Neurosurgery Residency Conflict Resolution Policy
Purpose:
To provide a general overview of the resident roles, responsibilities and functions while serving as a trainee in the Department of Neurosurgery at Augusta University. This is meant to address issues relating to degrees of independent clinical practice, interactions with and supervision by faculty, performance of procedures and interactions with or supervision of other house staff or medical students. It is expected that residents will demonstrate ongoing maturity during each training year.
Delineation of Resident Responsibility for Patient Care
Overview:
Residents play a fundamental role in providing care to patients with neurosurgical disorders. The role they play is instrumental to their learning and development. The following list of responsibilities is meant to provide a framework to facilitate the residents understanding of expectations related to patient care. All actions taken related to patient care must first be approved by the attending physician of record.
1. Performance and documentation of complete history and physical examinations of patients evaluated in the inpatient, outpatient, operating theater, and emergency room settings
2. Reconciliation of medications in the inpatient and outpatient setting
3. Enter orders into the electronic medical record for admission, discharge, and transfer of patients
4. Relay information concerning patients’ condition, concerns, and plans of care to appropriate members of patients’ families or designees after discussion with attending physician
5. Obtain consents for procedures as directed by the attending physician
6. Obtain consultations from required services as directed by the attending physician
7. Round on inpatients on a daily basis and document condition, plan of care, and any pertinent information after discussion with the attending physician
8. Review all diagnostic studies in a timely manner and relay pertinent results to the attending physician
9. Perform credentialed bedside procedures (epriv webpage) with either direct or indirect supervision following approval from the attending physician
10. Screen and provide instruction to patient calls through the physician’s answering service consistent with standards of care. For nonurgent calls relay details of communication via email to attending physician of record. Emergent calls should be instructed to present to the emergency room for evaluation. If the house officer has questions concerning appropriate instruction they should be addressed with attending of record or attending on call if after hours, on weekends, or holidays.
Progressive Responsibility Policy
In general, the roles, responsibilities and functions of a Department of Neurosurgery resident, per training year, are as follows:
PG-1 - Patient Management, Basic operative skills, Critical Care
PG-1 clinical year is organized to introduce residents to basic general surgery problems. The objectives are to:
• Expose the resident to the breadth of Neurological Surgery • Provide the fundamentals of basic science needed by the neurosurgical resident
Master preoperative and postoperative patient care, in both the in-patient and the out-patient settings Instill the basics of caring for critically ill patients in the ICU Train the resident in basic surgical techniques and introduce more advanced skills
PGY 1 residents require Direct Supervision until competency is demonstrated for:
Patient Management Competencies:
1. Initial evaluation and management
2. Evaluation and management of post-operative complications
3. Evaluation and management of critically-ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing and other treatments.
Procedural Competencies:
a. Central venous access placement
b. Arterial catheterization d. External Ventricular Drains
e. Lumbar drains
f. lumbar punctures
g. shunt taps and programming
h. cervical traction
i. airway management
PGY 1 residents require Indirect Supervision for:
1. Patient Management Competencies:
1. Evaluation and management of a patient admitted to hospital, including initial history
and physical examination, formulation of a plan of therapy, and necessary orders for
therapy and tests.
2. Pre-operative evaluation and management, including history and physical examination,
formulation of a plan of therapy, and specification of necessary test.
3. Evaluation and management of post-operative patients including the conduct of
monitoring and orders for medications, testing and other treatments
4. Transfer of patients between hospital units or hospitals
5. Discharge of patients from the hospital
6. Interpretation of laboratory results
PGY-2 and 3 – Patient Management and Leadership, Advanced Operative skills
PGY 2 – 3 residents who demonstrate good performance may be given responsibility for independent judgment and surgical decision-making with continued attending supervision.
The PG2 resident is responsible for day-to-day care of neurosurgical patients and patients they follow as consultants. They will be supervised at all times by senior residents and faculty. The major goal of the second year of residency is to allow graded responsibility for patient care, including instruction in pre- and postoperative care, and the evaluation and management of patients seen in consultation. The PGY-2 will gain additional valuable experience in the operating room both as an assistant and as the primary surgeon on uncomplicated minor surgeries.
