UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS LINES OF RESPONSIBILITIES

The lines of responsibility for fellows are identical at all teaching hospitals:

1.                  Parkland Health and Hospital Systems (PHHS)

2.                  Veterans Affairs North Texas Health Care System (VANTHC)

3.                  Zale Lipshy University Hospital (ZLUH)

4.                  St. Paul University Hospital

I.                    Legal Responsibilities

A.                 The ultimate legal responsibility for the training program is vested in (a) the Chief of Nephrology and (b) the Program Director.

B.                 On each rotation, the fellow is under the direction and reports to the attending Physician assigned to that rotation. The Attending Physician is responsible for all medical care and teaching. The Fellow is directly responsible to the Attending Physician, whose decisions on medical care are final.

C.                 In outpatient clinics, the Fellow is responsible to and directed by the Attending Physician.

D.                 The Fellows, teaching faculty, and Program Director interact with the hospital CEO and administration of each teaching hospital according to the bylaws of that hospital. At PHHS, this interaction occurs through the Medical Advisory Council. At VANTHC and ZLUH, these interactions occur through the Executive Committee of the medical staff. The administrations of the teaching hospitals have no authority over the teaching programs.

II.                 Clinical Responsibilities

A.                 Inpatient Services

1.                  The Fellow is responsible for the care of all patients assigned by the Attending Physician. The Fellow is expected to demonstrate independent thought in devising a clinical plan and writing orders, but he/she should discuss these with the Attending Physician.

2.                  The Fellow must know in detail and follow all patients on the service. She/he must guide the residents and students who may be on the service as well as teach both theory and practice. Organization of work on teaching rounds is the responsibility of the Fellow, who reports directly to the Attending Physician. The Attending Physician should write daily notes, which should be reviewed by the Fellow.

B.                 Outpatient Services

In the outpatient clinics, especially continuity clinics, the Fellow will manage her/his patients independently. Prior to the patient’s discharge from the clinic, a brief summary should be presented to the Attending Physician(s). With more complicated patients, or those with whom questions arise regarding further workup and management, the Attending Physician should be involved earlier.

III.               Chief Fellow

            Scheduling of clinical rotations is under the direction of the Chief Fellow, along with the Program Director. All Fellows are expected to follow these assignments. The Chief Fellow also assigns vacations, education leaves and absences required because of emergencies, such as family illness or death, with final approval by the Program Director.

IV.              Program Director/Attendings

A.                 The day to day operation of the Fellowship Program is vested in the office of the Program Director. The Program Director executes the policies of the Department of Internal Medicine and the Division of Nephrology and is responsible for conformity to the bylaws of the teaching hospitals.

B.                 The Attending is the first source of counseling should a Fellow have difficulty or if disputes arise during a rotation. If problems cannot be solved by the Attending, they may be referred to Dr. Biff Palmer (Program Director).

V.                 Interactions with House Staff in Internal Medicine and with Consultants for Other Departments

            House Staff and other consultants should be treated with dignity and respect, and their recommendations should be carefully considered.

VII. The lines of responsibility are now described in more detail.

The program director coordinates all aspects of the nephrology fellows education and training, including their supervision by faculty members.  Fellows are provided with responsibilities consistent with their level of training.  Every patient examined, and every procedure or test performed is either done under the direct supervision of a faculty member or is reviewed with a faculty member.  Faculty members are directly responsible for ensuring that resident procedures are performed to the high standards set by the Program and that appropriate documentation is completed (including documentation for resident credentialing).  Appropriate faculty supervision is provided during all educational experiences.  The specific mechanisms for proper supervision of residents are as follows:

A. Clinical Training 

Nephrology fellows round and present clinical cases in teaching rounds, Nephrology Continuity experience, and Outpatient Dialysis Ambulatory experience and receive one-on-one instruction and feedback in history taking, physical examination and in-patient and outpatient management of nephrology patients. These case presentations may include review of clinical data, urinalysis, review of pathologic specimens, and imaging data.  Nephrology teaching faculty members interview, examine and discuss assessment and plans with the nephrology fellows for all inpatient consultations, nephrology continuity clinic outpatients, and outpatient dialysis ambulatory patients. All inpatient consultations and follow up care, Nephrology Outpatient Clinic visits, and Outpatient Dialysis patients are discussed and supervised by Nephrology teaching faculty members. All outpatient supervision, whether in the Nephrology Outpatient clinic or for Outpatient Dialysis Ambulatory experience is directly supervised with the attending present. During the Nephrology Consultation rotations, the Nephrology fellow directs a team of residents, and medical students.  The nephrology fellow is responsible for organization of rounds, assisting the attending physician with the education of the Internal Medicine residents and medical students, and supervising the Internal Medicine residents and medical students.

B. Procedural Supervision

Procedures such as renal biopsy, urinalysis, placement of the temporary vascular access catheters, and hemodialysis and peritoneal dialysis procedures are directly supervised by attending physicians.  The placement of vascular access catheters is supervised in all cases. Fellows’ advancement to independent performance of procedures is based upon successful completion of procedures as well as review with attending physicians who must certify residents based upon clinical and procedural competency.  

At times hemodialysis and peritoneal dialysis treatments may not be directly supervised.  For example, an attending may not be present on site after hours. However in all cases, prior to the initiation of any procedure, the case, indications, risk and benefit for the procedure are fully discussed.  At any time during the two year training period, attending physicians will be available to come in to the hospital to directly supervise any procedure.  Fellows receive formal feedback to procedural competence as part of each post rotational evaluation. An on-line log of procedures or equivalent which nephrology fellows are credentialed to perform is maintained.

C. Research

Throughout the course of any research project, Nephrology fellows meet regularly with their faculty research mentor to report their progress and discuss the design and content of their projects.  Every Nephrology fellow research project is supervised by a faculty mentor who is available to discuss any issues that may arise.  Residents also discuss their progress with other residents and other interested attending faculty at various research conference and clinical conferences.