Supervision of Pediatric Residents Policy

To provide an organized educational program with guidance and supervision of the resident that facilitates professional and personal growth while ensuring safe and appropriate patient care. Residents are expected to assume progressively greater responsibility through the course of a residency, consistent with individual growth in clinical experience, knowledge and skill. The Department gives residents significant but appropriately, well-supervised latitude in the management of all patients and provides a comprehensive experience in their specialty area in order for them to become independent and knowledgeable clinicians with a commitment to the life-long learning process that is critical for maintaining professional growth and competency.

The Supervision Policy for the University at Buffalo can be found on the Office of Graduate Medical Education website.

On-call schedules listing the attending physicians for Inpatient Pediatrics, Newborn Nursery, Ambulatory Pediatrics, Pediatric subspecialty services, Pediatric Surgery, and Pediatric Surgery subspecialty services are located on the hospital website. If there are any concerns regarding faculty supervisory coverage, residents can also contact the hospital operator who has a daily schedule of all faculty assignments as well. If the residents are unable to reach the appropriate attending they are to reach out to the Pediatric Chief Residents, Program Director, or Associate Program Director.

The Pediatric Residency Program’s Supervision of Pediatric Resident Policy is in line with the University’s policy regarding supervision of residents. Every patient seen by a resident is seen under the supervision of a staff physician who assumes complete responsibility for those patients for whom they are the attending physician. The staff physician is also responsible for education of the residents. Attending supervision may be direct or indirect. Indirect supervision occurs when the responsible staff is aware of the patient and is available to assist or provide direct supervision if needed but is not physically present. In these situations, a senior resident may provide direct supervision of a more junior resident. Supervision is always available from more senior residents and attending physicians. Residents (Senior and Junior) should always obtain help in any clinical situation in which they are inexperienced or uncomfortable.

In all instances, the level of resident supervision must ensure the highest quality, safety and effectiveness of patient care. The level of supervision must be appropriate for individual resident’s progressive responsibility as determined by the resident’s level of education, competence and experience.

Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care of the individual patient; assuring the development of the skills, knowledge and attitudes in the resident to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty who give value, context and meaning to those interactions. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence including graded and progressive responsibility.

Residents in the Pediatric Residency Program practice only under the supervision of attending physicians who are licensed and credentialed by our participating institutions including Oishei Children’s Hospital and affiliate clinics, and Roswell Park Comprehensive Cancer Center. All patients cared for by resident physicians will have an identifiable supervising faculty member or other approved licensed independent practitioner who assumes ultimate responsibility for the actions of the resident to whom portions of care will be delegated based on the needs of the patient and the skills of the residents. A patient’s responsible supervising attending physician or licensed practitioner should be identified to residents, faculty members and patients. Residents and faculty should inform patients of their respective roles in each patient’s care.

While the Program Director and faculty assign to each resident the privilege of progressive responsibility, authority, and supervisory role in patient care based on specific criteria, the attending physician has the ultimate responsibility for all medical decisions regarding his/her patients including those made by senior residents, junior residents and medical students under their supervision. The attending physician may determine additional service specific levels of supervision and teaching required for each trainee based on the resident’s level of training, experience and competence. Faculty members are expected to devote sufficient time to fulfill their supervisory and teaching responsibilities. This includes supervision assignments of sufficient duration, both block and longitudinal assignments, to assess the knowledge and skills of each resident in order to delegate to him/her to appropriate level of patient care authority and responsibility.

• To have ultimate responsibility for all medical decisions regarding his/her patients.
• To be responsible for providing supervision of all care provided by residents.
• To develop a plan for the medical management of each patient in conjunction with the residents and consulting services.
• To be responsible for the implementation of diagnostic and therapeutic plans as well as their documentation in the medical record.
• Inpatient: The attending will document their involvement and agreement with the resident’s plan with a note written within 24 hours of admission that demonstrates that the attending took a history and performed an exam needed for care and decision making in the case.
• Outpatient: The attending will document their involvement and agreement with the resident’s plan with a note at the time the patient is seen.
• To respond promptly and professionally to any question or concern from residents no matter what time of day or day of the week.
• To encourage residents to seek guidance at any time the resident needs help in the care of patients.
• To be readily available to provide supervision and consultation at all times or to have a clearly designated covering physician at any time for the level of supervision required by each resident at each training level on each clinical service.

