This is a general overview of the resident roles, responsibilities and functions while serving as a trainee in the Department of Neurosurgery at Augusta University. It 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.
Jump to: Overview PGY-1 PGY 2 & 3 PGY 4 - 7Research Residents, Supervision & Patient CareDuty Hours & Program Dismissal
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).
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.
Conflict Resolution Policy
Conflict is an expected occurrence during the course of residency training. Conflict can be broadly categorized as task conflict, process conflict, and relationship conflict. Identifying the source of the conflict is important in facilitating a resolution to the conflict. Not all conflict is harmful. Sometimes conflict can be beneficial in that it forces us to address issues that otherwise may be ignored. For a conflict to be addressed the person experiencing the conflict must make a formal complaint in writing and have it signed by the party or parties involved in the presence of a witness or submit the formal written complaint to the GME Ombudsman person.
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:
Progressive Responsibility Policy
In general, the roles, responsibilities and functions of a Department of Neurosurgery resident, per training year, are as follows:
PGY-1 clinical year is organized to introduce residents to basic general surgery problems
Objectives:
PGY 1 residents require direct supervision until competency is demonstrated for:
Patient Management Competencies:
Procedural Competencies:
PGY 1 Residents are responsible for indirect supervision of patient management:
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
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:
Residents in the research year are expected to spend one year conducting basic and/or clinical research.
The objectives of the research experience are to:
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.
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:
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 dictatedby 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:
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.
Residents should review every patient during the transition of care:
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:
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 Fatigue & Stress
Program 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.
The site directors, service chiefs, and program director will periodically monitor
these transitions to ensure compliance with all the above.