By the third year, residents may be given more responsibility for evaluating surgical patients in the emergency room, initiating preoperative treatment and arranging for further surgical care. In addition, PGY 3 residents are more involved with the technical aspects of the surgery in the operating room.
The goal for the PGY-3 residents is to expose them to some of the more complex aspects of clinical neurosurgery and to develop the clinical judgment necessary to decide who needs an operation, what operation, and the appropriate timing. PGY-3 residents are expected to master basic surgical techniques as well as more advanced techniques. Leadership and supervisory skills are further developed.
Outpatient objectives
· Able to evaluate and treat patients with most neurosurgical diseases
· Develop surgical skills in ambulatory procedures
· Master outpatient postoperative follow-up
Inpatient objectives
· Assume increased responsibility for surgical decision making
· Perform moderately complex surgeries
PGY4 PGY5 PGY6 PGY7– Coordination of Patient Management, Advancement of Independent management and operative Skills, Leadership, Role Model
These years of clinical training are designed to provide residents with an extensive operative experience. The PGY-6 and PGY-7 residents are team leaders (chief residents) and under the supervision of the faculty they supervise junior residents and make decisions about patient care. They perform complex operations under the supervision of the faculty. These senior residents are expected to exercise increasing degrees of independent responsibility for surgical decision-making and perform more advanced surgical procedures, while attending surgeons monitor their progress and continue to supervise the service. Senior residents are allowed and encouraged to exercise independent surgical judgment to the degree that is consistent with good patient care. The goal of these years is to transition the individual from a resident to an independently practicing surgeon. It is expected that residents will be able to:
· Identify high-risk patients and anticipate perioperative problems.
· Possess a thorough knowledge of anatomy.
· Recognize and understand the indications for surgery
· Discuss options in managing neurosurgical pathology, and guide clinical decision making with appropriate imaging and exams. Gain more specific knowledge of neurological surgery.
· Develop leadership skills of a surgical team: identify strengths and weaknesses of team members, provide feedback to all team members, identify one’s own strengths and weaknesses in leadership skills, balance educational and service needs of all team members
· Function more independently in patient and critical care management.
· Increase critical decision-making skills.
· Ensure that junior house staff and students participate in the educational activities of the service at a level appropriate to their level of training.
· Hone interactive skills with patients, families, and ancillary staff.
· Present a cogent linkage of basic research experience with clinical surgical problems at a forum of peers, such as during management conferences, morbidity and mortality conference and Grand Rounds.
· Increase proficiency and ability to do independent work-ups, determine the need for surgery, and determine special requirements for Postoperative Care.
Research Residents
Residents in the research year are expected to spend one year conducting basic and/or clinical research. The specific objectives of the research experience are to:
· Learn the fundamentals of research study design
· Learn basic research techniques
· Learn clinical study design
· Master the fundamentals of statistics as they apply to basic and clinical research
· Hone computer skills, including how to develop and manipulate database and spread sheet programs, statistical programs, and graphic programs
· Prepare oral and written scientific presentations
· Participate in a regular reading program and teaching conferences
· Participate in patient safety, quality improvement and administrative committees
The research experience also allows time for thoughtful reflection and specific planning of the resident’s future career, including investigating fellowship opportunities and practice possibilities
Supervision of Residents
Overview:
The Augusta University Neurosurgery Residency Program follows the principle that supervision is necessary at all resident levels but recognizes that a delicate balance exists in which graduated responsibility and opportunity to make decisions is vital to the growth and development of surgical judgment by the resident. The principle of graduated responsibility under supervision begins in the PGY-1 year with resident credentialing in critical skills and progression from specific to general supervision. As residents gain knowledge, proficiency in manual and problem solving skills, and demonstrate acquisition of good judgment, the intensity of supervision decreases to foster independent decision-making.
Supervision Policy:
The program recognizes the ACGME's three classifications or Levels of Supervision:
1. Direct Supervision: The supervising physician is physically present with the resident and patient.
2. Indirect Supervision:
1. With direct supervision immediately available: The supervising physician is physically within the confines of the site of patient care, and is immediately available to provide Direct Supervision
2. With direct supervision available: The supervising physician is not physically present within the confines of the site of the patient care, but is immediately available via phone and/or electronic modalities, and is available to provide Direct Supervision.
