The Policies
Here are some of the main polices for the Neurology program. The Evaluation and Promotion Policy is outlined in the Program Description. The Resident selection and Appointment Policy is outlined in the Application Process. For a more in depth look at the Residency Program policies please visit the Graduate Medical Education website at: http://www.uthscsa.edu/gme
Resident Supervision Policy
Section I. Introduction
Careful supervision and observation are required to determine the trainee’s abilities to perform technical and interpretive procedures and to manage patients. Although not licensed independent practitioners, trainees must be given graded levels of responsibility while assuring quality care for patients. Supervision of trainees should be graded to provide gradually increased responsibility and maturation into the role of a judgmentally sound, technically skilled, and independently functioning credentialed provider.
Section II. Definitions
The following definitions are used throughout the document:
Resident – a professional post-graduate trainee in a specific specialty or subspecialty.
Licensed Independent Practitioner (LIP) – a licensed physician who is qualified usually by board certification or eligibility to practice his/her specialty or subspecialty independently.
Medical Staff – an LIP who has been credentialed to provide care in his/her specialty or subspecialty by a hospital.
Staff Attending – the immediate supervisor of a resident who is credentialed in his/her hospital for specific procedures in their specialty and subspecialty that he/she is supervising.
Section III. Procedures
- Residents will be supervised by credentialed providers (“staff attendings”) who are licensed independent practitioners on the medical staff of the teaching hospital in which they are attending. The staff attending must be credentialed in that hospital for the specialty care and diagnostic and therapeutic procedures that they are supervising. In this setting, the supervising staff attending is ultimately responsible for the care of the patient.
- Each UTHSCSA Program Director will define policies in his/her discipline to specify how trainees in that program progressively become independent in specific patient care activities in the program while still being appropriately supervised by medical staff. Graduated levels of responsibility will be delineated by a job description for each year of training. A program's resident supervision policies must be in compliance with JCAHO policies on resident supervision. The policies will delineate the role, responsibilities and patient care activities of trainees and will delineate which trainees may write patient care orders, the circumstances under which they may do so, and what entries if any must be countersigned by a supervisor. Each UTHSCSA Program Director will complete a listing of resident clinical activities that are permitted by year of training, the required level of supervision for each activity, and any requirements for independence in the performance of that activity (See Appendix A).
- Yearly, we review the job descriptions and listing or resident clinical activities and make changes as needed.
- The Program Director will ensure that all supervision policies are distributed to and followed by trainees and the medical staff supervising the trainees. Compliance with the UTHSCSA resident supervision policy will be monitored by the Program Directors.
- Annually the Program Director will determine if residents can progress to the next higher level of training. The requirements for progression to the next higher level of training will be determined by standards set by each Program Director. This assessment will be documented in the annual evaluation of the trainees.
Section IV. Supervision of Trainees in the Inpatient Setting
- All lines of authority for inpatient care delivered by inpatient ward or consult teams will be directed to one credentialed staff provider, who will be clearly identified in the medical record. The attending staff provider has the primary responsibility for the medical diagnosis and treatment of the patient. Trainees may write daily orders on inpatients for which they are participating in the care. These orders will be implemented without the co-signature of a staff physician. It is the responsibility of the resident to discuss their orders with the attending staff physician. Attending staff may write orders on all patients under their care. Trainees will follow all local teaching hospital policies for how to write orders and notify nurses and will follow verbal orders policies of each patient care area.
- The following are the job descriptions of trainees by year of training.
Postgraduate year 2 (PGY2) resident
First-year neurology residents (PGY-2) serve as ward residents in the model of the Department of Medicine. They will directly supervise and teach rotating residents, interns and students assigned to their ward. The neurology resident is responsible for delivery of high-quality patient care for both neurologic and non-neurologic problems in addition to instructing medical students in the neurological histories and the basic neurological examination. The neurology resident will be responsible for a complete neurological history and physical examination (H&P) on all new admissions to the teaching service and will document them on the approved hospital forms in the paper or computerized clinical record. After discussion with the attending physician and supervising resident, the PGY2 will write an assessment and initial management plan and institute a therapeutic intervention. This will include summarizing the patient’s problems along with pertinent physical and laboratory data and the diagnostic impression and plan. Credentialed medical staff and residents in postgraduate year 2 or above are allowed to write restraint orders.
The (PGY-2) neurology resident is responsible for thoroughly evaluating patients admitted by the “on-call” resident. These patients should be evaluated prior to attending rounds. The neurology resident note should be on the chart by the time of attending rounds. The neurology resident should discuss the patient’s problem and diagnostic plan with the intern and students prior to attending rounds.
