Virginia Commonwealth University Department of Internal Medicine
and Division of Hematology-Oncology
Graduate Medical Education Supervision Policy
The Internal Medicine Department training programs will adhere to the official supervision policy
of Virginia Commonwealth University Health Systems (VCUHS) and its Graduate Medical
Education (GME) program, which can be found on the GME website,
http://www.medschool.vcu.edu/gme/policies/index.html. The following policy is consistent with
the institutional policy and is more restrictive in specific areas. This policy applies across all
levels of GME trainees in the Department, as noted. Individual programs may be more
restrictive.
Additional Hematology-Oncology Training Program requirements are thus indicated in italicizes.
GENERAL PRINCIPLES
As outlined in the Joint Statement on Supervision by the Virginia medical schools, the
Department of Internal Medicine at Virginia Commonwealth University agrees with the
philosophy that the most effective learning environment for post-graduate medical trainees is
one that allows sufficient freedom for residents and fellows to assume primary responsibility for
decision-making in patient care, and yet provides adequate faculty presence and involvement in
order to provide feedback to trainees about their actions, and to guarantee the quality and
safety of the care rendered to patients. In order to preserve this type of learning environment for
its teaching program, the Department of Internal Medicine advocates the following principles as
the cornerstone of its policy on resident education and supervision:
1. Attending physicians are ultimately responsible for care rendered to patients. However,
graduate medical trainees may assume primary responsibility for patients admitted to the
teaching services and clinics, and as such are responsible for the writing of orders, for the
maintenance of records, and for the execution of diagnostic, therapeutic, and discharge
plans (under the supervision of their attending physician of record).
2. All spheres of graduate medical trainee activity will be supervised by attending faculty
members who will share responsibility with residents and fellows for patient care rendered,
and who will have ultimate responsibility and authority for final decision making and patient
care.
3. To facilitate a more effective and meaningful evaluation and feedback process, the number
of attending physicians with which a graduate medical trainee must interact on a given
rotation should be minimized.
The structure of trainee-attending interactions and the form that faculty supervision of trainees
takes will vary according to site and type of patient care setting and are summarized below.
These rules are uniform for both VCUHS Hospitals and the McGuire Veteran’s Affairs Medical
Center.
Levels of Supervision Defined
For the purposes of this policy document, the levels of supervision will be characterized using
the terms defined by the ACGME. The terms are defined as follows:
1. Direct Supervision – the supervising physician is physically present with the resident and
patient.
2. Indirect Supervision with direct supervision immediately available – the supervising
physician is physically within the hospital or other site of patient care, and is immediately
available to provide Direct Supervision.
3. Indirect Supervision 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.
4. Oversight – the supervising physician is available to provide review of procedures
Inpatient General and Subspecialty Ward Services
1. All patients admitted to inpatient teaching services will be managed by a patient care
team consisting of medical students, interns and residents, and fellows (on subspecialty
services) under the direction of faculty attending physicians. Each patient will have an
assigned and readily identified attending physician who will have ultimate responsibility
for the patient. This attending physician MUST be available continuously by pager during
the time assigned. This attending physician also serves as the teaching physician for the
team.
2. All PGY1 residents will function under Direct Supervision at all times when admitting and
managing patients on the inpatient services. Direct Supervision may be provided by a
PGY2 resident, a PGY3 resident, a fellow, or an attending physician. When a PGY1
resident is called for cross-coverage of a patient, at night or when covering other teams,
Direct Supervision is immediately available and is required if the PGY1 resident
physically sees the patient involved.
3. All PGY2 residents, PGY3 residents, and fellows on inpatient services function under
Indirect Supervision with Direct Supervision immediately available from 8am through
6pm (from either upper level residents, fellows or attending physicians) or available from
6pm through 8am (again from either upper level residents, fellows or attending
physicians).
4. On inpatient ward services, the supervising attending physician will personally see all
new patients within 24 hours of admission and all follow-up patients daily. The
supervising attending physician will personally discuss the resident/fellow’s assessment
and care plan for all patients at least daily.
5. All admission, consultation, transfer, follow-up, procedure, change of status, and
discharge notes generated by a housestaff member at any level are to be forwarded to
the responsible supervising attending for review and signature by the attending
physician for the purpose of supervision, regardless of whether a billable service was
provided. Additionally, physician encounters by a trainee at any level with the patient
and/or family for the purpose of 1) informing of diagnosis, prognosis, and/or
therapeutics; 2) counseling in regard to obtaining informed consent; and 3) counseling
regarding end-of-life directives should be documented in the electronic medical record
with appropriate designation as to content in the subject line. These notes should be
forwarded to the attending physician.
