Residency Policies & Procedures
V. CLINICAL ROTATIONS
Roles, Responsibilities and Patient Care Activities
A physician who is engaged in a graduate education program in psychiatry
or a psychiatric subspecialty, and who participates in patient care
under the direction of attending physicians (or licensed independent
practitioners) as approved by the Psychiatry Review Committee of the
ACGME. Note: The term "resident" includes all residents and fellows,
including individuals in their first year of training (PGY1), often
referred to as "interns," and individuals in approved subspecialty graduate
medical education programs who historically have also been referred
to as "fellows."
As part of their educational program, residents are given graded and
progressive responsibility according to the individual resident's clinical
experience, judgment, knowledge, and technical skill. Each resident
must know the limits of his/her scope of authority and the circumstances
under which he/she is permitted to act with conditional independence.
Residents are responsible for asking for help from the supervising physician
(or other appropriate licensed practitioner) for the service they are
rotating on when they are uncertain of diagnosis, how to perform a diagnostic
or therapeutic intervention, or how to implement an appropriate plan
Attending of Record (Attending):
An identifiable, appropriately-credentialed and privileged attending
physician, or licensed independent practitioner, who is ultimately responsible
for the management of the individual patient and for the supervision
of residents involved in the care of the patient. The attending delegates
portions of care to residents based on the needs of the patient and
the skills of the residents.
To ensure oversight of resident supervision and graded authority and
responsibility, the following levels of supervision are recognized:
Direct Supervision - the supervisor (attending,
licensed independent practitioner, or senior resident with documented
supervisory capability) is physically present with the resident
- Indirect Supervision:
a) with direct supervision immediately available - the supervisor
is physically within the hospital or other site of patient care
and is immediately available to provide Direct Supervision
b) with direct supervision available - the supervisor is not physically
present within the hospital or other site of patient care, but is
immediately available by means of telephonic and/or electronic modalities
and is available to come to the site of care in order to provide
- Oversight - the supervising physician is available to provide review
of patient care with feedback provided after care is delivered.
The clinical responsibilities for each resident are based on PGY-level,
patient safety, resident education, severity and complexity of patient
illness/condition and available support services. The specific role
of each resident varies with their clinical rotation, experience,
duration of clinical training, the patient's illness and the clinical
demands placed on the team. The following is a guide to the specific
patient care responsibilities by year of clinical training. Residents
must comply with the supervision standards of the service on which
they are rotating unless otherwise specified by their program director.
PGY-1 (Junior Residents)
PGY-1 residents are primarily responsible for the care of patients
under the guidance and supervision of the attending physician and
senior residents. They should generally be the point of first contact
when questions or concerns arise about the care of their patients.
However, when questions or concerns persist, supervising residents
and/or the attending physician should be contacted in a timely fashion.
PGY-1 residents are initially directly supervised and, when merited,
will progress to being indirectly supervised with direct supervision
immediately available (see definitions above) by an attending or senior
resident. PGY-1 residents may progress to being supervised indirectly
with direct supervision available only after demonstrating competence
a) the ability and willingness to ask for help when
b) gathering an appropriate history;
c) the ability to perform an emergent psychiatric assessment; and,
d) presenting patient findings and data accurately to a supervisor
who has not seen the patient.
Progress to indirect supervision with direct supervision immediately
available requires demonstration of a), b), and d) on at least three
different occasions. PGY-1 residents may supervise medical students;
however, the attending physician is ultimately responsible for the
care of the patient.
PGY-2 (Intermediate Residents)
Intermediate residents may be directly or indirectly supervised
by an attending physician or senior resident but will provide all
services under supervision. They may supervise medical students; however,
the attending physician is ultimately responsible for the care of
PGY-3, PGY-4, and above (Senior Residents)
Senior residents may be supervised directly, indirectly, or by oversight.
They may provide direct patient care, supervisory care, or consultative
services, with progressively graded responsibilities, as merited.
