Supervision

The objective for supervised graduate medical education is to prepare the resident physician for the independent practice of medicine and includes:

1. Participation in safe, effective and compassionate patient care.
2. Developing an understanding of ethical, socioeconomic and medical-legal issues that affect graduate medical education, and how to apply cost containment measures in the provision of patient care.
3. Participation in the educational activities of the training program, and as appropriate, assumption of responsibility for teaching and supervising other residents and students, and participation in institutional orientation and education programs and other activities involving the clinical staff.
4. Participation in institutional committees and councils to which the house staff physician is appointed or invited.
5. Performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments and other institutions to which the house staff physician is assigned; including, among others, state licensure requirements for physicians in training.

The resident physician is both a learner and a provider of medical care. The resident physician is involved in caring for patients under the supervision of more experienced physicians. As their training progresses, resident physicians are expected to gain competence and require less supervision, progressing from on-site and contemporaneous supervision to more indirect and periodic supervision.

Resident physicians are given progressive responsibility for the care of the patient. The determination of a resident physician's ability to provide care to patients without a supervisor present or act in a teaching capacity includes formative and summative evaluations of the resident physician's clinical experience, judgment, knowledge, and technical skill. These evaluations follow institutional guidelines and align resident physician learning in relation to the general competencies of medical knowledge, patient care, practice-based learning, interpersonal and effective communication, professionalism, and systems-based practice.

Ultimately, it is the decision of the Program Director and attending physician with direct responsibility of the resident as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. The overriding consideration must be the safe and effective care of the patient.

Both formal examinations and performance evaluations by the faculty are utilized, and the resident physician is personally apprised of his or her strengths and weaknesses at appropriate intervals at least twice annually. Completion by the program director of resident yearly report forms is an important part of this evaluation process.

The Residency Program Director has the responsibility to determine that the resident physician possesses the skills necessary to practice at the level commensurate with their training. Annually, at the time of promotion, or more frequently, appropriate documentation will be provided to the Department Chair, the Graduate Medical Education (GME) Director (Designated Institutional Official), Residency Program Coordinator or Administrator, and into the residency program's records.

Licensed independent practitioners who are faculty members practicing at Dartmouth Hitchcock Medical Center or affiliated institutions are among those who supervise all resident physicians.

The resident physician shall participate in patient care under the direction of physicians whose clinical privileges are appropriate to the activities in which the resident physician is engaged. Neither the resident physician's clinical privileges nor their clinical responsibilities shall exceed in scope those of their supervising physician. The supervising physician shall make clinical assignments to each assigned resident physician consistent with the resident physician's experience and demonstrated clinical competence, and strive to ensure that each resident physician performs assigned duties in an appropriate manner. Resident physicians shall be responsible in their clinical activities to the Chief of the designated Section and through the Chief to the Clinical Department Chair. Except for admitting privileges, the responsibilities of each resident physician are determined by the appropriate Section members and Department Chair in context of the respective professional graduate training program requirements.

General supervision

General Supervision is provided by appropriately privileged teaching staff. This supervision is proximal, continual, and based on normative and summative evaluations following Accreditation Council for Graduate Medical Education (ACGME) and institutional guidelines. All resident care is supervised and the attending physician is ultimately responsible for care of the patient. The proximity and timing of supervision, as well as the specific tasks delegated to the resident physician, depend on a number of factors, including:

• The level of training (i.e., year in residency) of the resident
• The skill and experience of the resident with the particular care situation
• The familiarity of the supervising physician with the resident's abilities
• The acuity of the situation and the degree of risk to the patient

Outpatient clinics

Resident physicians in all outpatient clinics are supervised by attending faculty members on-site. Resident physician clinics are held in designated areas (or the same practice area as the faculty practice) and are supported in the areas of nursing, laboratory and other services in the same manner as the faculty practice settings.

Inpatient settings at night and on weekends

Faculty members are available at Dartmouth Hitchcock Medical Center 24 hours per day (or generally present in-house but available by telephone at all times). A faculty member will customarily see any complex or seriously ill patient promptly after admission. Immediate specialty consultations by attending faculty are available on-call at all times to resident physician staff in the same manner that is available to any active member of the medical staff. Faculty review all patients admitted by resident physicians. In the case of critically ill patients, an attending staff member usually initiates a treatment plan and/or consultants in the Emergency Room prior to transfer to the critical care units.

Emergency room

Full-time emergency room faculty supervise resident physicians 24 hours per day. The faculty members are responsible for demonstrating and instructing resident physicians in proper emergency patient management. They supervise the clinical activity of the resident physician and assume the responsibility for evaluating the resident physician's clinical competence and delegating increasing patient care responsibilities as appropriate.