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Resident Responsibilities Policy

I. Purpose of Policy

The purpose of this policy is the expectation that each Graduate Medical Education (GME) Residency and Fellowship program develops and maintains specific descriptions for progressively increasing levels of patient care responsibility for residents, under the supervision of qualified faculty.

II. Policy Scope

The policy applies to all Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs at Dartmouth-Hitchcock (D-H).

III. Definitions

Resident: Any physician in an accredited graduate medical education program, including interns, residents, and fellows.

IV. Policy Statement

  • Clinical Care
    • Residents are expected to provide competent and compassionate patient care, and to work effectively as a member of the health care team. This implies professional demeanor and conduct both in direct patient care and in communication with family members, other health care professionals, and support staff. The highest level of professionalism is expected at all times. Residents are directly responsible to the faculty attending to whom they have been assigned for all matters related to the professional care of patients. Under the supervision of attending physicians, general responsibilities of the resident physician may include:
      • Initial and ongoing assessment of patient’s medical, physical, and psychosocial status
      • Perform history and physical
      • Develop assessment and treatment plan
      • Perform rounds
      • Record progress notes
      • Order tests, examinations, medications, and therapies
      • Interpret results of tests
      • Arrange for discharge and after care
      • Write or dictate admission notes, progress notes, procedure notes, and discharge summaries
      • Provide patient education and counseling health status, test results, disease processes, and discharge planning
      • Perform procedures
      • Assist in surgery

    • Residents at all levels should have a strong commitment to patient safety and professionalism. Training programs must educate residents and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider. In addition, the program must be committed to and responsible for promoting patient safety and the program director must ensure that residents are integrated and participate in clinical quality improvement and patient safety programs.

    • Programs must design clinical assignments to minimize the number of transitions in patient care. All training programs must develop and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. Residents must be competent in communicating with team members in the hand-over process.

  • Learning and Education
    • Residents are recognized as adult learners and ultimately the acquisition of knowledge, skills, and professional attitudes is the responsibility of each individual.

    • The institution and the residency programs will provide an ample selection of educational offerings. The expectation is that residents will make every effort to benefit from the education offered, by attending educational conferences as required for each program. The conference programs are designed to provide a didactic forum to augment the resident’s reading and clinical experience.

    • An essential component of learning is the development of life-long learning skills; all physicians must practice disciplined ongoing acquisition of medical knowledge. The resident is expected to develop a personal program of reading. Besides the general reading in the specialty, the resident should do directed daily reading relating to problems that they encounter in the care of patients. The resident is responsible for reading prior to performing or assisting in procedures that they have not yet had the opportunity to see.

    • The ACGME has defined the following six areas as General Competencies and stipulates that programs require their residents to develop them to the level of a new practitioner by the completion of training:
      • Patient Care
      • Medical knowledge
      • Practice-based learning and improvement
      • Interpersonal and communication skills
      • Professionalism
      • Systems-based practice
        • For a full listing of the six General Competencies and their respective sub-competencies, residents are referred to the specialty-specific curricula provided by their program and the ACGME website.

  • Discipline-Specific Education
    • A primary responsibility of graduate medical students is to meet the educational goals of their specific programs. In all D-H-sponsored GME programs, the residency program director is responsible for the organization and implementation of discipline-specific educational objectives. The resident is expected to manifest active involvement in learning, and has responsibility for the following:
      • Familiarity with the program’s educational objectives and residency curriculum
      • Development of competence in the six areas listed above
      • Development of a personal growth program of learning to foster continued professional growth
      • Experience with quality assurance/performance improvement

    • All residents must provide data on their educational experience to their Program Director and GME office as requested. The provision of regular feedback on faculty, program and overall educational experiences via confidential written or electronic evaluations, is an essential part of the continuous improvement of the educational programs within our institution and is required by the ACGME.

    • Active participation in departmental and hospital committees provide an opportunity for residents to become familiar with administrative aspects of health care and involvement with such experiences is strongly encouraged.

  • Teaching Others
    • Residents are also expected to teach and mentor junior residents, medical students, and other learners with whom they interact. Collaborative learning is an important part of graduate medical education and residents’ involvement with the education of other members of the health care team is vitally important.