The (PGY-2) neurology resident is responsible to check out all patients on the service to the on-call resident. This is done at approximately 4:30p.m at each hospital. The resident should hand off a patient check out list on his/her patients so the night team has the most information possible to best serve the patients.
The (PGY-2) neurology resident will conduct morning work rounds with the students and interns every day to evaluate the status of each inpatient on the service prior to the daily 8:00am conference. Every patient is seen at the bedside every morning by the neurology resident. The neurology ward resident leads work rounds.
The (PGY2) neurology resident, under the supervision of the senior resident and attending physician, will participate in daily attending rounds (6 days a week) with the ward team. The resident will supervise the medical student scheduling on his/her team. Medical students should be given one weekend day off per week not a weekday because they miss too many lectures and clinics during the week. The (PGY-2) neurology resident is responsible to write daily progress notes which include an interim history and physical exam, laboratory and radiographic data, and an assessment and plan. If a significant new clinical development arises, there will be timely communication by a member of the resident team with the attending. The house staff and attending must communicate with each other as often as is necessary to ensure the best possible patient care.
The (PGY2) neurology resident may be responsible for completion of discharge summaries. Transfer notes and acceptance notes between critical care units and floor units, when required, can be written by the PGY2 resident. Such transfer notes shall summarize the hospital course and list current medication, pertinent laboratory data, active clinical problems, and physical examination findings. The supervising resident and the attending must be involved to ensure that such transfer is appropriate. When there is a ward intern they may complete the discharge summaries and transfer notes. The (PGY-2) will then complete an addendum to their note summarizing the pertinent diagnostic evaluation and therapeutic plan. The (PGY-2) neurology resident will approve all discharges from the ward and complete a brief on-service and off-service note summarizing pertinent clinical data about the patient. The new resident team must notify the attending physician of the change in resident teams and review the management plan with him/her.
The (PGY2) neurology resident is responsible for teaching on the ward to the students, interns, and rotating residents. They will also participate in giving lectures to the MS III’s, Occupational and Physical Therapists, residents and faculty in the Neurology Resident Basic Science Lecture Series, and UH/VA nursing staff. The resident will also present cases at Grand Rounds supervised by their senior resident. The ward resident will give the VA nursing staff lectures twice a month. Times and topics will be coordinated by our Nurse Practitioner.
Postgraduate year 3 (PGY3) resident
PGY3 residents, when assigned to the service, will take responsibility for organizing and supervising the teaching service, in consultation with the attending physician, and will provide the PGY2 residents and medical students under his/her supervision with a productive educational experience. In this role, they work directly with the PGY2 residents in evaluating all new admissions and reviewing all H&Ps, progress notes, and orders completed by the PGY2 resident daily. They will also supervise, in consultation with the attending physician, all procedures performed by the PGY2. PGY3 residents may perform any of the PGY2 tasks outlined above at the discretion of the attending in accordance patient care area policies. PGY3 residents must maintain close contact with the attending physician for each patient and notify the attending as quickly as possible of any significant changes in the patient’s condition or therapy. All decisions related to invasive procedures, contrast radiology, imaging modalities, and significant therapies must be approved by the attending.
The (PGY3) neurology resident will expand his/her learning exposure to include a hospital based home care (HBHC) program, which serves homebound Veterans. This will provide experience with chronic disability in the home environment, learning to work as a member of an interdisciplinary team, and experiences with end-of-life, ethics, communication, and professionalism in an environment outside of their healthcare setting.
As a part of the graded responsibilities, the (PGY3) neurology resident will be given more complicated topics and provide lectures to some higher level resident/faculty within and outside of our division. They will participate in giving lectures to the MS III’s, Occupational and Physical Therapists, residents and faculty in the Neurology Resident Basic Science Lecture Series, and UH/VA nursing staff.
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Postgraduate year 4 and above (PGY4) resident
PGY4 residents will follow all responsibilities of the PGY3 outlined above when acting in a similar supervisory capacity. PGY4 residents may perform any of the PGY2 or PGY3 tasks outlined above at the discretion of the attending in accordance with patient care area policies. They will also be available to provide assistance with difficult cases and provide instruction in patient management problems when called upon to do so by other residents. They will assume direct patient care responsibilities when needed to assist more junior residents during times of significant patient volume or severity of illness.
