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Levels of Supervision
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 resident during the key portions of the patient interaction.
- UW clinics and bedside teaching rounds are generally conducted under direct supervision.
- Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the fellow for guidance and is available to provide appropriate direct supervision.
- Fellows provide much inpatient care, and some outpatient VA care, with this type of supervision. Even when fellows provide consultations, or answer patient calls overnight without discussing with an attending physician in real-time, the attending faculty nonetheless are available to provide guidance to any fellow on any case at any time.
- 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.
Epilepsy 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 indirect 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.
Our Culture of Safety
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 epileptologists. 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.
Chain of Command
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 fellow, backup is available in the form of faculty. Following is the chain of command for neurology patients:
- Junior resident. Listed as first call in all call schedules on WebXchange
- 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.
- Clinical Neurophysiology/Epilepsy Fellow: Will be listed in the call pool in WebXchange when they are on service and/or taking call.
- Attending physician. Always listed in the call schedules.
- Fellowship program director. Not always available on pager, but telecommunications can call his/her cell phone at any time.
Epilepsy 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 the fellow is considering the interpretation of acute seizure or status epilepticus, in which case they need to confirm the finding with the attending. This later requirement will be considered at the 6-month CCC meeting and if the fellow is unanimously approved by the CCC, this requirement will be waived. They are responsible for writing preliminary reports and ensuring handoff to the oncoming team.
Clinical Situations Requiring Communication with Faculty
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.