Resident Levels of Care-Explanatory Notes

1. Internal Medicine is a broad field encompassing a number of recognized subspecialties and the evaluation and management of hundreds of diseases and clinical problems. The complexity of any given problem or patient is modified by a number of factors, including age, co-existing disease, previous pharmacologic intervention, and psycho-social issues. For these reasons, it is difficult to delineate precisely the level of supervision required of a resident who is dealing with a particular problem. Only general guidelines, as stated in the accompanying charts, can be established. These are based both on accepted standards stated or implied in medical textbooks and journals, and the experience of the faculty in dealing with residents at different levels.

2. In a training program, as in any clinical practice, it is incumbent upon the physician to be aware of his/her own limitations in managing a given patient, and to consult a physician with more expertise when necessary. While the concept of “usual standard of care” may be invoked, physicians with similar levels of training and experience may vary widely in their ability to manage certain types of problems. Appreciation of one’s limitations is a goal of the Internal Medicine residency program, and the extent to which a physician asks for consultation when necessary is constantly assessed by the Program Director and faculty.

3. In a training program, some degree of oversight by the faculty and more advanced residents is always appropriate, even for common problems and uncomplicated paitents. This may be done in a variety of ways, including record review and independent evaluation of a patient by the reviewer, even when direct supervision is not required.

4. The Delineation of levels of care of PGY-2 and PGY-3 residents cannot be separated because the rotation schedule of each resident is different. Skills within a given area will therefore be acquired at varying points in the training schedule, and the precise mix of patients that will be encountered on a given rotation cannot be predicted with accuracy.

5. In general, procedural skills require supervision until it is documented that the resident can perform the skill satisfactorily. The number of satisfactory observations required depends on complexity of the skill and the likelihood of complications. Listed on the accompanying charts is the number established for each skill. Supervision may be by faculty or a more advanced resident. While it is anticipated that many residents will reach the required number in the PGY-1 year, the requirement continues into the PGY-2 and PGY-3 years until the requirement is satisfied.

6. Some more complex procedures may require supervision.

7. It is expected that some of the skills listed under “Cognitive Clinical management” will be acquired to a satisfactory degree prior to beginning post-graduate training and that supervision is not required. However, a number of these are assessed during the observed Clinical Evaluation Exercise in the PGY-1 year. Others are a part of the written evaluation for every rotation. Any deficiences in these areas are noted, and the resident is subject to close evaluation until the deficiency is corrected.

Resident Training Level: PGY-1

JOB DUTIES

Cognitive Clinical Management:
The resident performs and documents history and physical exam. Develops differential diagnosis and problem list. Develops and documents initial plan of care*. Writes daily progress notes. Writes orders for diagnostic studies. Modifies daily plan of care*. Write daily progress notes. Writes orders for routine diagnostic studies, medications, and other care modalities*. Evaluates patients with acute medical problems upon request of nurses and other physicians*. Obtains informed consent for procedures in PGY-1 scope of practice. Orders appropriate consults for diagnostic studies, evaluation of other physicians, physical/rehabilitation therapy, specialized nusring care, and social services. Initiates discharge planning. Dictates discharge summary. Evaluates new and follow-up patients in outpatient setting.

Non-Invasive Clinical Mangement:
The resident performs digital rectal exam. Performs breast exam. Performs pelvic exam, pap smear.

Invasive Clinical Management:
The resident performs abdominal paracenteses. Performs arterial puncture. Inserts central venous catheter. Performs oral endotrachial intubation. Performs nasal endotrachal intubation. Performs nasogastric intubaton. Performs thoracenteses. Performs arthrocenteses: Knee, Hand, wrist. Inserts urethral catheter. Inserts arterial catheter. Performs Bone marrow aspiration and biopsy. Performs flexible sigmoidscopy**.

Resident Supervision:
For these procedures, the resident must perform the listed number satisfactorily under the direct supervision of an upper level resident or faculty member, and document the supervision in the Procedure Log Book. Thereafter, this notation will be removed and the resident can perform the procedure without supervision. However, if difficulty is encountered the resident or the nurse must still call an upper level resident or faculty member for assitance.

*Skill may require supervision of an upper level resident or faculty if the disease/problem involved is unusual or complicated.

**Resident should seek help from upper level resident or other specialty if any difficulty encountered.

***Procedure always requires presence of fellow or faculty (See Explanatory Notes).

Resident Training Level: PGY-2 & 3 (and Med/Peds 4)

JOB DUTIES

Cognitive Clinical Management:
The resident performs and documents history and physical exam. Develops differential diagnosis and problem list. Develops and documents initial plan of care*. Orders and interpets routine diagnostic studies. Modifies daily plan of care*. Writes daily progress notes. Writes orders for routine diagnostic studies, medications, and other care modalities*. Evaluates patients with acute medical problems upon request of nurses or other physicians. Obtains informed consent for procedures in PGY-2 & 3 scope of practice. Orders appropriate consults for diagnostic studies, evaluation by other physicians, physical/rehabilitation therapy, specialized nursing care, social services. Initiates discharge planning. Dictates discharge summary. Evaluate new and follow-up patients in outpatient setting.

Non-Invasive Clinical Management:
The resident performs dignital rectal exam. Performs breast exam. Performs pelvic exam, pap smear. Performs ACLS*. Initiates/adjusts mechanical ventilation*. Orders, adjusts artificial feeding modalities*.

Invasive Clinical Management:
The resident performs abdominal paracentesis. Performs arterial puncture. Inserts central venous catheter. Performs oral endotrachial intubation. Performs nasal endotrachcial intubation. Performs nasogastric intubation. Performs thoracentesis. Performs arthrocenteses: Knee, Hand, wrist. Inserts urethral catheter. Inserts arterial catheter. Performsarterial catheter. Performs bone marrow aspiration and biopsy**. Performs flexible sigmoidoscopy**. Inserts pulmonary artery catheter***. Inserts chest tube***.

Resident Supervision:
For these procedures, the resident must perform the listed number satisfactorily under the direct supervision of a higher level resident or faculty member, and document the supervision in the Procedure Log Book. Thereafter this notation will be removed and the resident can perform the procedure without supervision. However, if difficulty is encountered the resident or the nurse must call a higher level resident of faculty member for assistance.

*Skill may require supervision of a fellow or faculty if the disease/problem involved is unusual or complicated.

**Resident should seek help from a fellow or other specialty if any difficulty encountered.

***Procedure always requires presence of fellow of faculty. (See Explanatory Notes)