An effort has been made to give selected clinical and teaching responsibilities to the (PGY4) neurology senior resident. The senior resident is responsible for the clinical neurology service at the assigned hospital. This requires overseeing both the inpatient and consultation teams. Consults at the assigned hospital will be seen with the assistance of the rotating residents from medicine. The (PGY4) neurology resident is responsible for evaluating potential admissions in the UH ER/ VA Triage, outpatient and inpatient consults. All intensive care unit consultation patients (MICU, CCU, and SICU) and transplant unit patients are seen first by the senior neurology resident and then presented to the attending. All ICU consultation patients are evaluated on a daily basis by the consult resident and attending on weekdays and the on-call resident and attending on weekends. The senior resident at the VA will see consults with our Nurse Practitioner. The neurology resident will be available for consultation with the Nurse Practitioner. She will be conducting her own clinic two days a week, Monday general neurology clinic, as well as fielding phone calls and patient requests.
The (PGY4) neurology resident will give additional lectures to housestaff from other divisions/departments (Rehabilitation, IM, FP, etc.). They will present more complicated topics. They will participate in giving lectures to the MS III’s, Occupational and Physical Therapists, residents and faculty in the Neurology Resident Basic Science Lecture Series, and UH/VA nursing staff. The resident will also present cases at Grand Rounds and present one didactic session at Grand Rounds toward the end of their PGY4 year.
The senior resident designated as Chief resident will assist with administrative duties, scheduling, coverage, and trouble shooting.
Staff supervision of care for hospitalized patients must be documented in the inpatient record. Documentation requirements for inpatient care are outlined below. These are the minimal requirements and may be more stringent depending on the UTHSCSA teaching hospital or residency teaching program.
- Documentation that must be performed by staff
Documentation, in writing, by staff of concurrence with the admission, history, physical examination, assessment, treatment plan, and orders is required within 24 hours of admission. Concurrence with major therapeutic decisions, such as “Do Not Resuscitate” status, must be documented by specific mention in a staff-written progress note. Documentation by an attending note must be done when any major change occurs in the patient’s status, such as transfer into or out of an intensive care unit. - Documentation that can be done by trainees
Trainees must document patient care and staff supervision by writing progress notes and/or co-signing notes written by medical or dental students. The condition of the patient determines how often progress notes are to be written. For admissions to critical care units, there must be documentation of notification of the admission and concurrence of the staff or fellow with trainee health care. There should be documentation of staff concurrence with discharge plans before the patient is discharged, with decisions to transfer the patient to another provider, service, or facility, and with issues dealing with Advance Directives, informed consent, and refusal of care.
- Documentation that must be performed by staff
Section V. Supervision of Trainees on Inpatient Consult Teams
All inpatient consultations performed by trainees will be documented in writing, with the name of the responsible staff consultant recorded. The responsible staff consultant must be notified verbally by the trainee doing the consult within an appropriate period of time as defined by the particular consulting service. The consulting staff is responsible for all the recommendations made by the consultant team. If requested by the patient’s primary staff, the consulting staff must see the patient.
Section VI. Supervision of Trainees in Outpatient Clinics
All outpatient visits provided by trainees will be conducted under the supervision of a staff provider. This staff provider will interview and examine the patient at the staff’s discretion, at the trainee’s request, or at the patient’s request. The staff doctor has full responsibility for care provided, whether or not he/she chooses to verify personally the interview or examination. The name of the responsible supervising staff will be clearly recorded in the patient record.
Section VII. Supervision of Trainees in the Emergency Department
The responsibility for supervision of trainees providing care in the Emergency Department (ED) to patients who are not admitted to the hospital will be identical to that outlined in the schema for outpatient supervision above. The responsibility for supervision of trainees who are called in consultation on patients in the ED will be identical to that outlined in the schema for consultation supervision above. Consulting staff should be notified promptly of ED consultations.
Section VIII. Supervision of Trainees in Interpretive Settings
Trainees who primarily do interpretation of lab, radiology, or pathology specimens must also be supervised, and this supervision must be documented. It is the responsibility of each training program/department in these areas to establish supervisory regulations in compliance with JCAHO and RRC requirements.
Section IX. Supervision of Trainees Performing Procedures
A trainee will be considered qualified to perform a procedure if, in the judgment of the supervising staff and his/her specific training program guidelines, the trainee is competent to perform the procedure safely and effectively. Residents at certain year levels in a given training program may be designated as competent to perform certain procedures independently, based upon specific written criteria set forth and defined by the Program Director. In this instance, trainees may perform routine procedures that they are deemed competent to perform (such as lumbar puncture) for standard indications without prior approval or direct supervision of staff. However, the patient’s staff of record will be ultimately responsible for all procedures on inpatients. In addition, residents may perform emergency procedures without prior staff approval or direct supervision when life or limb would be threatened by delay. In this case the most senior trainee available will supervise the procedures. All outpatient procedures will have the staff of record documented in the procedure note, and that staff will be ultimately responsible for the outpatient procedure. Program Directors will designate the PGY level at which each procedure in their specialty can be performed.
