Department of Neurological Surgery – Residency Program Policy

Policy: Supervision

Program Chair: Michael Rosner, MD

Last Revision: March 11, 2020


To ensure that residents are provided adequate and appropriate levels of supervision at all times during the course of the educational training experience and to ensure that patient care is delivered in a safe manner.  


All residents in patient care settings must be supervised by qualified faculty in such a manner that permits a resident to assume progressive, increased responsibility for patient care according to their level of training, ability, and experience.

The program director must demonstrate that the appropriate level of supervision is in place for all residents who care for patients.  For clinical rotations occurring at affiliate sites, the supervising physician must be approved by the program director.

To ensure oversight of resident supervision and graded authority/responsibility, the program must use the ACGME classification of supervision (CPR VI.D.3.)

Direct Supervision: 

The supervising physician is physically present with the resident and patient.

Indirect Supervision: 

With direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.

With direct supervision available – the supervising physician 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 provide Direct Supervision.


The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available.

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.

Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.

Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.

Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members. 

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.


Clinical Supervision

  • A faculty member will provide indirect supervision (with direct supervision available) for residents in all clinical settings, including Neurosurgery Department clinics, inpatient wards and consultations in the Emergency Department or elsewhere in the hospital.  
  • Initial patient visits, admissions or consultations must involve appropriate timely bedside participation by a faculty member.   
  • A resident may perform subsequent simple follow-up visits alone based on level and ability, as long as the supervising faculty member approves and is available for consultation (indirect supervision with direct supervision available).
  • Junior residents (R-2 and 3) will perform urgent consultations on medically unstable patients (such as trauma system admissions) with supervision of the senior backup resident and indirect supervision of the faculty member on call.
  • The Chief Resident in Neurological Surgery provides back-up to residents on his/her team. The on-call Neurosurgery Attending Surgeon is continuously available at all hours on all days to the resident staff for consultation and bedside assistance. A back-up call Attending is available at all hours on all days to the resident staff. This information is provided to the resident team monthly in advance, and published in WebExchange.

Procedural Supervision

Neurosurgical residents may perform bedside neurosurgical procedures in the hospital under indirect supervision with direct supervision available, only after participation in the SNS PGY1 Bootcamp with appropriate certification.

Procedures for which residents may be certified include: 

  1. intra-cranial pressure, temperature and/or tissue oxygen monitoring, 
  2. external ventricular drainage
  3. lumbar drainage
  4. lumbar puncture
  5. CSF shunt tap
  6. cervical traction
  7. stereotactic frame placement.

Certification involves:

  1. Annual didactic conference presentation of appropriate indications, procedural techniques and complication avoidance, recognition and management.
  2. Study of assigned readings with review by a Department clinical faculty member.
  3. Supervised teaching and performance of the procedures, with ‘check-out’ performance and signature by clinical faculty member.
  4. Maintenance of certification records as part of each resident’s portfolio. Certification is expected during the first one-half of the PGY 1 year.
  5. Notification of resident certification through GME to each patient care unit.

Operative Supervision

  1. Members of the attending neurosurgical faculty must supervise operative procedures either directly or indirectly with immediately available direct supervision. 
  2. Exception: In cases of life-threatening trauma requiring immediate craniotomy, the in-house Trauma Service Attending may serve as direct supervisor to an appropriately trained (as determined by the attending neurosurgeon) resident until the attending neurosurgeon arrives.
  3. The level of direct supervision required for performance of a particular procedure by an individual resident is determined by the attending surgeon, taking into account the resident’s milestone achievements, including all key portions of the procedure.  
  4. During indirectly-supervised portions of the procedure, the attending surgeon remains immediately available for consultation and/or return to the operating room.

Attending Notification

Members of the attending neurosurgical faculty must be notified immediately in the following circumstances:

  1. Death of a Patient
  2. Transfer of patient to a higher level of care (ICU)
  3. Change in neurological exam which results in urgent imaging
  4. Patient discharged AMA (Against Medical Advice), not formally discharged, or missing.

Rapid Response, Code Blue, Cath Attack or Brain Attack

Any Sentinel Event (as defined by the Joint Commission)

Approved by GMEC: 4/20/2020