August 2016

The Anatomic and Clinical Pathology Residency Program ensures that it provides appropriate supervision for all residents, as well as a duty hour schedule and a work environment that optimizes quality patient care, fortifies the educational trajectory of house staff members, and addresses all applicable program requirements. On-call duties are necessary components of University of Iowa Hospitals & Clinics clinical care systems and educational programs; these duties are managed to ensure adequate periods of rest with appropriate levels of supervision to deliver safe, effective patient care. (The terms "resident" or "house staff member" used in this policy shall refer to resident and fellow physicians and dentists at all house staff levels.)

Supervision

The clinical activities of all residents are supervised by teaching staff and/or more advanced house staff members in such a way as to ensure that the resident assumes progressively increasing responsibility according to each resident’s level of education, ability and experience as appropriate to the patient situation and resident capability. The teaching staff determines the level of responsibility accorded to each resident. On-call schedules for teaching staff and more advanced house staff members are structured to ensure supervision is readily available to those on duty.

The following guidelines have been established to assure the appropriate supervision of residents on all services/rotations across all levels of training. Pathology faculty are assigned on a daily basis to staff all services. Detailed coverage schedules are created monthly and are widely distributed to everyone in the department. Each resident is assigned to a primary service and supervision is provided by the faculty assigned for that day. All rotations provide for daily personal faculty interaction. The clinical involvement of faculty and the low trainee to staff ratio ensures that these interactions are frequent and instructive. The intensity and closeness of supervision varies considerably with the experience and abilities of the resident. The faculty determines the level of responsibility accorded to the resident. These factors are judged individually after formal discussions by faculty, and review of resident evaluations. The level of supervision is not dependent solely on the length of time in training.

All call is taken from home in this residency program, with a corresponding faculty member or fellow on call at all times. The resident on call for a particular service knows exactly which pathologist is on call for every service via the departmental call schedules, which are available on the intranet and posted in multiple locations in the department. Residents can contact them at any time via the pager system or phone. Every year the department also publishes a call manual, which provides guidelines for frequently asked questions encountered on call as well as providing contact numbers for all house staff and faculty.

The Anatomic and Clinical Pathology Residency Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every service has an attending pathologist assigned who is responsible to assure the excellence of medical care and to supervise and teach pathology house staff involved in patient care. Each clinical service is continuously covered by a faculty member who is accessible at any time by means of the pager system. These levels of supervision include:

• Direct Supervision - The supervising physician is physically present with the resident and patient.
• Indirect Supervision
  i) with direct supervision immediately available – The supervising physician is physically present within the hospital or other site of patient care, and is immediately available to provide direct supervision.
  ii) with direct supervision available – The supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision (within 20 minutes travel to the hospital).

PGY 1 residents are supervised either directly or indirectly with direct supervision immediately available while they acquire basic knowledge and skills specific to the specialty. As required by the Pathology RC of the ACGME, direct supervision and documentation is done for the first three of each of the following procedures: autopsy, fine need aspiration, apheresis, and grossing of surgical pathology specimens (first three in each organ system). Activities of PGY 2 residents and above are supervised by any level of supervision, as appropriate to the patient situation and resident capability. Supervision does not equate merely to the presence of more senior physicians nor with the absence of independent decision making on the part of residents. These supervision standards encompass the concepts of graded authority, responsibility and conditional independence that are the foundation of delegation of authority to more senior house staff members. Should a resident ever need further assistance or information, they can contact the senior resident or faculty on call. Residents are expected to communicate with the appropriate supervising faculty when leaving for vacation or other absences to ensure all patient care responsibilities are transitioned appropriately. Residents are also expected to have a conversation (in person, via phone, or email) post-call to relay relevant information to the resident taking over the next day. At the end of a rotation each resident is expected to communicate with the resident moving onto that rotation to assure a smooth transition and continuity of patient care.

Duty Hours

Residents work hours are monitored by the Program Director/Associate Program Directors and Program Coordinator by means of a work hour record on MedHub that residents are expected to complete weekly. The work hours for day and night duty on all rotations are designed such that hours worked will fall within the ACGME rules for resident work hours: no more than 80 hours per week when averaged over 4 weeks; one day off in seven when averaged over 4 weeks; there is at least a 10 hour period free of clinical duty between shifts.

All residents will report any concerns about resident hours directly to the Program Director/Associate Program Directors or via rotational evaluations solicited at the end of every rotation.