Resident Dismissal Policy
The following policy is to implement fair procedures in accordance with our institutional policies and procedures (http://www.uthscsa.edu/gme) regarding academic discipline and resident complaints or grievances.
The residency Program Director discusses resident issues with the faculty, at a specially called faculty meeting (Committee for Resident Evaluation and Promotion), in a timely fashion. This occurs within a maximum of 30 days of notification of the program director of the relevant concerns. The resident may be present for the meeting and/or have a faculty advocate present for the meeting. The residency program director collects and presents to the faculty information relevant to the resident’s performance. All such information is confidential. There is an opportunity for the resident and /or their advocate to address the Committee regarding the information presented. The resident may provide written comments to the Committee. An opportunity is provided for the Committee members to ask questions of the resident and/or the faculty advisor of the resident.
The Committee discussion to yield a resolution occurs with the resident excused from the committee meeting. The resident’s faculty advocate may remain for the discussion. After a decision is made the resident will return to the meeting and the Committee decision will be shared with the resident. Recommendations of the Committee to the residency Program Director are as follows: no action, remedial work, negative sanctions which may include an official letter of reprimand to be placed in the resident’s permanent file, time limited probation, non-renewal of contract, termination, or alternative remedies. Non-renewal of contract or termination should generally be preceded by a period of probation, unless the Committee deems that the issue(s) leading to the adverse action were of a particularly egregious nature. A copy of the written recommendation of the committee, including the basis for the recommendation, is placed in the resident’s permanent file and a copy is given to the resident. When a resident is placed on probation or remediation the Committee will reconvene to review this resident’s progress and situation within three months of the action. All adverse actions by the residency Program Director upon recommendation of the Committee require the consent of the Chair of Neurology.
Housestaff Grievance Procedure
The University of Texas Health Science Center at San Antonio
The Graduate Medical Education Committee, excluding the University Health System representative, serves as the appeals body for all residents in programs sponsored by the UTHSCSA, independent of their funding source, for dismissal or non-renewal. Such dismissal or non-renewal could occur because of failure to comply with his/her responsibilities or failure to demonstrate appropriate medical knowledge or skill as determined by the program's supervising faculty. This appeals mechanism is open to a resident dismissed during the academic year or a resident whose contract for the following academic year is not renewed in a categorical program in which there has been no explicit information provided to the resident that advancement was on a pyramidal system.
Warning period - It is the responsibility of the department or division to document a warning period prior to dismissal or failure to reappoint a house officer and to demonstrate efforts for the provision of opportunities for remediation. It should be unusual to dismiss a resident without a probationary period except in instances of flagrant misconduct (see next paragraph). Opportunities must be provided and documented for the resident to discuss with the department or division's program director or chair the basis for probation, the expectations of the probationary period and the evaluation of the resident's performance during the probation.
Dismissal without warning - According to the UTHSCSA Handbook of Operating Procedures 5.13.3 B 2, several specific examples of misconduct for which an individual may be subject to dismissal include (but is not limited to) the following: being under the influence of intoxicants or drugs; disorderly conduct, harassment of other employees (including sexual harassment), or the use of abusive language on the premises; fighting, encouraging a fight, or threatening, attempting, or causing injury to another person on the premises. The full text is available at: http://www.uthscsa.edu/hop2000/4.9.4.pdf.
Formal grievance procedure - In the event that a resident is to be dismissed or his/her contract not renewed, he/she may initiate a formal grievance procedure. The resident shall present the grievance in writing to the Associate Dean for Graduate Medical Education within thirty (30) working days after the date of notification of termination or non-renewal. The grievance shall state the facts upon which the grievance is based and requested remedy sought. The Associate Dean for Graduate Medical Education shall respond to the grievance with written answer no later than ten (10) calendar days after he/she received it.
If the resident is not satisfied with the response, he/she may then submit, within ten (10) days of receipt of the Associate Dean for Graduate Medical Education's response, a written request for a hearing.
Hearing - The hearing procedure will be coordinated by the Associate Dean for Graduate Medical Education, who will preside at the hearing, but will not be a voting participant. The hearing will be scheduled within thirty (30) days of the resident's request for a hearing. The hearing panel will consist of at least three (3) members of the Graduate Medical Education Committee. The Associate Dean will determine the time and site of the hearing in consultation with the resident and program leadership. The resident shall have a right to self-obtained legal counsel at his/her own expense; however retained counsel may not actively participate or speak before the hearing participants, nor perform cross-examination.
