Pediatric Intensive Care Sub-internship - PEDS8027 Curriculum & Curse Overview The fllwing infrmatin prvides an verview fr the Pediatric Intensive Care Sub-internship Curse Curriculum. All curse infrmatin can als be fund n the CANVAS learning management system fr this curse, including learning materials and requirements. Pediatric Intensive Care Sub-Internship Faculty & Staff Cntact Infrmatin Directr Angela Czaja, MD MSc Phne: 303-724-2393; Email: Angela.Czaja@childrensclrad.rg C-Directr Jennifer Sep, MD Phne: 720-777-5417; Email: Jennifer.Sep@childrensclrad.rg Curse Staff Cntact Jyce Carpenter Phne: 303-724-2393; Email: Jyce.Carpenter@childrensclrad.rg Curse Crdinatr Michael Baca Phne: 720-777-4804; Email: Michael.Baca@childrensclrad.rg Training Site Children s Hspital Clrad 13121 E. 16 th Ave (Pediatric Intensive Care Unit 3 rd flr)
Aurra, CO 80045 Disclaimer: This handbk/syllabus des nt cnstitute a cntract, either expressed r implied, with the University f Clrad Schl f Medicine and the University reserves the right at any time t change, delete r add t any f the prvisins at its sle discretin. Furthermre, the prvisins f this dcument are designed by the University t serve as guidelines rather than abslute rules, and exceptins may be made n the basis f particular circumstances.
Welcme Welcme t the nline prtal fr yur Pediatric Intensive Care Sub-Internship curse. This inpatient clinical rtatin is designed fr medical students wh are planning a residency in Pediatrics and t prepare him/her fr internship. There is ne distinct clinical site fr this Sub-Internship, the Pediatric Intensive Care Unit (PICU) within the Children's Hspital Clrad (CHCO). If yu have questins r cncerns abut the rtatin, please feel free t cntact Dr. Czaja r Michael Baca (Sub-I Curse Crdinatr). Ratinale and Expectatins During the Pediatric Intensive Care Sub-internship, students are expected t advance their knwledge base and skills needed t prvide medical care fr critically ill infants and children within a quaternary care system. Furthermre, they will develp experience wrking with an inter-disciplinary team including advanced practice practitiners, nurses, respiratry therapists, pharmacists, dieticians, scial wrkers and child life specialists. It is expected that students will functin mre independently during their sub-internship than they did during their Phase III training, mving beynd bservatin and participatin int the rle f the primary prvider. As interns d nt rtate thrugh the PICU at the Children s Hspital f Clrad, students will be wrk clsely with the secnd and third-year pediatric residents, and pediatric critical care fellws, in the care f their patients. They will be supervised by the pediatric critical care attendings/faculty, wh rtate ne week at a time. Students will gain independence thrugh the mnth, such that, by the cmpletin f the rtatin, they shuld be able functin at r near the level f a starting intern with respect t the bjectives f the rtatin. Curse Gals and Objectives Cre Gals 1. Prvide patient care that is cmpassinate, apprpriate and effective fr the treatment f health prblems. 2. Recmmend and interpret cmmn diagnstic tests and vital signs. 3. Prvide cmplete, well rganized dcumentatin f a clinical encunter. 4. Prvide a cmplete, well rganized ral presentatin f a pediatric patient. 5. Recgnize a pediatric patient requiring urgent r emergent care and seek help apprpriately. 6. Cmmunicate effectively with patients, families and all members f the health care team. 7. Demnstrate prfessinalism by shwing cmpassin, integrity and respect fr thers, respnsiveness t patient needs 8. and accuntability t curse requirements. 9. Demnstrate the medical knwledge necessary t care fr cmmn pediatric cnditins. 10. Prvide high quality care and advcate fr patients within the cntext f the health care system. 11. Use evidence based medicine and self directed learning in the care f patients and educatin f thers. 12. Develp the attitudes and skills necessary fr self reflectin that leads t imprvement in practice. Link t Learning bjectives: Pediatric Intensive Care Sub internship Gals and Objectives