3. Oversight: The supervising physician is available to provide review of procedure/encounters with feedback provided after care is delivered.
Outpatient clinics:
Each outpatient clinic is staffed by a surgical attending. Every patient that is evaluated by a neurosurgical resident is done so under attending direct or indirect supervision. Notes may be dictated
by the attending or the resident. If the resident dictates the clinic note, it is read, amended as appropriate and counter-signed by the attending with the appropriate teaching attestation. On occasion, a patient may be seen in clinic or the Emergency Department when the designated attending is not presently available (e.g., scrubbed in the OR). In these instances, the resident will contact the attending at the time of the evaluation, discuss care and disposition and dictate the appropriate note to be counter-signed by the attending.
Inpatient Care:
Similarly, each inpatient has an assigned attending who is responsible for the care of each patient and provides direct or indirect supervision to the residents. Every patient that is evaluated by a neurosurgical resident is done so under the oversight of an attending. Daily care plans are discussed prior to implementation. Notes may be dictated/written by the attending or the resident and handled as with clinic notes.
Operating Room:
Each patient has an attending responsible for his/her care who provides immediate direct supervision in the conduction of operations assisted by the resident staff. The supervising physician shall be physically present during the critical portion of each surgical procedure. Operative Notes may be dictated by the attending or the resident. If the resident dictates the note, it is read, amended as appropriate and counter-signed by the attending with the appropriate teaching attestation.
Only members of the Medical Staff who have been granted appropriate privileges and who have been selected by the Residency Program Director shall supervise residents.
Attending Notification:
Any significant change in a patient’s condition should be reported immediately to the appropriate attending physician. “Significant changes” in the patient’s condition include:
• Admission to hospital of any unstable patient
• Transfer of the patient to the intensive care unit
• Need for intubation or ventilatory support
• Cardiac arrest or significant changes in hemodynamic status
• Development of significant neurological changes
• Development of major wound complications
• Medication errors requiring clinical intervention
• Any significant clinical problem that will require an invasive procedure or operation
A resident may request the physical presence of an attending at any time and is never to be refused. Attendings will be available for immediate consultation by pager/phone 24 hours a day.
Residents must be aware of the supervisory lines of responsibility. If there is a serious concern related to supervision or any other aspect of the training, any resident can bypass the supervisory lines and communicate directly with the Program Director or the Chairman of the Department of Neurosurgery.
Duty Hours
The program director has established an environment that is optimal for both resident education and patient care, while ensuring that undue stress and fatigue among residents is avoided. Residents will not be required to perform excessively difficult or prolonged duties regularly. Residents work schedules will be designed so that, on average, excluding exceptional patient care needs, residents will average at least 1 day out of 7 free of routine responsibilities and be on-call in the hospital no more often than every third night. Different rotations may require different working hours and patterns. There will be adequate backup so that patient care is not jeopardized during or following assigned periods of duty. Moonlighting is not allowed during residency training.
A distinction is made between on-call time in the hospital and on-call availability at home vis-a-vis actual hours worked. The ratio of hours worked to on-call time will vary, particularly at the senior levels, and therefore necessitates flexibility.
During on call hours, residents will be provided with adequate sleeping, lounge, and food facilities. Support services will be such that the resident does not spend an inordinate amount of time in non-educational activities that could be discharged properly by other personnel.
Resident Selection
The Neurosurgery Program will select residents after screening applications, inviting qualified candidates for interviews and evaluation by faculty and current residents. The rank order list will be prepared by the Program Director after consultation with the faculty and residents.
Promotion
A resident will be promoted when, in the opinion of the faculty, the resident has performed acceptably and demonstrated mastery of the knowledge and skills at the current level and has no non-academic performance matters which warrant attention by the Program Director.
Evaluation
Residents will be evaluated, in writing, at least every six months by the faculty. The Program Director will meet with each resident to discuss the evaluation.
The residents are required to take the American Board of Neurological Surgeons written exam for self assessment yearly, to pass the self assessment exam prior to taking it for credit and to pass the written boards prior to becoming Chief Resident (PGY 6).
