Resident Supervision Guidelines

I. POLICY STATEMENT

Trainees in the UCSF General Surgery Residency Training program learn to provide optimal patient care under the supervision of faculty members who not only instruct but serve as role models of excellence, compassion, cultural sensitivity, professionalism, and scholarship. The care of patients is undertaken with appropriate faculty supervision and conditional independence, allowing residents to attain the knowledge, skills, attitudes, judgment, and empathy required for autonomous practice. 

Although the attending physician is ultimately responsible for the care of the patient, every physician shares in the responsibility and accountability for their efforts in the provision of care. Effective programs, in partnership with their Sponsoring Institutions, define, widely communicate, and monitor a structured chain of responsibility and accountability as it relates to the supervision of all patient care. Supervision in the setting of graduate medical education provides safe and effective care to patients, ensures each trainee's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine, and establishes a foundation for continued professional growth.

Every patient must have an identifiable, appropriately-credentialed and privileged attending physician who is responsible and accountable for that patient's care. This information must be available to residents, fellows, faculty, other members of the healthcare team, and patients. Residents, fellows, and faculty must inform each patient of their respective roles in that patient's care when providing direct patient care. 

Residents must be provided with prompt and reliable systems for communication with attending physicians.

The appropriate level of supervision is based on each resident's level of training and ability, as well as patient complexity and acuity. Supervision may be exercised in multiple ways, including direct observation and physical presence of the faculty member, availability of the faculty member through communication technology, or post-hoc review of the trainee-delivered care with feedback. In some instances, supervision may be provided by a senior resident or fellow.

II. REASON FOR POLICY

This policy describes specific supervision policies for residents in the general surgery residency program at UCSF. Per ACGME common program requirements, the program must ensure that all resident clinical activities be appropriately supervised, and that the appropriate levels of supervision are exercised in specific clinical settings. 

These policies outline the minimum levels of supervision that are required, and the attending physician responsible for patient care must determine if a higher level of supervision is warranted on a case-by-case basis. This should be informed by an assessment of an individual resident's clinical competency and level of training.

III. DEFINITIONS

1. Direct Supervision: The supervising physician is physically present with the trainee during the key portions of the patient interaction; or, the supervising physician and/or patient is not physically present with the trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
2. Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
3. Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
4. Supervising physician: 1) attending physician with credentials to perform the procedure or activity at the clinical site in question, or 2) a surgical resident at the PGY2 level of higher whose supervision level is designated as "oversight."
5. Resident: This policy applies to all clinical residents in the UCSF General Surgery Residency Program, including the following:
   1. All categorical General Surgery residents PGY1-5
   2. Non-designated preliminary surgery residents PGY1-2
   3. Designated preliminary PGY1 residents in OMFS, Ophthalmology, and Interventional Radiology
6. Faculty attending physician: A physician on the medical staff, credentialed in the procedure or activity at the clinical site where the procedure or activity is occurring. 

IV. PROCEDURES

A. Principles

The attending physician is responsible for the care provided to individual patients. All residents function under the supervision of appropriately credentialed attending physicians.

Residents as individuals must be aware of their limitations. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the resident from patient care activities.

PGY1 residents must initially be directly supervised until competency is obtained. This assessment will be informed by entrustable professional activity microassessments, rotation evaluations, skills lab evaluations, and direct observations by faculty, residents, and other providers. 

All procedures performed in the operating room must be directly supervised by an attending physician for the key portions of the procedure.

The Program Director evaluates each trainee's abilities based on regular evaluations, guided by the ACGME Milestones. The General Surgery Residency Program's evaluation process includes regular review of end-of-rotation evaluations, peer evaluations, self-evaluations, EPA microassessments, case logs, in-training exam performance, scholarly activity, and faculty observations. These are reviewed for all general surgery residents on a semi-annual basis at the Clinical Competency Committee, chaired by the Associate Program Director for Assessment and Feedback.

Faculty members functioning as supervising physicians must delegate portions of care to trainees based on the needs of the patient and skills of each trainee. Patient care activities may occur in the operating room, wards, intensive care units, emergency department, or clinics. Each service, as coordinated by the designated faculty education lead, determines the appropriate workflow, supervision level, and delegation of care responsibilities to residents. This is informed by the individual trainee's level as well as assessment of their level of proficiency in the various settings. 

B. Competencies (Table of Procedures)

Below is a table of procedures indicating which procedure a surgical resident may perform, with or without supervision. In all cases the clinical situation, the experience of the specific resident, and the judgment of the more senior residents and the attending physicians, will determine if a higher level of supervision is required. 

Legend

DS = Direct Supervision
IS = Indirect Supervision
O = Oversight
DS/IS = Direct Supervision, until competency is achieved, then Indirect Supervision
I = Insertion
R = Removal