Curse frmat and timeline Fur weeks in length, this curse is designed fr students interested in further training in pediatrics, and fr thse interested in acquiring additinal knwledge and skills in caring fr critically ill children. Attendance Plicy (Required) Refer t Attendance & Absence Plicies fr Phases III & IV, ICC in SOM White bk at http://www.ucdenver.edu/academics/clleges/medicalschl/educatin/studentaffairs/studentresurces /Dcuments/StudentHandbk.pdf. Recmmended Resurces Children s Hspital Clrad Clinical and Research Library University f Clrad Schl f Medicine Health Sciences Library Up-t-date (nline at My Children s Clrad) PubMed (Online at My Children s Clrad) Current Diagnsis and Treatment Pediatrics; sectin n critical care Rgers Handbk f Pediatric Intensive Care Evaluatins and Grading Cmpletin f the curse and faculty/resident evaluatins is vital t the nging imprvement f the subinternship. We take yur suggestins fr imprvement very seriusly. Furthermre, faculty and residents truly value yur input n hw t imprve their teaching skills. Please be cnstructive in yur evaluatins. Faculty and residents receive a cmpsite reprt f their evaluatins annually and nly if they receive 3 r mre evaluatins t maintain annymity f students. Nte: all curse evaluatins must be cmpleted within ur nline evaluatin system, New Innvatins, t receive yur final grade fr the Sub-Internship. All clinical evaluatins are cmpleted in New Innvatins. Belw are the instructins fr access evaluatins thrugh this sftware. Here is the link t New Innvatins: https://www.new-innv.cm/lgin/ (links t an external site) The Institutin Lgin shuld be already filled in as CUGME (all caps). Enter yur username and passwrd, which are bth the same, unless yu have lgged in befre and changed yur passwrd. It shuld be yur first initial and last name (all lwercase). Fr example, Nancy Drew wuld be ndrew in bth fields. Once yu lg in yu will have the ptin t change yur user name and/r yur passwrd by clicking n the CHANGE PASSWORD link n the menu bar
Overview f Grading We fllw the University f Clrad SOM Advanced Studies Elective Grading and Remediatin Plicy. Students are required t have at least 3 clinical evaluatin frms cmpleted, ne f which must be cmpleted by an attending physician. Students prvide a list f evaluatrs t the Sub-Internship Crdinatr wh will create the evaluatins in ur electrnic evaluatin system, New Innvatins. Sub-Internship Withdrawal The fllwing prcedure applies t bth UCD SOM students and externs. Please nte an extern s hme schl has the right t change the grade. A student may unilaterally withdraw frm a sub-internship when nt eligible t drp an elective curse by 5:00 PM n the seventh calendar day f the elective and receive a grade f Withdraw (W). After 5:00 PM n the seventh calendar day and prir t 5:00 PM n the last calendar day f the sub-internship, prir apprval is required frm the Directr f the sub-internship befre a student may withdraw. Apprval r disapprval f the withdrawal is at the Sub-Internship Directr s discretin; the Sub-Internship Directr will cnfer with the Sub Internship Cmmittee Chair prir t issuing the final decisin. The Sub-Internship Directr may present the student with ne r mre f the fllwing grade ptins: Withdraw (W) Incmplete (IP) Anther apprpriate grade based n the student s perfrmance during the cmpleted prtin f the sub-internship, including Fail (F). If there are extenuating circumstances, the Sub-Internship Directr and Sub Internship Cmmittee Chair may decide t refer the issue t the Sub-Internship Cmmittee; this ptin will delay the final decisin and affect the student. See sectin I.B.1 fr grading ptins A student wh leaves a sub-internship after seven days and fails t cntact the Sub Internship Directr will receive a grade f Fail (F). A student may nt withdraw frm a sub-internship after 5:00 PM n the last calendar day f the sub-internship. The final grade is determined by the average f the clinical evaluatins. Students must als successfully cmplete all f the prject wrk by the final day f the rtatin t pass the curse. Ultimately, the Sub-I Curse Directr reserves the right t assign the final grade (Hnrs, High Pass, Pass, r Fail) based n all the infrmatin available t him/her. There is n limitatin n the number f hnrs assigned fr the sub-internship.
