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Responsibilities and Supervision Policy

Program Responsibilities

1. The assessment of a Fellow's competence shall serve as the basis for determining the minimum level of supervision required for different activities. Objective criteria to evaluate a Fellow's progressive ability to function independently shall be developed and consistently applied. This assessment will include the evaluation of the Fellow's communication skills, patient management, medical knowledge, and capacity to perform as required. The Program Director will communicate the assessment of the Fellow's competence to the Fellow semi-annually, and when significant progress or deficiencies are noted.

2. All patients seen by a Fellow on an inpatient or outpatient bases will be seen by, discussed with, and reviewed by the responsible Attending Physician.

3. On-call schedules for Attending Physicians will provide for supervision that is readily available to a Fellow on duty 24 hours per day, 7 days per week. Under circumstances in which urgent judgments by the Attending Physician are required, the Attending Physician will be immediately available on site at all times. Under other circumstances, Attending Physicians can provide adequate supervision off site as long as their physical presence within a reasonable time can be assured in case of need. The Program Director will assure that a schedule with the name and contact number of the responsible Attending Physician is available at all times to the fellows.

4. The program will continuously monitor and improve compliance with its supervision policies and competency assessments, using feedback from the fellows and Attending Physicians.

5. The program director will ensure direct and adequate supervision of fellows at all times. Fellows will be provided with rapid, reliable systems for communicating with supervising faculty.

6. Faculty schedules are structured to provide residents with continuous supervision and consultation.

7. Faculty and fellows will be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract its potential negative effects.

Attending Physicians Responsibilities

1. An attending physician is responsible for and actively involved in the care provided to each patient (both inpatient and outpatient).

2. An attending physician directs the care of each patient and provides the appropriate level of supervision for a Fellow based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and level of education, ability, experience, and judgment of the Fellow being supervised.

3. The attending physician will accord the Fellow progressive responsibility for the care of the patient based on the fellow's clinical experience, judgment, knowledge, skill, and capacity to function.

4. The attending physician will inform the program director if he/she believes a change in the level of the Fellow's responsibility and supervision should be considered. The overriding consideration must be the safe and effective care of the patient that is the personal responsibility of the attending physician.

5. The attending physician fosters an environment that encourages questions and requests for support or supervision from the Fellow, and encourages the Fellow to call or inform the attending physician of significant or serious patient conditions or significant changes in patient condition.

Fellow Responsibilities

1. A Fellow's responsibilities shall include patient care activities within the scope of his/her clinical privileges, attendance at clinical rounds and conferences, timely completion of medical records, and other responsibilities as assigned or are required of all members of the Medical Staff.

2. Each Fellow will take action as necessary to remain knowledgeable of the clinical status of all patients assigned to him/her, and discuss any significant changes in clinical status with the attending as soon as possible.

3. In life-threatening emergencies, Fellow's may initiate or modify major diagnostic and therapeutic actions consistent with their level of ability and training.

4. In case of an emergency, the Fellow may ask another health care provider to immediately contact the attending physician while the Fellow initiates emergency interventions but must inform the attending as soon as possible and receive additional instruction as indicated.

Fellow's Duties

Each vascular Neurology fellow will spend a minimum of 6 months on the acute and inpatient stroke service. The two fellows will alternate being on service, one week at a time. While on service, the fellow will participate in the daily rounds on the Neurology patients in the Neuro ICU and the inpatient stroke service. He/She is required to be familiar with all aspects of the individual patient's care, but may delegate some case presentations to the Neurology residents. Our stroke service runs the Neuro ICU in conjunction with the department of Anesthesia. While the Anesthesia team and Neurology resident on rotation assume direct line patient responsibility, the fellow will be required to supervise and teach the Neurology residents and medical students, and write detailed daily progress notes. The chief residents will have direct line patient responsibility, under the supervision of the attending, for patients on the inpatient stroke service. In all cases, the fellow will serve as an adjunct to the attending with responsibilities delegated as the attending sees fit.

The fellow will respond to Stroke Pager calls during weekdays and nights and weekends, when on service, and provide 24-hour coverage for the acute stroke service, including urgent Emergency Department evaluations and inpatient consultations, with individual case review for each case by the attending. The fellow will be required to obtain history, perform physical and neurological examinations, review all diagnostic studies, and write a detailed note on all patients seen as "code stroke".

