Altru Family Medicine Residency

RESIDENCY SUPERVISION POLICY

The faculty is committed to supervision commensurate with resident competency and complexity of care while the educational curriculum and faculty and call schedules are designed to ensure such supervision.  Progressive increase in resident responsibility with independence is provided individually on the basis of expertise in the six ACGME core competencies with incorporation of the family medicine specific milestones and determined by multiple evaluation modalities.  Notwithstanding, patient care complexity may always exceed resident capability and should be recognized.

  1. General Supervision Policy

  1. In each patient assignment, the resident will identify the practitioner ultimately responsible for the patient’s care

  2. That practitioner will be appropriately credentialed for his/her area of expertise.

  3. The resident will introduce himself/herself at the beginning of each patient encounter and inform the patient of his/her role in the healthcare team.

  1. Level of Supervision

  1. Family Medicine Residency Clinic Supervision

    1. Faculty Availability

      1. Faculty supervision is mandated whenever a resident is involved in patient care.

      2. The minimum ratio of faculty to residents actively involved in patient care is 1:4.

      3. Supervising faculty physicians are free from responsibilities that might prevent immediate availability.

      4. Regardless of a resident’s assigned degree of independence, the faculty physician may obtain further history or perform a focused physical examination if either determines additional evaluation is necessary.

    2. PGY-1 residents or upper-level residents who are transferring into the Program will be directly observed.  This observation may be supplemented with patient module(s) in the simulation lab.  Evaluation will be based upon the six core competencies mapped to appropriate milestones.  Evaluations will be reviewed by the Clinical Competency Committee to permit advancement to indirect supervision with direct supervision immediately available within an outpatient setting.

    3. Residents will precept all Medicare patients.

    4. Clinic procedures will have direct supervision until the resident is considered competent to perform the procedure with ‘indirect supervision with direct supervision immediately available’, as a result of faculty evaluation of skill and experience.

  2. Nursing Home Supervision

    1. A nursing home patient assigned to a resident will have an identifiable attending physician ultimately responsible for the patient’s care though the resident is expected to function as an important member of patient’s healthcare team.

    2. Residents will see assigned nursing home patients monthly with documentation in the electronic medical record which will be reviewed by the patient’s attending physician.

    3. PGY-1 residents are assigned one nursing home patient and are not permitted to write orders without discussion with the patient’s attending physician.

    4. PGY-2 and PGY-3 residents are assigned two nursing home patients and provide continuity of care as long as the patient remains in the nursing home.  Such residents are permitted to write orders as their documented competency permits, though any major change in patient’s status is required to be discussed with the attending physician.

  3. Hospital Supervision

    1. Specialty Rotations

      1. Specialty rotations will be directly supervised by the physician preceptor or physician group (i.e. pediatricians for pediatrics) for the rotation.

    2. Family Medicine Teaching Service

      1. Each patient on the teaching service will have an identifiable attending physician ultimately responsible for the patient’s care.

      2. PGY-1 resident is directly supervised while involved in patient care by a family medicine physician or senior resident who has previously qualified to function in a supervisory role. (see stated requirements)

        1. Graded and progressive responsibility is encouraged and ‘indirect supervision with direct supervision immediately available’ is permitted for PGY-1 residents after thorough review of performance and evaluations at CCC meetings. Advancement will be documented in meeting minutes in addition to documentation within the resident file.

      3. Prior to completion of the first year of training, in preparation for advancement to PGY-2 level of training, all evaluations will be reviewed by the Clinical Competency Committee to determine if the resident has performed satisfactorily to permit ‘indirect supervision with direct supervision available’.  Appropriate documentation will be provided in the resident’s file prior to advancement to the second year of training.

      4. PGY 3 residents serve as chief resident on the teaching service with responsibility for assisting in supervision of residents, medical students, educational opportunities and management of service.

      5. Residents at all levels of training and independence are required to directly communicate with the attending physician any major change in patient’s clinical status, transfer of care to a higher level of service (ICU, etc) or initiating end-of-life orders.

  4. Obstetrics

    1. Residents provide continuity of obstetrical care, including prenatal, antenatal and postnatal care, at the Family Medicine Residency Center.

      1. All residents, regardless of level, require preceptor approval of an initial obstetrical visit, intended induction of labor, or any time a pregnancy is deemed to have deviated from normal.

      2. Preceptor approval is required at 28 and 36 weeks gestation.

      3. A resident is required to be present on the labor floor while the patient is in labor.  A patient of the Family Medicine Residency Center will be supervised by the patient’s attending physician but if the primary physician is a resident, then the attending physician will be the second preceptor on duty during the day or the family medicine department physician on call for labor and delivery after clinic hours.  The minimum supervision required is defined below.

    2. Supervision of Labor and Delivery

      1. All patients on the labor floor will have an easily identifiable attending physician, either a member of the OB/GYN department or a family physician with obstetrical privileges.

      2. Direct supervision for residents at all levels of training is required at the time of delivery, for the third stage of labor, as well as at the discretion of the attending physician depending on the resident’s experience and/or complexity of care required to manage the labor.

      3. Circumstances requiring direct notification of the attending physician, include but not limited to: pregnancy related complications (i.e. pre-eclampsia, HELLP syndrome); non-reassuring maternal or fetal status; prior to initiating augmentation for labor dystocia; and postpartum hemorrhage

      4. In-house supervision is available at all times for a PGY-1 resident by either the attending physician, OB fellow, or a senior resident. Senior residents are permitted to function in a supervisory role by successful completion of prior obstetrical rotations during the first year of training.