ICU settings (inclusive of MRICU, VAICU, CCU)
1. All patients admitted to ICU teaching services will be managed by a patient care team
consisting of medical students, interns and residents, and/or fellows under the direction
of faculty attending physicians credentialed in the care of ICU patients. Each patient will
have an assigned and readily identified attending physician who will have ultimate
responsibility for the patient. This attending physician MUST be available continuously
by pager during the time assigned. This attending physician also serves as the teaching
physician for the team.
2. All PGY1 residents will function AT ALL TIMES under Direct Supervision in the ICU
setting. Direct Supervision may be provided by a PGY2 resident, a PGY3 resident, a
fellow, or an attending physician.
3. All PGY2 residents and PGY3 residents in the ICU settings function under Indirect
Supervision with Direct Supervision immediately available from 8am through 6pm (from
fellows or attending physicians) or available from 6pm through 8am (again from either
fellows or attending physicians).
4. All fellows in ICU settings function under Indirect Supervision with Direct Supervision
available AT ALL TIMES by their on-call attending physician.
5. In the ICU settings, the supervising attending physician will personally see all new
patients within 24 hours of admission and all follow-up patients daily. The supervising
attending physician will personally discuss the resident/fellow’s assessment and care
plan for all patients at least daily.
6. All admission, consultation, transfer, follow-up, procedure, change of status, and
discharge notes generated by a housestaff member at any level are to be forwarded to
the responsible supervising attending for review and signature by the attending
physician for the purpose of supervision, regardless of whether a billable service was
provided. Additionally, physician encounters by a trainee at any level with the patient
and/or family for the purpose of 1) informing of diagnosis, prognosis, and/or
therapeutics; 2) counseling in regard to obtaining informed consent; and 3) counseling
regarding end-of-life directives should be documented in the electronic medical record
with appropriate designation as to content in the subject line. These notes should be
forwarded to the attending physician.
Inpatient Subspecialty Consultation Services at VCUHS and VAMC
On the inpatient consultation services at VCUHS and VAMC, the housestaff members at all
levels will, at a minimum, present all new patient consults to the supervising attending physician
on the day of consultation.
1. All PGY1 residents will function under Indirect Supervision with Direct Supervision
immediately available at all times on consult services. Supervision may be provided by
PGY2, PGY3 residents, fellows or attending physicians.
2. All PGY2 and PGY3 residents will function under Indirect Supervision with Direct
Supervision available at all times on consult services. Supervision will be provided by
either fellows or attending physicians.
3. All fellows will function under Indirect Supervision with Direct Supervision available for
initial consults and may function under oversight for follow up consultation visits.
Supervision will be provided by attending physicians credentialed in the specialty area.
4. All initial consult, follow-up consult, and procedure notes generated by a housestaff
member are to be forwarded to the responsible supervising attending for review and
signature regardless of whether a billable service was provided by the attending
physician for the purpose of supervision.
5. Physician encounters by a trainee at any level with the patient and/or family for the
purpose of 1) informing of diagnosis, prognosis, and/or therapeutics; 2) counseling in
regard to obtaining informed consent; and 3) counseling regarding end-of-life directives
should be documented in the electronic medical record with appropriate designation as
to content in the subject line. These notes should be forwarded to the attending
physician.
6. The consult fellow will generate a consultation summary letter/note to be sent to the
patient’s primary care physician, referring physician, and primary hematologistoncologist within 24 hours of signing off of the patient. This letter/note will be forwarded
to the supervising attending physician for review and signature.
Ambulatory Block Rotations and Continuity Clinics at VCUHS and VAMC
1. All patient encounters in the ambulatory setting will be supervised by an attending
physician who will serve as the attending of record for the patient encounter. This
physician is ultimately responsible for the care provided to the patient during the
encounter. This attending physician should be identified easily in the patient record and
should sign off on all documentation for the encounter. The level of supervision required
varies by stage of training as noted below.
2. PGY1 residents function under Direct Supervision for the first six months of training in all
ambulatory settings. Supervision MUST be provided by an attending physician.
3. PGY2, PGY3, and PGY1 residents six months into training function under Indirect
Supervision with Direct Supervision immediately available (at a minimum). Supervision
may be provided by fellows or attending physicians.
4. Fellows in clinic during regularly scheduled clinics function under Indirect Supervision,
Direct Supervision immediately available.
5. Fellows in clinic outside of regularly scheduled clinic hours function under Indirect
Supervision, Direct Supervision available.
6. It is expected that any registered outpatient physician encounter seen by a trainee in an
ambulatory clinic setting will have documentation of the patient encounter entered into
the electronic medical record. This documentation is to be forwarded by the trainee to
the responsible supervising attending for review and signature regardless of whether a
billable attending encounter occurred.
