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Supervision and Procedures: Shreenath, Aparna (MD)

The Residency Supervision Area is designed to assist hospitals and clinics with the protocols outlined for specific duties residents and fellows can perform. These guidelines are determined by the faculty of the University of Tennessee College of Medicine Chattanooga, Gastroenterology Fellowship.  Any questions about certain procedures not listed should be addressed to the faculty and not decided by the resident or fellow.

A credentialed and privileged attending physician ultimately provides supervision or oversight of each Resident's patient care activities. Direct supervision by a qualified attending physician (or a more senior Resident with Indirect Supervision immediately available) is required in the OR/Delivery Room or for non-routine invasive procedures like Cardiac Cath, Endoscopy, and Interventional Radiology. 

Aparna Shreenath

Aparna Shreenath, MD

PGY-6 (3rd Year Fellow)


Resident Supervision will consist of four categories/levels:

  • 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 sites of patient care, and is IMMEDIATELY available to provide Direct Supervision.
  • Indirect Supervision with Direct Supervision available - the supervising physician is not physically present within the hospital or other sites of patient care, but is IMMEDIATELY available by means of telephone or other electronic means, and can be available if required for Direct Supervision
  • Oversight - Supervising Physician is available to provide a review of procedures or the encounter with feedback after the care is provided but the procedure or care does not warrant the physical presence of the attending.
  • In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available as described in the levels of supervision, unless denoted as Oversight in the list that follows.
  • In an emergency, defined as a situation where immediate care is necessary to preserve life or prevent serious impairment, residents are permitted to initiate whatever care is necessary and reasonable to save a patient from serious harm even if an attending physician is not immediately available to supervise. The appropriate Medical Staff member should be notified as soon as possible.  
  • Supervising physicians may be more advanced residents or fellows. 
Certifications current when the resident/fellow entered training at the UTCOMC.                
Basic Life Support (BLS)
Advanced Cardiac Life Support (ACLS)

As a 3rd Year Fellow in the Gastroenterology Fellowship (PGY-6), the Fellow can perform any Gastroenterology or Internal Medicine physician skill or procedure deemed appropriate by his/her attending physician or specialty physician skill or procedure deemed by an attending physician in a department in which the Resident or Fellow is assigned for rotation (e.g., Emergency Medicine, Critical Care, etc.).  Residents and Fellows are expected to progressively assume more responsibility throughout each level of training and demonstrate competence in skills/procedures requiring less Direct Supervision.  The supervising physician may make adjustments in the level of supervision required for that specific procedure.

Patient Care Skills or Procedures that do not require Direct or Indirect Supervision presence of a supervising physician (i.e., Oversight/General Supervision) are listed below.  Anything not specifically listed requires either Direct Supervision, Indirect Supervision with Direct Supervision Immediately Available, or Indirect Supervision with Direct Supervision available by phone or other electronic media, at the discretion of the supervising physician. 

PGY-4, PGY-5, and PGY-6 Gastroenterology Fellows can perform the procedures listed below with Indirect Supervision:
PGY-4 Gastroenterology Fellows can perform the procedures under Indirect Supervision or Oversight highlighted in blue.
PGY-5 Gastroenterology Fellows can perform the procedures under Indirect Supervision or Oversight highlighted in orange.
PGY-6 Gastroenterology Fellows can perform the procedures under Indirect Supervision or Oversight highlighted in grey.
Differential Diagnosis, Treatment, and Patient Care Skills            PGY-4
1st Year Fellow 
2nd Year Fellow 
3rd Year Fellow
    Perform all Internal Medicine related procedures since they are already eligible for the Internal Medicine Boards or are already ABIM certified.  X X X
    Gastroenterology consults in the Emergency Department  X  X  X
    Clinical and Social History  X  X  X
    Communicate with patients and family members  X  X  X
    EKG - perform and interpret  X   X  X
    Formulate diagnostic and treatment plans  X  X  X
    Formulate pre-and post-operative treatment plans  X  X  X
    Incision and Drainage Superficial Abscesses & Hematomas  X  X  X
    Interpret basic x-rays and imaging studies, including but not limited to skull, spine, chest, abdomen, and extremities   X  X  X
    Interpret laboratory and diagnostic studies and tests  X  X  X
    Mark diagnostic and surgical procedures on patients  X  X  X
    Obtain consent for endoscopic procedures X X X
    Order radiologic, laboratory, or other diagnostic tests  X  X  X
    Participate in and run a code (adults)  X  X  X
    Participate in a code (pediatrics) X X X
    Request specialty and subspecialty consults  X  X  X
    See patients and write patient orders  X  X  X
    Supervise Medical Students, Residents, and more junior Gatroenterology  
 X  X  X
    Physical Examination  X  X  X
    Rectal Examination (including DIgital) X X X
    Write admission, treatment orders, and notes in the Electronic Health
 Cardiopulmonary Resuscitation and Airway Maintenance PGY-4
1st Year Fellow
PGY-5 2nd Year Fellow PGY-6 3rd Year Fellow

