The position of resident or fellow physician entails provision of patient care matching with the individual physician's level of advancement and competence. Residency is the phase of formal medical education beginning at graduation from medical school and ending after the educational requirements for the medical specialty certifying board has been completed. A resident physician's responsibilities include patient care activities within the scope of their clinical privileges commensurate with the level of training, attendance at clinical rounds and seminars, timely completion of medical records, and other responsibilities as assigned or as required of all members of the medical staff. 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.
- Arrange for discharge and after care.
- Write / dictate admission notes, progress notes, procedure notes, and discharge summaries.
- Provide patient education and counseling covering health status, test results, disease processes, and discharge planning.
- Perform procedures.
- Assist in surgery.
A: Purpose and Scope
The objective of medicine under the watchful eye of attending faculty clinicians and includes:
- participation in safe, effective and compassionate patient care;
- 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;
- 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;
- participation in institutional committees and councils to which the house staff physician is appointed or invited; and
- 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.
B. Graded Responsibilities
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 are based on formative evaluations 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 staff practitioner 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 that is the responsibility of the staff practitioner.
Both formal examinations and performance ratings 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 an annual summative review is an important part of this evaluation process. The Residency Program Director has the responsibility to determine and to document in writing, that the resident physician possesses the skills necessary to practice at the level commensurate with their training.
C. Organizational Relationships and Supervision
All resident physicians are supervised by licensed independent practitioners who are faculty members practicing at Dartmouth-Hitchcock (D-H) or affiliated institutions.
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 the 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 privileges 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 is provided by appropriately privileged teaching staff. This supervision is proximal, continual, and based on normative and summative evaluations following 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
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 D-H 24 hours per day (or generally present in-house but always 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. All patients admitted by resident physicians are reviewed by faculty. In the case of critically ill patients, a treatment plan is usually initiated by an attending staff member and/or consultants in the Emergency Room prior to transfer to the critical care units.
Resident physicians are supervised by full time emergency room faculty 24 hours per day. The faculty members are responsible for demonstrating and instructing resident physicians in proper emergency patient managements. 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.
All residency programs participate in the medical center-wide quality assurance system. Performance evaluations of residents are coordinated and administered by Residency Program Directors (staff physicians within a particular specialty). Performance evaluations are reflective of both academic knowledge and patient care/clinical skills. These evaluations are considered to be confidential and privileged (by New Hampshire laws RSA 151:13a and RSA329:29a). The ultimate goal of a performance evaluation is to determine if a resident physician's skill, knowledge and experience is sufficient to provide quality care to patients in the future.
A. Education and Training
Applicants must meet one of the following qualifications to be eligible for appointment to ACGME-accredited residency and fellowship programs at D-H:
- Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees. Some programs require successful passage of board exams (or good faith effort to pass) for promotion through subsequent years of fellowship.
- Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA) and successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
- Graduates of medical schools outside the United States and Canada who meet one of the following qualifications:
- Have a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment, or
- Have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are in training, and
- Successful completion of any pre-requisite accredited training specified by ACGME Residency Review Committees.
- Graduates of medical schools outside the United States who have completed a Fifth Pathway program* provided by an LCME-accredited medical school and successful completion of any pre-requisite accredited training.
* A Fifth Pathway program is an academic year of supervised clinical education provided by an LCME-accredited medical school to students who meet the following conditions: (1) have completed, in an accredited college or university in the United States, undergraduate premedical education of the quality acceptable for matriculation in an accredited United States medical school; (2) have studied at a medical school outside the United States and Canada but listed in the World Health Organization Directory of Medical Schools; (3) have completed all of the formal requirements of the foreign medical school except internship and/or social service; (4) have attained a score satisfactory to the sponsoring medical school on a screening examination; and (5) have passed either Parts I and II of the examination of the National Board of Medical Examiners or Steps 1 and 2 of the United States Medical Licensing Examination (USMLE).
B. Technical Requirements
The resident physician must be in possession of a NH Training or unrestricted license, a valid DEA number and current BLS certificate plus other advanced competencies as deemed necessary for their level of training, (ACLS, ATLS, PALS, etc.) to become involved in direct patient care.