During daytime hours, supervising attending physicians are expected to be able to be physically present with residents and patients (direct supervision) as well as physically within the confines of the site of patient care and immediately available to provide direct supervision (indirect supervision with direct supervision immediately available). After hours and on weekends, supervising attending physicians must be available for a telephone/pager consult at any time and able to come promptly to the hospital to provide on-site supervision and consultation to the resident (indirect supervision with direct supervision available). For urgent consultations on the non-ICU inpatient floors, a Neonatology Fellow/Attending, a Critical Care Fellow/Attending, and an Emergency Medicine Attending are in-house and available.

Supervising attending are expected to be readily available including physical presence at the site of patient care with either immediate availability to provide direct supervision (continuity clinics, same day sick/acute care clinic, specialty clinics) or immediately available via phone and available to provide direct supervision (specialty consults).

To communicate with the resident expectations for when to be contacted in the care of the patient. While communication with the attending should be frequent and ongoing, the timeliness of communication will vary with the severity and urgency of the patient. At minimum, significant changes, events or circumstances in the patient’s condition must be communicated to the supervising attending.

Supervisory residents will provide care as part of a team led by an attending physician. Given that independent development of progressive treatment and management plans is important for senior residents, the attending accepts responsibility for all decisions made by the senior. Senior residents will also serve in the supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the resident.

• To supervise the junior residents (PL-1), sub-I’s and medical student in the care all patients.
• To make the patient’s parent or legal guardian aware of the name of the attending and his/her role as the responsible caregiver for the child as well as their role as resident in the patient’s care.
• To document in the medical record the accepting attending for each patient.
• To develop a diagnostic and therapeutic plan for each patient under the supervision of the attending physician and to ensure that the plan is carried out.
• To write a note at the time of each admission or when a patient’ s condition changes that demonstrates the senior’s involvement in the plan for the patient and that includes a history and exam findings that are needed for care and decision making in the case.
• To manage the team as a whole and facilitate the interactions between the attending, team, consultants, nurses, and other members of the health care team.
• To communicate clearly, effectively and promptly with the attending from admission through discharge.
• To be available for any urgent or emergent situations that arise in the care of patients.
• Τo be immediately available to actively participate in the treatment and management of the junior residents patients.
• To know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence for each individual clinical assignment.

The junior and the supervising resident will provide care as a team. Given that independent development of treatment and management plans is important for juniors, the supervising resident accepts responsibility for all decisions made by the junior.

• The junior shall not accept responsibility for care of any patient until their supervising resident and attending have been notified and accept responsibility for the patient.
• To keep the supervising resident immediately informed and in agreement with all management plans.
• To know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence for each individual clinical assignment.
• If a junior resident is not comfortable with the decisions of the supervising resident, the senior resident is not immediately available because of another patient care responsibility or if the junior has further questions, the junior will call the attending physician.

The supervising physician is physically present with the resident and patient.

The supervising physician is physically within the hospital or other site of patient care and is immediate available to provide direct supervision.

The supervising physician is not physically present within the hospital or other site of patient care but is immediately available my means of telephonic and/or electronic modalities and is available to provide direct supervision.

The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Admission, transfer to and from ICU, need for intubation or other ventilator support, DNR or other end of life decision, cardiac arrest, changes in hemodynamic status requiring intervention fluid or ionotropic support, neurological changes, medication errors requiring clinical intervention, clinical problem requiring an invasive procedure, care of medically complex patient, or any incident that compromises patient safety.

It is expected that the overnight team (Junior and Senior if possible) call the attending to review any questions regarding the admission and management plan or with any significant change in patient status. All after hour admissions are reviewed by the attending with both the night and day teams at 8:00 AM every morning (Oversight Supervision). In addition, all admissions should be discussed with the general pediatrics attending in as reasonable a time from the admission as patient care necessitates.

All admissions are to be discussed with the attending or fellow at the time of admission. (Indirect Supervision with direct supervision available)