The format of the hearing will include a presentation by a departmental representative; an opportunity for a presentation of equal length by the house officer; an opportunity for response by the representative, followed by a response of equal length by the house officer. This will be followed by a period of questioning by the Graduate Medical Education Committee members present. The Associate Dean in consultation with the departmental representatives and the resident will determine the duration of the presentations and the potential attendees at the hearing.
The resident will have a right to request documents for presentation at the hearing and the participation of witnesses. The Associate Dean at his/her discretion will invite the latter, following consultation with the hearing panel.
A final decision will be made by a majority vote of the Graduate Medical Education Committee participants and will be communicated to the resident within ten (10) working days after the hearing. This process will represent the final appeal within the Health Science Center and its affiliated hospitals.
Moonlighting by Residents Policy
Moonlighting is defined as compensated clinical work performed by a resident during the time that he/she is a member of a residency program.
The Graduate Medical Education Committee and the UTHSCSA-sponsored graduate medical education (GME) programs take seriously the responsibility of ensuring a high quality learning environment for the residents, notably by ensuring a proper balance between education and patient care activities within duty hour limitations as prescribed by the ACGME Institutional and Program Requirements. Because of these concerns, moonlighting is, in general, discouraged for residents in ACGME-accredited programs sponsored by UTHSCSA. During residency training, the resident's primary responsibility is the acquisition of knowledge, attitudes, and skills associated with the specialty in which he/she is being instructed.
Moonlighting is not allowed for first-year residents (PGY-2). Moonlighting is permitted for second and third-year residents (PGY 3 and PGY 4) if they are not on a clinical service (wards, consults, pediatric neurology) with the exception that they may moonlight on weekends if they have no assigned responsibilities.
Under special circumstances, a resident may be given permission by his/her program director and Neurology Department Chair to engage in moonlighting. In such cases, the moonlighting workload must not interfere with the ability of the resident to achieve the goals and objectives of his or her GME program. Each program may have its own policy on such outside activities, which may be more restrictive than that of the Institution.
Two forms of moonlighting are considered in this policy:
- Moonlighting
- Internal moonlighting
Moonlighting - the compensated clinical work is not a part of the residency program, it occurs outside of the institution, and the UTHSCSA does not provide professional liability coverage for the activity. Without compromising the goals of resident training and education, a program director may allow a resident to moonlight if all of the following conditions are met:
- The responsibilities in the moonlighting circumstance are delineated clearly in writing and are approved in writing by the resident's program director.
- The written documentation of the moonlighting activity is filed with resident records and is available for GME Committee monitoring.
- The moonlighting workload is such that it does not interfere with the ability of the resident to achieve the goals and objectives of the GME Program.
- The moonlighting opportunity does not replace any part of the clinical experience that is integral to the resident's training program.
- The resident is licensed for unsupervised, independent medical practice in the state where the moonlighting will occur.
- The total hours in the combined educational program and the moonlighting commitment must not exceed the limits set by the program or the Residency Review Committee.
In addition, the resident considering moonlighting should seek written assurance of professional liability (including "tail" insurance), and workers' compensation coverage from any outside employer. Professional liability insurance is provided by the University of Texas System Medical Liability Self-Insurance Plan only for those activities that are an approved component of the training program. There is NO coverage for professional activities outside of the scope of the residency program.
Internal moonlighting - the compensated clinical work occurs within the residency program, and is simply an extension of the same type and location of clinical work performed as a requirement of the GME program. For a resident to participate in internal moonlighting, all of the following conditions must be met:
- The resident must be a current resident in the program, and must be in good standing.
- The situation must meet ACGME requirements, including requirements for faculty supervision.
- Faculty supervision is not necessary if the resident has completed training in a primary residency program and is working in that capacity (e.g., a resident (Fellow) in Neurophysiology may perform internal moonlighting as a general neurologist without faculty supervision).
- The additional work performed by the resident must be considered part of his/her residency training program, except as outlined above. Evaluation of the residents in that situation must occur as in other training venues.
- The patient care site must be specified. A current affiliation agreement must be in effect between UTHSCSA and the site, and the program must have a current program agreement with the site.
- The total hours in the combined educational program and the moonlighting commitment must not exceed the limits set by the program or the Residency Review Committee.
For the resident to receive professional liability insurance coverage by the U.T. System Medical Liability Self-Insurance Plan for internal moonlighting, the program director must first submit a written request to the Executive Vice Chancellor for Health Affairs, which outlines the conditions of the proposed work. The GME Office can provide assistance with this request.