They must provide all services ultimately under the supervision of
an attending physician. Senior residents should serve in a supervisory
role of medical students, junior, intermediate, and (in the case of
fellows) PGY-3 or PGY-4 residents, in recognition of their progress
towards independence, as appropriate to the needs of each patient
and the skills of the senior resident; however, the attending physician
is ultimately responsible for the care of the patient. When a senior
resident is supervising a more junior resident, both residents should
inform patients of their respective roles in that patient's care.
Attending of Record
In the clinical learning environment, each patient must have an identifiable,
appropriately-credentialed and privileged primary attending physician
who is ultimately responsible for that patient's care. The attending
physician is responsible for assuring the quality of care provided
and for addressing any problems that occur in the care of patients,
and thus must be available to provide direct supervision when appropriate
for optimal care of the patient. The availability of the attending
to the resident is expected to be greater with less experienced residents
and with increased acuity of the patient's illness. The attending
must notify all residents he/she supervises of when he or she should
be called regarding a patient's status. In addition to situations
the individual attending would like to be notified of, the attending
should include in his or her notification to residents all situations
that require attending notification, per program policy. These are
The supervising attending needs to be informed by
the resident: a) when the patient's condition deteriorates unexpectedly;
b) when additional information puts the working diagnosis in doubt
or questions the treatment plan; c) when information is obtained
that raises concerns regarding the patient's risk for self-harm
or harm to others; d) when the patient or family members disagree
with the treatment plan; e) when there are serious disagreements
or conflicts within the treatment team or with other services or
providers; f) when decisions need to be made that have major clinical
or legal implications, such as decisions not to hospitalize suicidal
or homicidal patients
During on-call duty, the resident will notify the
on-call attending when: a) the resident has any questions or concerns
about the patient or the care provided; b) when patients decide
to leave AMA; c) when the resident intends not to hospitalize a
patient seen in the ER who has expressed ideas of self-harm or harm
to others; d) when the resident intends to turn down a request for
admission; e) when the resident plans to send home from the ER a
patient who has had a rapidly deteriorating clinical course (e.g.
recent onset of mania, anorexia with significant recent weight loss).
The resident will also call the on-call attending to review all
The attending may specifically delegate portions of care to residents
based on the needs of the patient and the skills of the residents
and in accordance with hospital and/or departmental policies. The
attending may also delegate partial responsibility for supervision
of junior residents to senior residents, but the attending must assure
the competence of the senior resident before supervisory responsibility
is delegated. The attending remains responsible for assuring that
appropriate supervision is occurring and is ultimately responsible
for the patient's care. Residents and attendings should inform patients
of their respective roles in each patient's care.
The attending and supervisory resident are expected to monitor competence
of more junior residents through direct observation, rounds, individual
and group supervision sessions, and review of the medical records
of patients under their care.
Faculty supervision assignments should be of sufficient duration
to assess the knowledge and skills of each resident and delegate to
him/her the appropriate level of patient care authority and responsibility.
Supervision of invasive procedures
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. When a resident requires supervision, this may be provided
by a qualified member of the medical staff or by a resident who is authorized
to perform the procedure independently. In all cases, the attending
physician is ultimately responsible for the provision of care by residents.
When there is any doubt about the need for supervision, the attending
should be contacted.
Procedures that psychiatry residents can perform on medicine, pediatrics,
or neurology rotations, and the required level of supervision, should
be as specified by supervision policies of those programs and departments,
as appropriate to the resident's level of training, experience, technical
skill, the procedure, and the clinical situation. The following procedures
may be performed on psychiatry rotations with the indicated level of
Direct supervision required by a qualified member
of the medical staff
Electroconvulsive therapy (ECT)
Indirect supervision required with direct supervision
available by a qualified member of the medical staff
Intravenous line insertion
Oversight required by a qualified member of the
Phlebotomy Suture removal
It is recognized that in the provision of medical care, unanticipated
and life-threatening events may occur. The resident may attempt any
of the procedures normally requiring supervision in a case where death
or irreversible loss of function in a patient is imminent, and an appropriate
supervisory physician is not immediately available, and to wait for
the availability of an appropriate supervisory physician would likely
result in death or significant harm. The assistance of more qualified
individuals should be requested as soon as practically possible. The
appropriate supervising practitioner must be contacted and apprised
of the situation as soon as possible.