Security, Student Safety, and Disaster Preparedness Institutinal emergency and disaster preparedness plicies and plan are utlined in the Emergency- Preparedness Quick-Reference Guide fr the Anschutz Medical Campus. The link is published in the Clinical Blck Syllabus, psted n Canvas http://ucdenver.canvas.cm, and lcated next t emergency phnes (e.g., ED1 and 2) as well as many f the student lunge areas, small grup rms, and lecture halls. Clrad Springs Branch students lcated have similar plicies and prcedures prvided by the branch. Medical Student Plicies and Prcedures Manual White Bk (http://www.ucdenver.edu/academics/clleges/medicalschl/educatin/studentaffairs/studentresurces /Dcuments/StudentHandbk.pdf) publishes emergency infrmatin (sectin 4.1), In an emergency, bth the Office f Student Life (303-724-6407) and the Registrar s Office (303-724-8053) will make reasnable effrts t cntact a student r a student s designated emergency cntact. Emergency infrmatin is als fund n the Student Life web site: http://www.ucdenver.edu/academics/clleges/medicalschl/educatin/studentaffairs/emergencies/page s/emergencies.aspx Security, student safety, and disaster preparedness as well as relevant cntact infrmatin fr all cre clinical sites will be prvided t students at individual clerkship rientatins and n the Canvas Phase III curse lcatin. Hazard Expsure/Needle stick Psted n Canvas fr Pediatric Intensive Care Sub-Internship Curse as well as delineated belw. At ALL clinical sites (exceptins belw), if yu experience a needle stick, sharp injury, bld/ther bdy fluid expsure r any ther hazardus expsure, immediately fllw these steps: 1. Wash needlesticks/cuts with sap and water 2. Flush splashes t the nse, muth, r skin with water 3. Irrigate eyes with clean water, saline, r sterile irrigants 4. Reprt the incident t yur supervisr 5. G t the nearest Emergency Rm 6. Questins: Call UCH ID Clinic 720-848-0191 Exceptins: University f Clrad Hspital, 8-4pm, Mnday-Friday, g t the Infectius Disease Clinic, 7 th Flr. Phne: 720-848-0191. Use Emergency Rm after hurs. Denver Health Medical Center, 8-3:30pm, Mnday-Friday, g t Occupatinal Health and Safety Center, 6 th and Bannck, 4 th flr. Phne: 303-436-7155. Use Emergency Rm after hurs. Children s Hspital f Clrad, 7-4:30pm, Mnday-Friday, g t Occupatinal Health Services, B260. Phne: 720-777-6577. Use Emergency Rm after hurs. Veteran s Affairs, 8-4pm, Mnday-Friday, g t Occupatinal Health 1055 Clermnt St. Phne: 720-777-2330. Use Emergency Rm after hurs. Memrial Hspital Clrad Springs, 7:30-5pm, Mnday-Friday, g t Occupatinal Health 175 S. Unin Blvd STe. 315. Phne: 719-365-6840. Use Emergency Rm after hurs.
Next Steps: 1. The University f Clrad prvides wrkers cmpensatin cverage fr students wh have a needlestick, sharps injury, bld/ther bdy fluid expsure r any ther hazardus expsure. 2. University Risk Management is respnsible fr payment. Send bills t: University Risk Management, 1800 Grant Street, Ste. 700 Denver, CO 80203. 3. File a claim within 4 days with University Risk Management at www.cu.edu/risk/incidentprcedure. 4. Fr fllw-up n expsure, g t ne f the Designated Medical Prviders listed nline. 5. Questins? Call University Risk Management 303-860-5682 r 888-812-9601. Duty Hur Requirements The CUSOM has develped a medical student duty hurs plicy based n the plicy requirements fr secnd year residents (e.g., PGY-2, R-2). The CUSOM duty hur plicy fr medical students applies t all clinical sites prviding educatin t medical students. Students shuld cntact the directr when they are appraching duty hur limits, and discuss with the directr abut hw t prceed including pssible schedule adjustment at the clinical site. Students will nt wrk mre than 80 hurs per week when averaged ver fur weeks. Students will have a minimum f ne day in seven ff, when averaged ver fur weeks. Students will nt wrk mre than 24 cnsecutive hurs f scheduled participatin during ne perid f time and n mre than 4 additinal hurs t accmplish an effective transitin f patient care. Students shuld have 8 hurs free f duty between wrk shifts. After a 24-hur shift, students shuld have 14 hurs free f duty. N mre than every 3rd night n call Duty hur activities include patient care and all required educatinal activities. Studying, reading and academic preparatin d nt cunt twards the wrk hur maximums. Travel time t rtatins des nt cunt as wrk hurs. Prfessinalism Student Expectatins Academic Hnesty Statement Students are expected t adhere t the Hnr Cde f the University f Clrad Schl f Medicine which states that students must nt lie, cheat, steal, take unfair advantage f thers, nr tlerate students wh engage in these behavirs. Please check the website fr infrmatin n the Medical Student Hnr Cde. http://www.ucdenver.edu/academics/clleges/medicalschl/educatin/studentaffairs/academiclife/hn rcuncil/pages/default.aspx Students are als expected t: Cntact the apprpriate blck faculty and student life fr all vluntary and invluntary absences. Check email and Canvas regularly fr cmmunicatin abut blck activities and updates. Respnd within 24 hurs t all blck emails requiring individual student respnse. Attend all blck cnferences and required events and arrive n time t these events.
