Supervision Policy

Supervisory Lines of Responsibility

• All patient care by the fellow is supervised by qualified faculty
• All on-duty faculty and fellows are available by pager at all times

The levels of supervision used in this policy are defined by the ACGME Common Program Requirements:

• Direct Supervision: the supervising physician is physically present with the fellow and patient.
• 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.
  • 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 telephone or other electronic means and is available to provide direct supervision.
• Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. As above, some types of after-hours patient care are effectively delivered by fellows with subsequent attending review, but even in those circumstances, a fellow may always call his or her supervising attending for advice when needed.

Clinical Neurophysiology fellows may be supervised for patient clinical encounters at any level during the course of the year, but it is expected that most patient encounters will be supervised at the levels of without direct supervision immediately available to oversight. The attending physician must be immediately made aware of any unexpected deterioration of a patient under the care of the fellow.

Ours is an interdisciplinary team effort designed to provide the best possible care for our patients as we develop the clinical skills in the next generation of clinical neurophysiologists. We strive to maintain in our program a culture of safety, meaning not only that the safe and appropriate care of our patients is always paramount, but also that our trainees and colleagues are always empowered to raise concerns about the care in which they’re participating.

Fellows should never hesitate to admit that they need help, don’t know something, may have committed or identified an error, etc. The program will never retaliate against anyone taking such actions in good faith.

Fellows should never feel isolated and out of their depth, as there is always more experienced backup available. Similarly, our nursing, allied health, and other clinical colleagues should know that if a patient appears to not be receiving the proper care from a junior resident, backup is available in the form of senior residents and fellows. Following is the chain of command for neurology patients:

1. Junior resident. Listed as first call in all call schedules on WebXchange
2. Senior resident. In order to avoid misdirected pages after hours, the senior resident is not always listed in WebXchange, but there is always someone on call—just call telecommunications (2-2122) to have the neurology senior resident paged.
3. Clinical Neurophysiology Fellow: Will be listed in the call pool in WebXchange when they are on service and/or taking call.
4. Attending physician. Always listed in the call schedules.
5. Fellowship program director. Not always available on pager, but telecommunications can call his/her cell phone at any time.

Clinical Neurophysiology fellows will have graduated from a neurology residency program in good standing and will be given responsibilities in accordance with that level of training.  After one month of indirect supervision with direct supervision available, they will be expected to practice with oversight in a majority of cases but will always have faculty-level backup available if needed.  They will be expected to staff patients with junior and senior residents for in-hospital and emergency department consults and admissions.  The fellow does not need to call the attending for new EEG hook-ups unless fellow is not sure in their interpretation. They are responsible for writing preliminary reports and ensuring handoff to the oncoming team.

Cortical mapping. All bedside and OR cortical mapping will be performed under direct supervision by the attending epilepsy physician.

Intra-operative monitoring: All intra-operative monitoring will be performed under direct supervision of the attending epilepsy physician.

Concern for seizure or status epilepticus: If the fellow has concern that an EEG shows an acute seizure or status epilepticus, they must move from indirect to direct supervision by contacting the epilepsy physician for review. This requirement may be waived at the 6-month CCC meeting if all faculty agree fellow is entrustable with this activity.

Procedures will be documented in a procedure log in MedHub.