Dismissal
The Program Director has broad latitude to act for the good of the program, in the interest of patients and as a resident advocate.
A resident who fails to perform satisfactorily may be counseled by the Program Director and other faculty as needed. A period of probation and performance goals may be established by the program director and approved by the faculty. A resident who fails to meet the established goals during the period of probation may be dismissed. This information will be communicated with the resident and documented in the file.
A resident may be dismissed when the Program Director finds academic deficiencies or non-academic performance difficulties which cast grave doubts upon the resident's potential capacities as a physician.
A resident will be afforded appropriate due process when the circumstances warrant it.
Resident Fatigue and Stress
The goal of this policy is to assist the Department of Neurosurgery in its support of high quality education and safe and effective patient care. The Department of Neurosurgery is committed to meeting the requirements of patient safety and resident well being. Excessive sleep loss, fatigue and resident stress are serious matters. In the event that any resident experiences fatigue and/or stress that is interfering with his/her ability to safely perform his/her duties, they are strongly encouraged and obligated to report this to his/her senior resident or attending on service.
Appropriate backup support will be provided when patient care responsibilities are especially difficult and prolonged, and if unexpected needs create resident fatigue sufficient to jeopardize patient care during or following on-call periods.
All attendings and residents are instructed to closely observe other residents for any signs of undue stress and/or fatigue. Faculty and other residents are to report such concerns of sleepiness, tardiness, resident absences, inattentiveness, or other indicators of possible fatigue and/or excessive stress to the supervising attending and/or Program Director. The resident will be relieved of his/her duties until the effects of fatigue and/or stress are no longer present.
TRANSITIONS OF CARE POLICY
Programs must design clinical assignments to minimize the number of transitions in patient care. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.
Programs must ensure that residents are competent in communicating with team members in the hand-over process. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care.
All patient orders, results, medications, progress and consult notes are located in our EMR systems at the various sites and all patients must have a medication reconciliation when they are transferred between care settings or services at all of our institutions. This helps to alleviate opportunities for loss of information and continuity during transitions of care. Ultimately as is designated in our supervision policy the attending physician is responsible for the care of any individual patient. We do however recognize that transitions of care occur between house staff as they come on and off shifts in order to minimize these effects our program encourages the following steps to minimize transitions, errors during transitions, and to maximize patient care:
Designate a quiet space where transitions of care occur. This room should: Include computers so residents can access medical information using the hospital EMR Allow for private uninterrupted discussions about each individual patient.
Reduce interruptions during transition of care.
The chief or senior resident on the service oversees the transition of care process If an interruption occurs, residents should begin the discussion of the patient again.
Use computerized templates (patient database list) for all transitions of care.
These Electronic templates that are generated from the hospital EMR system and have pre-populate patient information, such as:
• Patient name
• Medical record number
• Date of birth
• Room number
• Date of admission
• Primary diagnosis
• Attending physician of record.
Residents should review every patient during the transition of care.
Verbally identify each patient List the major medical issues and the to-do list the covering practitioner needs to
complete. Avoid nonstandard abbreviations. State all of the anticipated problems that may arise. The receiver should be an active listener, take notes, and should verify all of the items on the to-do list to ensure that they understood everything Verify that they know the contact information of the attending physician of record
Identify sick patients upfront.
If the patient is sick or the team is particularly concerned, the giver should say that at the beginning of the patient's transition of care
This helps to ensure that the physician receiving the information understands the seriousness of the situation and asks the appropriate questions.
If appropriate the resident or residents may see these patients together at the conclusion of the sign out discussions.
Explain the rationale.
· Residents handing off patients to another physician should explain their rationale for each management plan.
· Use if-then scenarios during transitions of care.
· Focus the discussion on contingencies (e.g., if patient reacts this way, do X; if patient reacts that way, do Y)
· Give the receiving physicians a clear understanding of what they should consider doing during their shift.
· Empower givers and receivers.
· Both parties should feel comfortable enough to ask the other practitioner to slow down or elaborate
The site directors, service chiefs, and program director will periodically monitor these transitions to ensure compliance with the above.