Cmplete all required cursewrk and evaluatin. Use smart phnes and electrnic tables with discretin Wear prfessinal dress, in accrdance with Children s Hspital Clrad plicy. Pediatric Standards fr Prfessinals A prfessinal cnsistently transmits respect fr patients/parents by his/her perfrmance, behavir, attitude and appearance. Respect fr privacy and cnfidentiality. Knck n dr befre entering (mther s) rm. Check with nurse if this is a gd time t examine the patient. D nt discuss patient infrmatin in a public area; including elevatrs, and cafeterias. Keep nise levels lw when patients are sleeping. Patient cnfidentiality includes fllwing HIPAA rules regarding apprpriate accessing f patient files, including electrnic files. Respect fr self-autnmy and the right t be invlved in care decisins. All prfessinals intrduce themselves t patient s families and explain their rle in the patient s care. All prfessinals wear name tags clearly identifying their names and rles. Time is taken t assure family understanding, and infrmed cnsent, f medical decisins and prgress. Once a healing relatinship is initiated a prfessinal never abandns a patient. A prfessinal assures cntinuity f care by clearly dcumenting wh will prvide care after a patient is discharged frm a hspital, and infrming the patient f hw that caregiver can be reached. A prfessinal respnds prmptly t phne messages and pages. A prfessinal is respnsible fr prviding reliable cverage thrugh clleagues when he/she is nt available. Present a prfessinal appearance. All prfessinals shall cmply with acceptable standards f dress as defined by the institutins in which they wrk. A prfessinal cnsistently transmits respect fr peers and c-wrkers. Respect is demnstrated by effective cmmunicatin. Primary care prviders will be infrmed f their patient s admissin, the hspital curse, and discharge plans. Cnsulting physicians will be given all data pertinent t prviding a cnsultatin. Medical recrds will be kept legible and up t date; including dictating r electrnically/writing discharge summaries within apprved guidelines. All nn-medical prfessinals wh are part f the care team will be kept infrmed f patient plans and prgress. Cntinuing verbal and written cmmunicatin will be given t referring physicians. By understanding a referring physician s needs and cncerns abut their patients. Respect is demnstrated fr diversity f pinin, gender, and ethnicity. The wrk envirnment must be free f harassment f any srt. The pinins f all prfessinals invlved in the care f patients must be respected.
