Lines of Supervision

Faculty supervision of fellows is essential for safe patient care. Supervision is direct, indirect while immediately available and indirect by phone and/or electronically but available as needed. All oversight performed by Pediatric Hematology/Oncology fellows during the instruction of residents similarly applies when they are learners.

Supervision of Fellows

  • All patient care must be supervised by qualified faculty. The program director must ensure, direct, and document adequate supervision of fellows at all times. Fellows must be provided with rapid, reliable systems for communicating with supervising faculty
  • Faculty schedules must be structured to provide fellows with continuous supervision and consultation
  • Faculty and fellows must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects

Faculty Supervision Expectations

  • The Pediatric Hematology/Oncology attendings are ultimately responsible for all aspects of patient care
  • The Pediatric Hematology/Oncology attendings supervise the Pediatric Hematology/Oncology subspecialty fellows in the performance of all procedures, such as bone marrow aspirates, bone marrow biopsies, and lumbar punctures
  • The Pediatric Hematology/Oncology attending is ultimately responsible for supervising care delivered by fellow physicians. As subspecialty fellows progress, they may at times conduct rounds with the fellows without direct faculty supervision. Immediately after these rounds, however, the subspecialty fellow will review with the attending decisions made during the rounds. This will provide the attending with an understanding of the subspecialty fellow’s capability in independent decision making. The Pediatric Hematology/Oncology subspecialty fellows may evaluate patients with residents. The subspecialty fellows may evaluate the residents
  • The Pediatric Hematology/Oncology attending is ultimately responsible for supervising care delivered by physician assistants and nurse practitioners.  The subspecialty fellow may deliver care in collaboration with the PAs and PNPs
  • Problems related to the training program/education should be referred to the Program Director
  • Problems related to staff or patient care should be referred to the Division Chief

Fellow Communication Expectations

Expectations concerning when to initiate communication

  • Newly diagnosed patients/patient transfers
  • Deterioration in clinical status. Examples include but are not limited to:  
    • Unstable vital signs despite appropriate interventions
    • Acute deterioration in respiratory status / impending respiratory failure
    • Acute change in mental status
    • PEW Score: a value of “3” in one category or a total score of 4 or higher
  • Change in level of care. Examples include but are not limited to:  
    • Transfer to PICU or IMC
    • Cancellation of a planned discharge for medical or social reasons
    • Patient death
    • New admission or transfer from OR with significant medical issues
  • Issues related to medical decision making and plan. Present the case in SBAR (Situation Background Assessment Recommendation) format. Examples include but are not limited to:  
    • New critical labs
    • Before calling another service for a consult (including before calling the PICU)
    • New decisions or recommendations by consultants emergent/occurring before the next planned discussion – endoscopy, biopsy, bronchoscopy, surgery, change in DNR status
    • Any time you wish to discuss your planned medical decision making
  • Seeking assistance with systems issues or hierarchy. Examples include but are not limited to:  
    • To ask for assistance in obtaining urgently needed services for a patient
    • To facilitate attending to attending discussion between services
  • Miscellaneous. Examples include but are not limited to:  
    • To discuss patient or family dissatisfaction that has not been adequately resolved
    • Medical error(s) which has/have impacted patient care or safety
    • Any concern, question or issue relevant to patient care or safety

Expectations concerning when to come to the hospital during beeper call:

  • Patient death
  • An unstable and critically ill patient
  • Newly diagnosed patients requiring emergent therapy
  • Complex procedure requiring planning
  • Family requests to speak with the physician
  • Fellows presence as requested by the attending physician

Supervision Definitions and Logistics

Level / Action Pediatric Hematology/Oncology PGY4s Inpatient ward, BMT/ Night Call, Procedures, Acute Clinic and Continuity Care Clinic
Preparation Orientation by faculty and program director
Introductory Didactic Lectures
Patient- and Family-centered Rounds(PFCR) – complete module
Session on communication and “sign-out” during orientation
Expected objectives:
  1. Safe, efficient, effective sign-out
  2. Appropriate requests for supervision / assistance (direct, via phone)
  3. Professional communication as part of FCR with patient, family, and team
  4. Demonstrated reasonable data gathering, analysis and plan formulation
  5. Detailed effective, timely medical notes
Direct Supervision (DS) The supervising physician is physically present with the resident and the patient (e.g. shoulder-to-shoulder).

DS by attending 7:30a – 5 pm weekdays and 8am – 4pm on weekends and for patient- and family-centered rounds

Attending Continuity Clinic
Indirect Supervision + DS

Immediately Available On Site
The supervising physician is physically within the hospital or other site of patient care and is immediately available to provide direct supervision (e.g. in the building within a short walking distance)

For all patients – Attending immediately available in person from 8 am to 6 pm, by phone or in person from 6 pm to 8 am.
Indirect Supervision + DS available Off Site Supervising physician is immediately available by phone and/or other electronic modalities and can be called in to provide direct supervision if necessary.

Direct supervision is available at all other times by PRG3 and Faculty (e.g. supervisor’s discretion, fellow’s request)
Oversight This is functionally independence for a fellow. Fellows who are capable of operating under oversight can also function as a supervision physician for more junior level fellows. The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Review notes, encounters, procedures, performance on rounds – provide formative feedback @ 2 and 4 weeks

Structure clinical observation (SCO); professionalism, analysis and decision making

Ongoing review during rotation with direct communication by faculty to fellow and PD for any issues / concerns