The RCRMC Surgical 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 care 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.
Basic General Surgery Residency Supervision Policy:
The program recognizes the ACGME's three classifications or Levels of Supervision:
- Direct Supervision: The supervising physician is physically present with the resident and patient.
- Indirect Supervision:
- 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
- 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.
- Oversight: The supervising physician is available to provide review of procedure/encounters with feedback provided after care is delivered.
The first year of residency emphasizes surgical diagnosis, pathophysiology and pre- and post- operative care. The PGY 1 resident, along with the more senior resident, is involved in the daily presentation of the patient to the attending surgeons where treatment decisions are finalized. The PGY 1 resident follows the patient to surgery, where he acts as one of the surgical assistants. In less complicated cases, such as hernia or appendectomy, the junior resident often performs the operation as directed by the attending surgeon.
PGY 1 residents require Direct Supervision until competency is demonstrated for:
- Patient Management Competencies:
- Initial evaluation and management
- Evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrhythmias, hypoxemia, change in respiratory rate, change in neurologic status and compartment syndromes.
- 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.
- Management of patients in cardiac or respiratory arrest (ACLS required)
- Procedural Competencies:
- Central venous access placement
- Arterial catheterization
- Temporary dialysis access
- Tube thoracostomy
- I & D of simple abscess at bedside
PGY 1 residents require Indirect Supervision for:
- Patient Management Competencies:
- 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.
- Pre-operative evaluation and management, including history and physical examination, formulation of a plan of therapy, and specification of necessary test.
- Evaluation and management of post-operative patients including the conduct of monitoring and orders for medications, testing and other treatments
- Transfer of patients between hospital units or hospitals
- Discharge of patients from the hospital
- Interpretation of laboratory results
PGY 2 – 3 residents who demonstrate good performance may be given responsibility for independent judgment and surgical decision-making with continued attending supervision. 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.
Fourth year residents are considered the senior/chief of the service and supervise junior residents and medical students. 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.
Fifth year residents are considered the chief of the service and supervise junior residents and medical students. Chief 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. Chief residents are allowed and encouraged to exercise independent surgical judgment to the degree that is consistent with good patient care.
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 of the Chairman of the Department of Surgery.
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.
Documentation of supervised order-writing shall be demonstrated by counter-signature of the resident's note or by referring to the resident's documentation in a separate attending note.
The supervising physician shall personally interview and examine the patient each day to confirm the resident's findings and to evaluate the resident's clinical care.
The supervising physician shall be physically present during the critical portion of each surgical procedure. This responsibility may be shared with a senior or chief resident who has been designated as being competent of performing a limited number of procedures without the direct presence of the supervising physician (i.e. chest tube placement, CVL, I&D of an abscess).
The supervising physician must approve any admission of a patient to the service. This will allow discussion of the resident's preliminary medical diagnosis and preliminary decision making.
The supervising physician shall be informed of transfer of a patient to another service or to another level of care e.g. ICU, intermediate, etc., or death of a patient.
The supervising physician must approve any recommendation to discharge a patient from the Emergency Room.
The resident shall order consultations and testing on behalf of the attending physician following discussion with the attending physician. This must be documented by the resident or by the attending in the order or in the physician's notes.
Any consultations requested by another service may be seen initially by the resident. The resident shall immediately discuss the consultation with the supervising physician for critically ill patients. The consulting physician shall personally evaluate the patient within one day of the request for consultation.
Residents in General Surgery will not operate independently. All cases taken to the operating room will be discussed with the attending physician and all operations will be performed under the supervision of the attending physician.
The GME office has instituted a system, New Innovations, which allows healthcare workers to track resident procedures that have been designated by the program director as competent to perform without direct attending supervision, i.e. chest tube placement, CVL, I&D of an abscess.
The resident's profile is updated as progression through the program and acquisition of skills and competency is acquired. In addition, the residency program will monitor interns in the acquisition of skills for invasive procedures. Once a predetermined number of specific procedures have been completed satisfactorily and the program director has indicated the resident is competent in performing such procedure, the resident may then perform such procedures with attending approval but without direct supervision.
Faculty Responsibilities for Supervision:
The supervisory faculty has accepted guidelines concerning supervisory expectations of faculty members as a condition of faculty appointment. The guidelines state that the faculty supervisor will:
- Accept the responsibility for the surgical residents assigned to his/her patients.
- Allow the residents to actively participate under his/her supervision and control in the care of their patients, including the performance of procedures, commensurate with the resident's level of training.
- Recognize that the residents and learners are involved in a program designed to help them master the art and science of surgery. Realize that residents have not reached that point in their careers when they can function without supervision by the surgical faculty attending staff.
- Recognize the responsibility of each surgical faculty member to assess the level of capability of each resident in each delegated task and to provide an appropriate level of supervision while delegating progressively increasing responsibility commensurate with increasing skill and judgment.
- Recognize that all responsibilities which a surgical resident assumes are delegated responsibilities and that ultimately the attending surgeon is the physician responsible for the safety and welfare of the patients under their care and for the resident's participation in the management of those patients.