Perform Basic CPR and related procedures (airway management,

emergency drug therapy, rhythm strip interpretation, intravenous

catheterization, closed chest massage, adult resuscitation,

electrocardioversion & defibrillation, and venous cut-down) 

 X  X  X
 Adult Resuscitation  X  X  X
Pediatric Resuscitation X X X
Insertion of Oral Pharyngeal Airway X X X
Endotracheal Intubation X X X
 Additional Specific Skills PGY-4
1st Year Fellow
2nd Year
3rd Year Fellow 
   Arterial puncture for Arterial Blood Gas Collection  X X  X
   Interpret Arterial Blood Gases   X  X  X
   Arthrocentesis  X  X
   Central Line Placement X X X
   Intra-arterial Puncture or Catheterization X X X
   Intravenous Catheterization X X X
  Joint Injection  X X X
   Lumbar Puncture  X  X
   Thoracentesis  X  X X
   Nasotracheal or orotracheal intubation  X  X X
   Paracentesis  X  X X
   Perform bladder catherization X X X
   Pulmonary catheter insertion  X  X X
   NG Tube Placement  X  X  X
   Participate in and supervise medical critical care patients  X  X  X
   Splinting of Fractures & Dislocations X X X
   Supervise residents assigned to Gastroenterology  X  X  X
   Supervise an Inpatient Gastroenterology Team    X  X
   Sutures  X  X  X
   Venipuncture  X  X  X
   Emergency Use of External Temporary Pacemakers X X X
   Emergency Treatment of 1st, 2nd, & 3rd Degree Burns X X X
   Diagnostic Peritoneal Lavage X X X

The following procedures may be performed by Gastroenterology Fellows under Direct Supervision.  After the Fellow has demonstrated to faculty competence in the procedure, with appropriate documentation from the Program Director, the Fellow may be able to perform the procedure without a faculty member being in the room but available.  The latter will be at the discretion of the supervising physician and Program Director:

Patient Care Skill or Procedure (Direct Supervision unless otherwise directed by the supervising physician or Program Director) PGY-4 1st Year Fellow PGY-5
2nd Year Fellow
3rd Year Fellow
    Biopsy of the mucosa of the esophagus, stomach, small bowel, and colon   X  X  X
    Capsule endoscopy  X  X  X
    Colonoscopy with polypectomy   X  X  X
    Conscious sedation   X  X  X
    Esophageal dilation Enteral and parenteral alimentation   X  X  X
    Esophagogastroduodenoscopy   X  X  X
    Non-variceal hemostasis, both upper and lower including actively bleeding patients   X  X  X
    Other diagnostic & therapeutic procedures utilizing enteral intubation   X  X  X
    Percutaneous endoscopic gastrostomy   X  X  X
    Retrieval of foreign bodies from the esophagus   X  X  X
    Variceal hemostasis including actively bleeding patients   X  X  X
    Endoscopic Retrograde Cholendochopancreatography, in all its diagnostic and therapeutic applications;   X  X  X
    Imaging of the digestive system, including --  X  X  X
        Computed tomography (CT); including CT entero/colography   X  X  X
        Contrast radiography   X  X  X
        Magnetic resonance imaging   X  X  X
        Nuclear medicine  X  X  X
        Percutaneous cholangiography   X  X  X
        Ultrasound, including endoscopic ultrasound   X  X  X
        Vascular radiography   X  X  X
        Wireless capsule endoscopy   X  X  X
    Interpret gastrointestinal and hepatic biopsies   X  X  X
    Motility studies, including esophageal motility/pH studies  X  X  X
    Gastrointestinal motility studies and 24- hour pH monitoring   X  X  X


All other procedures are performed under direct supervision of a faculty member or more senior fellow.  
Sep 16, 2022