Supervision of Consults
Residents may provide consultation services under the direction of
attendings or supervisory residents, including fellows. The attending
of record is ultimately responsible for the care of the patient and
thus must be available to provide direct supervision when appropriate
for optimal care. The availability of the attending and supervisory
residents or fellows should be appropriate to the level of training,
experience and competence of the consult resident and is expected
to be greater with increasing acuity of the patient's illness. Information
regarding the availability of attendings and supervisory residents
or fellows should be available to residents, faculty members, and
patients. Residents performing consultations on patients are expected
to communicate verbally with their supervising attending as soon as
possible after seeing the patient and certainly within 24 hours or
(for night float and on call residents) within the same call or night
float shift. Any resident performing a consultation where there is
credible concern for patient's life, requiring the need for immediate
intervention, MUST communicate directly with the supervising attending
as soon as possible prior to intervention or discharge from the hospital,
clinic or emergency department. If the communication with the supervising
attending is delayed due to ensuring patient safety, the resident
will communicate with the supervising attending as soon as possible.
Residents performing consultations will communicate the name of their
supervising attending to the services requesting consultation.
Supervision of Hand-Offs
Residents, attendings, and other primary providers on psychiatry services
must provide structured verbal and electronic handoffs when transferring
care of a patient, and must be available to receive handoffs when taking
over the care of a patient. Residents may be supervised directly or
indirectly, by an attending or supervisory resident, in giving and receiving
handoffs. Junior residents should be directly supervised in giving and
receiving handoffs initially, to establish competence. The attending
physician remains responsible for assuring that appropriate handoffs
are occurring and is ultimately responsible for the patient's care.
Resident Competence & Delegated Authority
The privilege of progressive authority and responsibility, conditional
independence, and a supervisory role in patient care delegated to each
resident must be assigned by the program director and faculty members.
The program director must evaluate each resident's abilities based on
specific criteria. In psychiatry, these criteria include:
a) Documentation, on at least three occasions, of a
PGY-1's (or beginning resident's) readiness for indirect supervision
with direct supervision available.
b) Documentation of a PGY-1's (or beginning resident's) competence in
providing and receiving handoffs.
c) Satisfactory peer evaluations of residents by training call residents
(supervisory residents evaluating junior residents) or by trainees (more
junior residents evaluating supervisory residents)
d) Clinical rotation evaluations
e) Clinical skills assessments f) Demonstration of supervisory capability
by PGY-3 and PGY-4 residents through structured role plays, as part
of the annual Teach the Teachers program.
Guidelines around Supervision and Progressive Responsibility
Attendings and residents should adhere to the SUPERB-SAFETY model in
providing and seeking supervision, as follows:
Attendings should adhere to the SUPERB model when providing supervision.
Set Expectations: set expectations on when they
should be notified about changes in patient's status.
Uncertainty is a time to contact: tell resident
to call when they are uncertain of a diagnosis, procedure or plan
Planned Communication: set a planned time for communication
(i.e. each evening, on call nights)
Easily available: Make explicit your contact information
and availability for any questions or concerns.
Reassure resident not to be afraid to call: Tell
the resident to call with questions or uncertainty.
Balance supervision and autonomy.
Residents should seek supervisor (attending or senior resident) input
using the SAFETY acronym.
Seek attending input early
Active clinical decisions: Call the supervising
resident or attending when you have a patient whose clinical status
is changing and a new plan of care should be discussed. Be prepared
to present the situation, the background, your assessment and
Feel uncertain about clinical decisions: Seek
input from the supervising physician when you are uncertain about
your clinical decisions. Be prepared to present the situation,
the background, your assessment and your recommendation.
End-of-life care (in psychiatry, including risk
assessment) or family/legal discussions: Always call your attending
when a patient is suicidal, homicidal, gravely disabled, or at
imminent risk, or when there is concern for a medical error or
Transitions of care: Always call the attending
when the patient becomes acutely ill and you are considering transfer
to another service, facility, or level of care.
Help with system/hierarchY: Call your supervisor
if you are not able to advance the care of a patient because of
system problems or unresponsiveness of consultants or other providers.
(Approved by the RESC on June 14, 2012.)