediatric Cardiology Fellowship Training 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 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 “fellow” or “house staff member” used in this policy shall refer to fellow and fellow physicians at all house staff 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 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. All fellow call is from home.
The following guidelines have been established to assure the appropriate supervision of house staff:
1. Inpatient Service
All patients admitted to the cardiology inpatient service are assigned an attending. The assignment to this pediatrician is made at the time of admission, regardless of the time of day. Faculty are notified of all admissions and work with the fellows to develop a working diagnosis and treatment plan to encourage the fellows' independent diagnostic and management plans. The timeliness of the notification of the attending depends upon the unit and the urgency of the problem. Daily attending rounds are made by the faculty who remains actively involved in directing patient care. The fellows are given progressively increasing responsibility, while continuously maintained under faculty supervision.
2. Outpatient Service
Cardiology Faculty staff the outpatient clinic on a daily basis. Each fellow is assigned a clinic one half day per week that rotates every six months to ensure teaching and exposure to the range of faculty and sub-specialties. All patients are evaluated and cared for by the Faculty are involved in the evaluation and care of all outpatients. Gradated levels of involvement and decision making are given to fellows through their training.
3. Cardiac Catheterization, Electrophysiology, and Echocardiography Laboratories
Fellows rotate in the cardiology subspecialty laboratories. Faculty staff the laboratories at all times, are present for all interventional procedures and are involved in the care and data interpretation for all patients. Graduated levels of involvement, data analysis and decision making are given to fellows through their training.
The Pediatric Fellowship program demonstrates that the appropriate level of supervision is in place for all patients cared for by all fellows. 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 is physically present with the fellow 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.
1st 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 2nd year fellows and above are supervised 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 house staff members. Should a fellow ever need further assistance or information, they can contact the faculty on call.
Fellows work hours are monitored by the Program Director/Associate Program Directors and Program Coordinator by means of a work hour record on MedHub that are expected to be completed monthly by the fellow. All call is from home. 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; post call, and at least a 10 hour period free of clinical duty between scheduled shifts.
All fellows will report any concerns about fellow 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:
- 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 fellowship program, both inpatient and outpatient, counts toward the weekly maximum. Additionally, the weekly maximum includes 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:
No schedule exceeds 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 does 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, 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 fellow management system (i.e., MedHub).
The Cardiology Fellowship Program has minimized the number of hand-offs, and has an inpatient data sheet to ensure the best possible patient care.
- 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. All call is from home.
- Maximum Frequency of In-House Night Float:
Fellows must not be scheduled for more than six consecutive nights of night float or as specified further by the program’s RRC, as applicable. Night float is not a component of the Pediatric Cardiology Fellowship Program.
- 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 does not include home call nor is the fellow is required to carry a pager. A day is defined as 24 consecutive hours.
- Minimum Time Off between Scheduled Duty Periods:
The Program Director monitors time off between scheduled duty periods.
Fellows in the Pediatric Cardiology Fellowship Program are all PGY4 or beyond. Fellows have 10 hours free of duty between scheduled duty periods, but there may be circumstances where fellows must stay on duty to care for their patients or return to the hospital after shorter intervals.
- 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 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. In order to ensure against any adverse effects on the fellow's educational or clinical program, the following departmental policy has been established for pediatric 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 fellow 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 fellow when he or she is engaged in clinical practice outside of 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 granted.
D. Moonlighting is allowed in a pediatric setting only. (Chief Fellows are technically faculty or fellows and, as such, may also request permission to moonlight.)
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 fellow 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. Because of this requirement, moonlighting is allowed only during elective rotations in the PL3 year.
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.
The Pediatric 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. The Pediatric Fellowship also distributes this policy at the time of interview and orientation. The Pediatric 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.