Specific duty hour requirements are as follows:

1. Maximum Hours of Work Per Week: The duty hours of any resident must be limited to 80 hours per week (or other applicable limit as specified by the appropriate Residency Review Committee (RRC), when averaged over a 4 week period, inclusive of all in-house call activities and any moonlighting activities. Any time spent in the UIHC or at another institution for clinical and academic purposes, related to the residency or fellowship program, both inpatient and outpatient, shall count toward the weekly maximum. Additionally, the weekly maximum shall include time spent for administrative duties related to patient care, the transfer of patient care, scheduled academic activities such as conferences, research related to the program, and any time the resident spends on-site after being called in to the hospital. Not included in the weekly maximum is time spent outside of UIHC (or outside another institution related to the program’s academic purposes) for academic preparation, reading, and studying.

Duty Hour Exception: University of Iowa Hospitals & Clinics, through its Graduate Medical Education Committee (GMEC) has established criteria and procedures for GME programs to petition for an exception to the weekly hour limit. (See the Procedures and Criteria to Petition the Graduate Medical Education Committee to Exceed the Weekly Rule on Duty Hours by 10%). If approved by the GMEC, the Program Director must also obtain approval from the appropriate RRC before the weekly limit is exceeded. If this exception is granted, at no time, shall the average number of duty hours exceed 88 hours per week, when averaged over a 4-week period.

2. Maximum Duty Period Length:

• PGY 1 residents - scheduled duty periods must not exceed 16 hours in duration.
• PGY 2 and above residents – no schedule shall exceed a maximum of 24 hours of continuous duty in the hospital, with no more than 4 additional hours used for any transitional activities (i.e. maintaining continuity of medical and surgical care, transferring patient care, or attending educational sessions).
• In no event shall the PGY 2 or above resident accept a new patient (any patient for whom the resident has not previously provided care) during this 4-hour extension period.
• PGY 2 or above residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
• In unusual circumstances, PGY 2 and above residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring or humanistic attention to the needs of a patient or family. Residents must appropriately hand over the care of all other patients to the team responsible for their continuing care.
• Any resident exceeding maximum duty period lengths will document their justification in the institution’s resident management system (i.e. MedHub).
• Residents are expected to have a conversation (in person or via phone) at the end of each call period to relay relevant information to the resident taking over the service the next day or taking the next call period to ensure continuity of care. At the end of each rotation the resident is expected to communicate with the resident moving onto that rotation to assure a smooth transition and continuity of patient care. Residents are expected to communicate with the appropriate supervising faculty when leaving for vacation or other absences to ensure all patient care responsibilities are transitioned appropriately.

3. Maximum Frequency of Over-Night In-House On-Call Duties: Not applicable, as pathology residents do not participate in in-house call.

4. Maximum Frequency of In-House Night Float: Not applicable, as pathology residents do not participate in in-house call.

5. Mandatory Time Free of Duty: Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). This day off shall not include home call nor shall the resident be required to carry a pager. A day is defined as 24 consecutive hours.

6. Minimum Time Off Between Scheduled Duty Periods: Based on the level of the resident, there are identified levels of time off between scheduled duty periods.

• PGY 1 residents – should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.
• Intermediate level residents (as defined by the program’s RRC) – should have 10 hours, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 continuous hours of in-house duty.
• Final year residents (as defined by the program’s RRC) – can participate in transition to practice activities when they are preparing to care for patients over irregular or extended periods. It is still desirable that these residents have 8 hours free of duty between scheduled duty periods, but there may be circumstances where residents must stay on duty to care for their patients or return to the hospital after shorter intervals.
• The Program Director monitors time off between scheduled duty periods.

7. Home Call:Residents returning to the hospital from home call must count their time spent in the hospital towards the 80-hour maximum weekly hour limit. The frequency of home call is not subject to the every-third-night limitation but must satisfy the requirement for 1 day in 7 free of duty, when averaged over 4 weeks.

• Home call activities must not be so frequent as to preclude rest and reasonable personal time for each resident.
• Residents are permitted to return to the hospital while on home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”

8. Moonlighting: Moonlighting is not permitted in the Department of Pathology.

The Anatomic and Clinical Pathology Residency Program meets the requirements of this policy as well as any applicable standard set by the ACGME, the appropriate RRC, or other accrediting or certifying body. This policy is distributed by the GME Office to all GME contract holders, as well as provided in the departmental orientation materials and posted on the departmental intranet. The Anatomic and Clinical Pathology Residency Program monitors resident duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.