A prfessinal is respnsible fr his/her wn educatin. One must be a mtivated self-directed learner We must recgnize the limits f ur knwledge r skills and ask fr help when apprpriate. Reprting Issues f Prfessinalism f Others: The Office f Prfessinalism exists t prvide faculty, residents, fellws and students a resurce n campus t btain a fair and equitable treatment fr all matters. Under apprpriate circumstances, the ffice can serve as an advcate fr fair and equitable treatment fr faculty, residents, fellws, and students and can facilitate safe reprting f mistreatment r abuse. The Office is available t help faculty, residents, fellws, and students with all issues and cncerns and prvides cnsultatins, shrt-term caching, cunseling, referrals, alternative dispute reslutin and facilitatin. The Office can als assist faculty, students, and staff members in preparatin fr varius meetings and cnversatins. The services f the Office f Prfessinalism are prvided free f charge. Cntact the ffice by emailing Barry H. Rumack, MD at barry.rumack@ucdenver.edu r Jsette Harris at Jsette.harris@ucdenver.edu. Fr faster respnse, (n cnfidential infrmatin please) call 303-724-7854. Offsite and nsite visits are by appintment nly. Building 500, 8 th flr, rm 8000C. Mistreatment If a student feels that he r she has been subject t mistreatment in the learning r clinical envirnment, there are a variety f ptins fr reprting. We recgnize that students may differ in hw they want t address this issue, and we seek t prvide a wide array f reprting ptins. Please check the website fr infrmatin and reprting in regards t mistreatment vs. subptimal learning. http://www.ucdenver.edu/academics/clleges/medicalschl/facultyaffairs/prfessinalism/pages/definit insexamples.aspx Curse Preparatin Cmmunicatin and respnsibilities Drp/Add email ntificatin is sent t prgrams 30 days prir t start f upcming rtatin Email ntificatin will include all students currently registered fr the entire academic year Any student wishing t drp after the 30-day ntificatin will need curse directr apprval CU students will begin rtatins n May 8, 2017 Visiting student rtatins will begin July 3, 2017 2 week curses will nt start until January f 2018 3 weeks prir t start f a current rtatin, the student, the curse directr and crdinatr are prvided with a curse preparatin email Email will include curse syllabus, hspital handbk and EMR affidavit
1 st time rtatrs will need t cmplete EPIC mdules and attend a practicum Prgram crdinatr needs t make sure rtatin schedule is created in advance Prgram crdinatr shuld reach ut t student t assist with excused absences Hlidays/Weekends are nt guaranteed time ff Students are entitled t 2 days f excused absences. Additinal days need t be apprved by Directr f Medical Student Educatin, Dr. Jennifer Sep. (jennifer.sep@childrensclrad.rg) 1 week prir t rtatin, ALL Peds students will received an rientatin email with directins and parking instructins At this pint all schedules are cnfirmed and n student can be added t a rster withut apprval frm curse directr and CHCO Training Crdinatr, Andrea Reed (andrea.reed@childrensclrad.rg) On the 1 st day f the rtatin all students will attend a hspital rientatin at 7:00 a.m. 1 st time rtatrs will receive a badge, parking access and will need t attend EPIC practicum Returning rtatrs are free t jin their team at 7:30 a.m. (rientatin is ptinal) After EPIC practicum students will be intrduced t prgram crdinatr t receive instructins at apprximately 10:30 a.m. Student is intrduced t team and begins rtatin Cmmunicate the preferred methds f cmmunicatin during yur clerkship (email, Canvas, phne, etc.) including the 24-hur Curse Calendar: 2017-2018 4th Year Student Academic Calendar.pdf Attire Dress cde guidelines are intended t assist staff members in meeting hspital standards. Guidelines fllw business casual dress, with the primary fcus n clean, neat, and prfessinal appearance. Departments may establish additinal dress cde standards and prcedures based n specific needs. Please review the fllwing: Clthing must be clean, unwrinkled, stain-free, prperly fitting, and in gd repair. Clthing must have a mdest neckline. Skirt and dress length must be at r belw the knee. Denim skirts and dresses (knee length) may be wrn; verall appearance must be prfessinal. Tailred capri pants (calf length) may be wrn. Scrubs may be required in designated/sterile areas. If required, hspital furnished, freshly laundered scrubs must be put n upn arrival at wrk and may nt be wrn t/frm the hspital. Unifrms may be required in designated areas. Unifrms must be maintained in gd cnditin, clean, and wrn as recmmended by department manager. Lab cats and ties must be laundered regularly.