Each fellow, whether on or off service, attends one half-day clinic session per week under the supervision of a stroke service attending. This is largely a Fellow-Attending precepting style clinic, with the majority of initial and follow-up evaluations performed by the fellow. Every visit has direct Attending Physician involvement in clinical evaluation, patient education, communication, and management decision making. The clinic will consist primarily of stroke patients (new and follow up from inpatient hospitalization). However, unoccupied slots may be given to general neurology patients. The clinic is a referral center for complex cerebrovascular disorders and second opinions. The Fellows are continuously guided through this process. The record keeping is entirely online, and all notes are co-signed by the tending Physicians. Direct feedback is provided on all aspect of patient-physician interactions. Fellows will rate their learning experience in parallel, and bidirectional feedback will contribute to continuous improvement of quality of patient care and the fellowship experience.

The fellow will take part in ongoing clinical studies and participate in the informed consent and data collection processes, under the direction of the Attending Physician. The fellow is also required to enter patients' data into our computerized stroke registry on a weekly basis, and is encouraged to maintain a log of patients evaluated throughout his/her training with regard to clinical diagnosis to assure that the diversity of cerebrovascular disorders cases has been seen and that an understanding of the condition has been achieved.

Supervision Policy

- Supervision of patient care

The vascular Neurology fellows will be supervised in all activities and at all times by the designated Stroke Attending Physician, during their inpatient, outpatient or elective rotations. All patients seen by the fellows will be reviewed with an Attending Physician to confirm critical components of the patient history, examination, and discussion of the management plan, all notes will be co-signed, and all data/studies related to patient care will be reviewed by the Attending Physician. In all "relatively" non-urgent inpatient and emergency department evaluations and in the clinics, the Attending Physician will evaluate the patient after the fellow to confirm his/her findings and provide real time teaching at the end of the evaluation. This provides for a system that establishes the fellow as the patient's physician while maintaining adequate supervision and provision of time for "teaching at the bedside". Feedback will be provided directly and immediately to the fellow by the attending. In addition, our division meets weekly to review programmatic issues and fellows' activities and performance. Our division maintains an "open door policy". Fellows are encouraged to discuss their concerns, stresses, challenges and plans with any of the Attending Physicians at any time. The supervising medical staff members have a current Full License issued by the Massachusetts Board of Registration in Medicine, and are properly credentialed.

- Medication initiation and refills

Initiation of any medications by the fellow should be after discussion with the Attending Physician. Continuation of medication (refills) in the outpatient setting for stable patients needs no further input.

- Data/tests interpretation

All relevant laboratory and imaging data, including MRI/MRA, CT/CTA, and TCD will be initially reviewed by the Fellow, then by the Attending Physician. The findings and interpretation will be discussed with the fellow to provide immediate feedback. For the TCD reports, the fellow will perform (initially under the attending's supervision & independently once adequate skills are met), review, interpret the findings discussed, and write a preliminary report that will be sent for co-signature by an Attending Physician. The study and report will be reviewed by the Attending Physician and discussed with the fellow. Further changes may occur before final sign off.

- Co-signature

All notes (electronic or hand-written in chart) will be co-signed by the Attending Physician.

- Out-of clinic communications

Telephone contact should be discussed with the Attending Physician and documented in the Online Medical Records, and sent for co-signature by the Attending Physician. The Attending Physician may request more details before final sign off.

- Progressive responsibility for patient management

The Vascular Neurology fellows will have graded responsibility. Initially, for at least the first 2 months the fellow will participate in morning and teaching rounds with the Stroke Service attending and resident staff. During the first months of training, the Fellow will make all clinical medical decisions in conjunction with the Attending Physician unless they are non-critical. As vascular Neurology fellows progress through their training, they will serve as adjuncts to the attendings and are given progressively larger responsibility for direct line patient care with less intensive supervision, unless so specified for individual Fellows based on their performance, (although all fellows will have direct and immediate access to an attending staff and all the notes will still require co-signature). In the outpatient setting, fellows are given gradually greater responsibility for managing their outpatients by the attending physician, as they show the aptitude and responsibility to assume that load.

- Supervision of research

Each fellow will be assigned a faculty supervisor to guide the fellows through a mentored independent or joint research project.