  • Graduated Levels of Responsibility
    • Graduate medical education is based on the principle of progressively increasing levels of responsibility in caring for patients under the supervision of the faculty. The overriding consideration must be the safe and effective care of the patient that is the responsibility of the faculty attending. The faculty is responsible for evaluating the progress of each resident in acquiring the skills necessary for the resident to progress to the next level of training. Factors considered in this evaluation include the resident’s clinical experience, judgment, professionalism, cognitive knowledge, and technical skills. At each level of training, there is a set of competencies that the resident is expected to master. Examples of expected competencies and responsibilities for each level of training include the following:

      PGY I - Individuals in the PGY I year are supervised by senior level residents or faculty either directly or indirectly with direct supervision immediately available. If indirect supervision is provided, such supervision must be consistent with Residency Review Committee (RRC) policies and specific criteria which PGY I residents must meet in order to be eligible for indirect supervision must be established. Examples of tasks that are expected of PGY I physicians include: perform a history and physical, start intravenous lines, draw blood, order medications and diagnostic tests, collect and analyze test results and communicate those to the other members of the team and faculty, obtain informed consent, place urinary catheters and nasogastric tubes, assist in the operating room and perform other invasive procedures such as arterial line or central line insertion under the direct supervision of the faculty (or senior residents at the discretion of the responsible faculty member). The resident is expected to exhibit a dedication to the principles of professional preparation that emphasizes primacy of the patient as the focus of care. With the assistance of an assigned mentor or the program director, the first year resident must develop and implement a plan for study, reading and research of selected topics that promotes personal and professional growth and be able to demonstrate successful use of the literature in dealing with patients. The resident should be able to communicate with patients and families about the disease process and the plan of care as outlined by the attending. At all levels, the resident is expected to demonstrate an understanding of the socioeconomic, cultural, and managerial factors inherent in providing cost effective care.

      PGY II - Individuals in the second post graduate year are expected to perform independently the duties learned in the first year and may supervise the routine activities of the first year residents. The PGY II may perform some procedures with indirect supervision (such as insertion of central lines, arterial lines) once competency has been documented according to established criteria. Specific procedures allowed with indirect supervision at the PGY II level will vary with training program and must be guided according to published criteria established by the faculty and program director. The PGY II should be able to demonstrate continued sophistication in the acquisition of knowledge and skills in his/her selected specialty and further ability to function independently in evaluating patient problems and developing a plan for patient care. The resident at the second year level may respond to consults and learn the elements of an appropriate response to consultation in conjunction with the faculty member. The resident should take a leadership role in teaching PGY I residents and medical students the practical aspects of patient care and be able to explain more complex diagnostic and therapeutic procedures to the patient and family. The resident should be adept at the interpersonal skills needed to handle difficult situations. The PGY II should be able to incorporate ethical concepts into patient care and discuss these with the patient, family, and other members of the health care team.

      PGY III - In the third year, the resident should be capable of managing patients with virtually any routine or complicated condition and of supervising the PGY I and PGY II in their daily activities. The resident is responsible for coordinating the care of multiple patients on the team assigned. Individuals in the third post graduate year may perform additional diagnostic and therapeutic procedures with indirect supervision once competency has been documented according to established criteria. Specific procedures allowed with indirect supervision at the PGY III level will vary with training program and must be guided according to published criteria established by the faculty and program director. The PGY III can perform progressively more complex procedures under the direct supervision of the faculty. It is expected that the third year resident be adept in the use of the literature and routinely demonstrate the ability to research selected topics and present these to the team. At the completion of the third year, the resident should be ready to assume independent practice responsibilities in those specialties requiring three years of training. In those specialties requiring longer training, the resident should demonstrate skills needed to manage a clinical service or be a chief level resident.

      PGY IV - Individuals in the fourth post graduate year assume an increased level of responsibility as the chief or senior resident on selected services and can perform the full range of complex procedures expected of the chosen specialty under the direct or indirect supervision of the faculty. The fourth year is one of senior leadership and the resident should be able to assume responsibility organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard tests and be facile in using the literature to solve specific problems. The resident will be responsible for presentations at conferences and for teaching junior residents and students on a routine basis. The PYG IV should begin to have an understanding of the role of practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians.

      PGY V or Higher - The fifth year resident (generally surgical residents) takes responsibility for the management of the major surgical teaching services, under the supervision of the faculty. The PGY V can perform most complex and high risk procedures expected of a physician with the supervision of the attending physician. The attending physician should be comfortable allowing the PGY V resident to manage all common problems expected to be encountered during independent practice. During the final year of training the resident should have the opportunity to demonstrate the mature ethical, judgmental and clinical skills needed for independent practice. The PGY V gives formal presentations at scientific assemblies and assumes a leadership role in teaching on the service. The mores and values of the profession should be highly developed, including the expected selfless dedication to patient care, a habit of lifelong study and commitment to continuous improvement of self and the practice of medicine.

      Fellowship Training - Subspecialty fellowship programs range from one to three years in duration. Fellow responsibilities include considerable autonomy, especially in the tasks already mastered in the core program. Fellows will be focused on becoming proficient in the skills defined by the subspecialty they are pursuing. As the fellow progresses through the training program, progressive responsibility is given in the skills that make up the information content of the specialty at the discretion of the faculty.


V. References

Accreditation Council for Graduate Medical Education

D-H Policy ID: 11314