If clthing becmes cntaminated with bld r ther infectius material, remve clthing, place in a blue plastic linen bag, change int scrubs and take cntaminated clthing t Materials Management. (See IC- 001-A Bldbrne Pathgen Expsure Cntrl Plan). Assignments and Respnsibilities All students will cmplete a Direct Cmmunicatin Observatin. The purpse f this assignment is t give yu the pprtunity t be bserved perfrming advanced cmmunicatin skills related t high value, cst-cnscius medicine. All students will cmplete a Quality Imprvement (QI) Prject. This purpse f this assignment is t intrduce yu t a QI tl and develp a better understanding fr hw t prvide higher value, higherquality medical care. By creating a Fishbne diagram, yu will learn mre abut hw t identify prblems within the system, ptimize healthcare delivery, and ultimately achieve the Institute fr Healthcare Imprvement's (IHI) Triple Aim: 1. Imprving the patient experience f care (including quality and satisfactin); 2. Imprving the health f ppulatins; and 3. Reducing the per capita cst f health care. All students will cmplete the ther assignments f the High Value, Cst-Cnscius Medicine Curriculum (readings, nline mdules, reflective writing piece, and small grup sessin). All students must have a Midpint Feedback Sessin with an Attending by the end f week tw. Yu shuld cmplete the midpint feedback frm with yur supervisr and submit t the Phase IV Sub-I Crdinatr (Michael Baca) by week 3 f yur rtatin. All students must cmplete faculty/fellw/resident and end-f-curse evaluatins. Expectatins fr the Rtatin Sub-interns in the PICU are expected t take primary respnsibility fr 1-3 critically ill patients, wrking clsely with ther team members including pediatric residents, pediatric critical care fellws, PICU advanced practice practitiners and attendings. They shuld perfrm all tasks required t prvide highquality family-centered care, such as pre-runding, presenting patients n runds, fllwing up n test results, cmmunicating with ther team members, subspecialists and family members, and ensuring adequate dcumentatin within the electrnic medical recrd system. Given the nature f critical care, it is expected that the student discuss decisin-making with anther team member prir t implementatin. Thrughut the mnth, the degree f independence and level f respnsibility shuld increase based n the student s perfrmance and acquisitin f knwledge and skills. Students shuld attend all educatinal sessins within the PICU, including case cnferences, fellw and resident didactic cnferences. They are als welcme and encuraged t attend departmental
cnferences, if they d nt interfere with their primary clinical respnsibilities. Students are als expected t read abut critical care tpics related t the care f their patients. If they are struggling t identify the apprpriate tpics, they shuld discuss with the attending, fellw r resident. Sign-ut and Runds It is expected that students will arrive at the hspital early enugh in the mrning t btain vernight signut and t pre-rund (gathering f data, examining the patient, speaking with bedside nursing, etc) n yur patients prir t wrk runds. The student shuld prepare t present their patients n runds using the PICU runding template (see subflder within Canvas), with a gal f being thrugh but cncise. PICU runds are multi-disciplinary, with residents, fellws, attendings, nurses, pharmacists, dieticians and respiratry therapists. They are als family-centered runds, in that parents and families are invited t participate. Overnight Call It is expected that yu will take vernight call during the rtatin (apprximately every 4-5 nights), with at least ne weekend built in. The specific schedule shuld be discussed with the pediatric critical care fellw at the beginning f the rtatin, t ptimize the student s learning experience. Planned vluntary absences frm yur sub-internship activity are generally nt permitted, but unique circumstances may be discussed with yur attending physician and the sub-internship Curse Directr. Generally speaking, yu shuld nt sign up fr yur sub-internship if yu have ther serius cmmitments t attend t during the fur-week blck. Feedback Yu are respnsible fr seeking feedback frm yur attendings, including suggestins abut hw t imprve yur perfrmance. If yu are having truble getting adequate feedback n yur perfrmance, please cntact the Curse Directr t help yu Absences If yu have an illness r emergency, please cntact yur attending and/r resident as well as the subinternship Curse Crdinatr (Mike Baca) prir t missing any time. He will ntify the apprpriate subinternship directrs. Hlidays Days ff are dependent n team call schedules. Sub-interns shuld nt assume they will have all University hlidays ff. Please speak with yur attending and supervising resident r fellw prir t the day in questin.
Duty Hur Requirements The CUSOM has develped a medical student duty hurs plicy based n the plicy requirements fr secnd year residents (e.g., PGY-2, R-2). The CUSOM duty hur plicy fr medical students applies t all clinical sites prviding educatin t medical students. Duty hur activities include patient care and all required educatinal activities. Studying, reading and academic preparatin d nt cunt twards the wrk hur maximums. Travel time t rtatins des nt cunt as wrk hurs. The duty hur plicy specifies that: Students will nt wrk mre than 80 hurs per week when averaged ver fur Students will have a minimum f ne day in seven ff, when averaged ver fur weeks. Students will nt wrk mre than 24 cnsecutive hurs f scheduled participatin during ne perid f time and n mre than 4 additinal hurs t accmplish an effective transitin f patient care. Students shuld have 8 hurs free f duty between wrk shifts. After a 24-hur shift, students shuld have 14 hurs free f duty. N mre than every 3rd night n call Students shuld cntact the directr when they are appraching duty hur limits, and discuss with the directr abut hw t prceed including pssible schedule adjustment at the clinical site.