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 faculty are 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 include the evaluation of the five ACGME competencies through the resident’s clinical experience, judgment, professionalism, cognitive knowledge, and technical skills. These levels are defined as postgraduate years (PGY) and refer to the clinical years of training that the resident is pursuing. The requirements for training in categorical pediatrics calls for three years of training. Programs leading to subspecialization after core programs range from one to three years. This training, traditionally called fellowship, includes considerable autonomy especially in the tasks already mastered in the core program. At each level of training, there is a set of competencies that the resident is expected to master. As these are learned, greater independence is granted the resident in the routine care of the patient at the discretion of the faculty who, at all times, remain responsible for all aspects of the care of the patient. Examples of expected competencies and responsibilities for each level follow.
Individuals in the PGY I year are closely supervised by senior level residents and/or faculty. Examples of tasks that are expected of PGY I physicians include: performance of a history and physical, start intravenous lines, draw blood, order medication 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, and perform other invasive procedures under the 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 for care. The first-year resident must develop and implement a plan for self-directed learning, reading and researching of selected topics that promote 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.
Individuals in the second postgraduate year are expected to perform independently the duties learned in the first year and may supervise routine activities of the first-year residents. The PGY II should be able to demonstrate continued sophistication in the acquisition of knowledge and skills in pediatrics 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. Beginning at the PGY II level residents may order restraints or seclusion. The PGY II may perform some procedures without direct (on-site) supervision such as insertion of central lines, arterial lines, diagnostic peritoneal lavage, chest tube insertion or placement of PA catheters. Second-year residents may manage critically ill patients including initial trauma care, ventilator management, resuscitation from shock, and anti-arrhythmic therapy. Residents at this level can perform procedures and endoscopy under the direct supervision of faculty or senior level residents. The resident should take a leadership role in teaching the PGY I and medical students the practical aspects of patient care and be able to explain 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.
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. The PGY III can perform progressively more complex procedures under the direct (on-site) 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 practice pediatrics independently.
Individuals engaged in training beyond the core program are expected to be competent in the skills learned in the core residency. They should be focused on becoming proficient in the skills defined by the subspecialty they are pursuing. As they progress through the training program, they are given progressive responsibility in the skills that make up the information content of the specialty at the discretion of the faculty and the subspecialty.
Residents at every level are expected to treat all other members of the health care team with respect and with a recognition of the value of the contribution of others involved in the care of patients and their families. The highest level of professionalism is expected at all times. Residents shall follow hospital policies and procedures and support the mission, vision, and values of the facility. Residents shall maintain a professional appearance and safety of the patient. The resident is expected to develop an individualized learning plan. Along with general reading in pediatrics, residents should do directed reading daily with regard to problems that they encounter in patient care. Residents are expected to attend all relevant conferences that are part of the educational program. The didactic portion of the educational program is designed to augment clinical experience and individual reading.
At each level of pediatric training the competency of the individual PG physician is evaluated based on the six ACGME competencies. An ACGME internet web-based log system is used by housestaff to document patient interactions. An advisor system is in place to review each PG physician on a quarterly basis. The program director meets at least biannually with each resident and as needed.