Performance of Procedures
Level of supervision requirements for procedures are independent of year of training. In all
settings, trainees at all levels will perform procedures under Direct Supervision until they have
demonstrated proficiency in that procedure, as required by the individual division or the
department for that specific procedure. PGY1 residents may be supervised by PGY2 or PGY3
residents, fellows, other credentialed providers, or attending physicians proficient in the specific
procedure. PGY2 and PGY3 residents may be supervised by fellows, other credentialed
providers, or attending physicians proficient in the specific procedure. Fellows may be
supervised by attending physicians or other healthcare professions proficient in the specific
procedure.
Once proficiency in a procedure is identified, the trainee is “credentialed” in that procedure in an
electronic tracking system and may perform that procedure with Direct Supervision Available.
Fellows may perform procedures, once “credentialed” under oversight. In addition, once
“credentialed” in a procedure, the trainee may act as a supervisor for non-credentialed trainees.
For patient safety purposes, scope of practice for independent performance of procedures is
identified in an electronic logging system which is updated continuously and available for review
by any healthcare practitioner in all practice settings. In this system, any provider (nurses,
residents, physicians, others) responsible for the patient’s management, is able to
independently confirm the credential status in advance of the procedure being performed as
necessary.
A procedure note will be entered in to the electronic medical record upon completion of the all
procedures performed by a housestaff member. The procedure note will be forwarded for review
and signature to the supervising attending physician or other credentialed provider who
supervised the procedure if such supervision was required based on the credential status of the
housestaff member performing the procedure. In addition, the procedure note will be forwarded
to the supervising attending responsible for the oversight of the patient’s care.
Subspecialty fellowships should specifically outline in their individual policies the expectations
for procedural supervision in the cardiac catheterization laboratory, electrophysiology laboratory,
endoscopy suite, bronchoscopy suite, operating room, and any other primary procedural area.
These policies should be consistent across the training sites, including but not limited to VCUHS
Hospitals and the McGuire Veterans’ Affairs Medical Center.
Ordering of Antineoplastic Agents
The fellows are expected to write the chemotherapy order in the form of a chemotherapy note
on the patients for whom they have clinical responsibility whether on an ambulatory, inpatient, or
consultative rotation at both VCUHS and the VA Medical Center. For the purposes of patient
safety and supervision, the chemotherapy notes are to be reviewed and co-signed by an
attending physician in accordance with each institution’s established policies and
procedures. The attending signature may be obtained directly, electronically, or via FAX subject
to each respective institution’s specific requirements. Verbal attestation of the orders alone by
the attending physician is not acceptable.
The only exceptions to the policy are the ordering of the following:
1.
Oral antineoplastics (cytotoxic and biologics therapies) that the patient has been
administered at home may be ordered by the fellow and administered upon inpatient
admission to maintain the home dose and schedule.
2.
Emergent administration of oral hydroxyurea for the purpose of emergent
leukoreduction may be ordered by the fellow and administered by nursing following
review of the situation, and therapeutic plan (including dose and frequency) with the
supervising attending via telephone.
In regards to the above noted exceptions, the medication, route, dose, and frequency should
still be documented in a formal chemotherapy note or specifically stated within the fellow’s
physician note entered into the electronic medical record for that day’s encounter including
documentation that the plan had been reviewed with an attending physician. The fellow must
review the medication dose and frequency with the attending physician in advance of ordering
though this communication may occur via the telephone. Co-signature by the attending is to be
obtained within 24 hours.
At-Home Call by Fellows and PGY3 residents
No trainee will take at-home call unless at the PGY3 level or above.
When taking at-home call, the PGY3 residents and fellows will have Indirect Supervision with
direct supervision available at all times by the on-call attending physician.
Electives Outside of the Department of Internal Medicine
The supervision requirements for all electives outside of the Department of Internal Medicine will
remain consistent with this document unless otherwise detailed in the formal educational
agreement and approved by the individual program director of the trainee.
Circumstances and Events Requiring Notification or Escalation
The Department of Internal Medicine recognizes the balance between autonomy and
supervision necessary for medical education while optimizing patient safety. As such, the
department recognizes specific situations it believes require timely notification of the supervising
attending physician. These situations include but need not be limited to the following:
1.
2.
3.
4.
5.
6.
7.
8.
Uncertainty or substantial controversy about clinical care decisions
Change in service for management of an acute medical condition
Acute need for surgical intervention
Change in level of care (move to step-down or intensive care unit)
End-of-life discussions
Unexpected death of a patient
Any other serious change in clinical condition
Patient insistence on leaving facility against medical advice
Reviewed and updated 7-29-2011, SAC
Reviewed and updated 8-1-2011, LKB
Reviewed and updated 6-26-2013, JCB