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Role standards

Providers

Medical fellow

What an internal medicine subspecialty fellow must do competently when running a consult service with graduated autonomy: reason past the question they were asked, recognise the complications of their own procedures, give consultation the primary team can act on, obtain real consent, and supervise the residents working under them. Drawn from the ACGME Milestones 2.0 for the internal medicine subspecialties, using Gastroenterology as the reference document because its structure - consultation, cognitive and technical procedural competence - is the shape of the role.

Practice this assessmentHire for this role
Expectations
10
Safety red lines
4
Sources
3
Version
1

Built from Accreditation Council for Graduate Medical Education, American Board of Internal Medicine. Reviewed by clinicians, last on .

01What the role is measured on#

Every verdict is made of the same five dimensions. Each is scored on its own, so a candidate sees where they are strong and where to work.

  • Clinical skillsThe hands-on and judgement work of the role: recognising what matters, acting in the right order, and knowing when something cannot wait.
  • Workflow and toolsGetting the work done in a real setting: the systems, records, equipment and handoffs the role runs on, used correctly and on time.
  • Patient communicationHow the role talks with patients, families and colleagues: listening, explaining plainly, and confirming what was understood.
  • Compliance and safetyThe rules that protect people: privacy, consent, infection control, reporting duties and the safety checks the role is accountable for.
  • Role knowledgeKnowing the job itself: what the role is responsible for, where its scope ends, and who to bring in when it does.

02What a ready hire does#

What a competent medical fellow does on day one, dimension by dimension.

Clinical skills

  • Reasons independently from the data rather than from the consult question, ranks the dangerous subspecialty causes first, and says what would change the recommendation.
  • Performs the subspecialty's core procedures within their privileges and supervision level, with a plan for the difficult step and a threshold for stopping or calling the attending.

Workflow and tools

  • Answers the consult question the primary team needs answered, with recommendations that are specific, prioritised and communicated so they are acted on, and follows the patient until signing off explicitly.
  • Writes consult and procedure notes that state the question, the answer, the reasoning and the specific recommendations, and that truthfully record what was done and found.

Patient communication

  • Obtains consent for their procedures as a conversation in which a patient with capacity, or the right surrogate, understands the material risks and alternatives including not proceeding, and chooses.
  • Delivers serious subspecialty news or discloses a procedural complication honestly and promptly, and coordinates with the primary team on what is said.

Compliance and safety

  • Recognises early the complications of their own procedures and the deteriorating consult patient, and escalates without waiting for certainty.
  • Recommends subspecialty drug therapy with the dose, the monitoring and the interactions spelled out, and manages anticoagulation around procedures safely.

Role knowledge

  • Supervises the residents and students on the consult service with autonomy matched to their ability and the patient's risk, and involves the attending when the situation requires it.
  • Appraises subspecialty evidence critically, translates it into absolute terms for the patient, and applies it with its limits in view.

03Safety red lines#

Any one of these keeps a candidate from Ready Day One, whatever the rest of the score. They are published so nobody meets them for the first time in the assessment.

  • Attributes new pain, tachycardia, hypotension, fever or breathlessness after a procedure they performed to expected after-effects such as gas or anxiety, and discharges or observes the patient without assessing and investigating for perforation, bleeding or pneumothorax.

    A perforation or bleed caught in the first hours is often managed without surgery; one caught the next day is a septic or exsanguinating patient.

  • Leaves a recommendation that must be acted on within hours - stopping a drug, emergency treatment, an urgent procedure or transfer - only in the written note, without speaking directly to the primary team, or presents recommendations on a patient they have not seen or reviewed as a formal consultation.

    A note is read hours later, if at all; the primary team cannot act on an urgent recommendation it has not heard, and advice on an unseen patient carries the authority of an examination nobody did.

  • Obtains consent for a procedure without the material risks or the alternatives including not proceeding, from a patient who lacks capacity without involving the surrogate, or after sedation has been given.

    A signature without understanding is not consent, and a procedure done on it is done without the patient's permission.

  • Leaves a resident to perform a procedure they are not entrusted to do alone, or to manage an unstable consult patient without the fellow seeing the patient, or keeps from the attending a patient who needs an urgent procedure or has deteriorated.

    Graduated autonomy is safe only when the supervision behind it is real; a resident alone with a complication or a sick patient is a patient without the expertise the consult promised.

04Outside the role#

Knowing where the role stops is part of the standard. Going past it is not extra credit.

  • Does not perform a procedure outside their credentialed privileges or without the supervision their program requires for it.Involves the attending or the privileged service, and keeps the patient safe until then.
  • Does not take over the primary team's orders or management without agreement.Makes clear, specific recommendations, agrees with the team who writes which orders, and speaks directly when something is urgent.
  • Does not give patient-specific advice on a complex question as a curbside without seeing the patient.Answers general questions, and converts the request to a formal consult when the answer depends on the patient.
  • Does not make decisions the program reserves for the attending, such as declining an urgent procedure or signing off a patient who is deteriorating, alone.Discusses them with the attending, and documents the decision and who made it.

05How it is assessed#

  • A spoken assessment

    An examiner talks the candidate through realistic cases from this role, and follows up the way a senior colleague would.

  • Five dimensions

    Each answer is read against the expectations above and rated on the same four-level scale.

  • The 70 bar

    Every scorecard shows the score against 70, overall and for each dimension, with the reason for the verdict.

  • Safety first

    Crossing one of the safety red lines holds a pass back, however strong the rest was.

The four levels

  1. Not yet
  2. Developing
  3. Proficient
  4. Exemplary
How a verdict is made

06Sources and review#

Drawn from the certification frameworks and practice standards below, and reviewed by clinicians. Version 1, last reviewed .

Cited as sources. Not an endorsement by the organizations named.

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