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General Surgery Residency

2013-2014 Vanderbilt Surgical House Officer Manual

Overall Education Goals

 

Vanderbilt University Surgical Residency Program Mission Statement: Our goal is to train surgical scholars.

The Vanderbilt University Department of Surgery maintains a century-long dedication to teaching, research, and service to patients. We recruit and seek to stimulate individuals with the dedication and motivation to acquire knowledge and skills which will enable them to achieve excellence in the care of surgical patients, and in addition, to make contributions of their own to surgery and to better surgical care. The Surgical Residency Program entails five clinical years plus usually one to three years of exposure and experience in research.

The Vanderbilt University Surgical Residency Program aspires to and expects quality patient care, scholarly endeavor, civility, stimulation and motivation vertically among members of the surgical faculty and house officer corps in an atmosphere of respect, courtesy, maturity, and propriety. In addition to developing technical and cognitive skills, the development of interpersonal skills and maintenance of positive esprit de corps are important components of this residency program.

 

The following sections relate to the educational goals, supervisory levels of responsibilities, resident stress issues, and teaching staff evaluations as well as departmental and institutional policies.

 

1.             Educational Curriculum and Goals

Our academic and clinical surgical curriculum is based on the following:

a. Clinical Rotations. Surgical rotations are crafted for each year and residents are given graduated responsibilities with supervision as they progress. Competency-based goals and objectives for every rotation for each of the 5 years of training are found at http://www.mc.vanderbilt.edu/root/vumc.php?site=gsr&doc=12132 on the Vanderbilt General Surgery Education Web site.

b. Electronic Resources. The ACS Fundamentals of Surgery Curriculum (FSC) Online Modules are offered to incoming interns for preparation for clinical responsibilities before and after starting the surgery rotations 1 July. The FSC is accessed at http://www.facs.org/education/fsc/index.html. The Surgical Council on Resident Education (SCORE) curriculum (http://surgicalcore.org/) is a foundational resource for the formal didactics. Evolving current information from the peer-reviewed surgical literature and information derived from presentations at national meetings are disseminated. Articles are provided electronically and as copies for journal club and other information. Eskind Biomedical Library (EBL)   (http://www.mc.vanderbilt.edu/diglib/journal.html) offers 24/7 access to over 3,800 full-text journals, 187,000 print volumes, and all the major medical information databases. In the quest for evidence-based medical practice, journal articles are frequently circulated and discussed. EBL also has a Patient Informatics Consult Service (PICS) program to provide VUMC patients and their families with health information. The practice of evidenced-based medicine is of the highest priority; through synchronous services (Library Information Desk, SearchDoc, the Librarian On Call, and Learning Site), staff expertise is available electronically 24/7. 

c. Skills Simulation. Simulation outside the operating room and the bedside are fundamental to the educational mission. The Vanderbilt Center for Experiential Leaning and Assessment (CELA) offers opportunities for skills acquisition using simulation with standardized patients and state-of-the-art facilities. Hands-on skills sessions for suturing, knot-tying, and other skills are offered in laboratory and classroom settings.

d. Educational Conferences.   Conferences addressing basic science as well as clinical knowledge are held regularly on a weekly basis including Resident Teaching Conferences, grand rounds, M & M, Wednesday Bonus Conference, attending walk rounds, and clinical conferences as well as the twice-monthly research conference. Surgical specialty education conferences and journal clubs are additional opportunities for learning and interaction with faculty.

e. Research Fellowships.  All categorical residents are encouraged to participate in a research fellowship during residency, usually after the third clinical year.

f. International Rotation.  A Surgery RRC-approved elective rotation in global surgery is available for PGY 4 residents.

g. Feedback and Evaluation.  Every 6 months each resident meets with a program director, associate program director, clerkship director, or a designated surgeon who is part of the surgery education office in order to participate in a self-assessment as well as receive feedback on the progress made in clinical skills, medical knowledge, and the other competencies that are measured against level-appropriate milestones. 

 

2.             Supervisory Lines of Responsibility

The care of the individual patient in the Vanderbilt University Surgical Residency Program is a group effort. The ultimate responsibility for care, decisions, procedures, etc., resides with the supervising faculty surgeon. The supervising faculty surgeon delegates aspects of the provision of care to the surgical residents on his/her service in proportion to the individual resident's level of training and expertise. Supervising faculty members will encourage and be open and receptive to calls from residents regarding patient care issues. The service chiefs state this explicitly at the beginning of each resident rotation and this practice is supported by the actions of all faculty members. The hierarchical system as a rule pertains (supervising faculty, chief resident, senior resident, junior resident, intern) with graded levels of responsibility, supervision, guidance, communication, and accountability. Circumstances and events in which residents must communicate with appropriate supervising faculty members include the transfer of a patient to an intensive care unit and when end-of-life or transition to comfort care decisions are being made.  

When supervising faculty or residents are away, off, or unavailable, specific supervising faculty and resident coverage arrangements will be communicated through Synergy, the robust Vanderbilt Synergy internal and external physicians' directory. One may access Synergy at https://synergy.mc.vanderbilt.edu/. Enter your VU user ID and password. There are call duty rosters and calls to the operator as well to gain the information required.  While the faculty may interact with any particular resident, communication and interaction among all members of the team are expected and normative. Documentation of supervision in the medical record is expected and encouraged. The Vanderbilt University Medical System online Synergy system allows residents to log in and access the database that lists every attending and resident on call (day or night) for each service, thus providing an electronic backup for supervision and assistance. Synergy mobile can be accessed at  https://synergy.mc.vanderbilt.edu/mobile/.

 

3.             Resident Stress

Recognizing that a surgical residency can be a period of physical, mental and emotional stress, the Program Director and the Associate Program Director provide at least semiannual conferences with individual residents to assess performance, learning, stress management, career objectives, and the resident's physical, mental and emotional health. Reviews of resident personnel and concerns re: performance are discussed at Clinical Competence Committee meetings (twice yearly) and at the Department’s Surgery GME Committee meetings held at least quarterly.

Should the resident perceive a need for assistance or counseling, guidelines for independent, confidential assistance information is provided in the Support Services section of the Vanderbilt University Medical Center House Staff Manual (http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf ). The resident is encouraged to contact the Surgical Education Office for individual advice, information, and attention. The Surgical Education Office will seek to detect residents experiencing problems and proactively make counseling and psychological support available. Attending surgeons are encouraged to be sensitive to the physical, mental and emotional needs and health of the residents and to report to the Program Directors or Surgical Education Office those residents who might warrant assistance.

When residents exhibit stressful or deficient behavior, drug and/or alcohol-related dysfunction will be one item considered. The VITA (Vanderbilt Institute for Treatment of Addiction), the Employee Assistance Program (EAP), the Psychological and Counseling Center, the Hospital Chaplains Office, and a psychiatrist are available resources for individuals as required.

Residents complete confidential assessments of each rotation. Input from these assessments plus information from interviews and "street knowledge" are used to identify the more stress-prone rotations. Rotations and training situations which consistently produce undesirable stress are reviewed adversely and actions taken to ameliorate, improve, and modify them.

Thus, resident stress is monitored by meetings with the individual residents, scrutiny of rotation evaluations (~ one to two monthly rotations depending on PGY level) submitted by the residents, plus an open door policy of the Surgical Educational Office to encourage and facilitate communication.

  

4.             Teaching Staff

Departmental Meetings (about 10/year) will devote time to a review of teaching program goals and objectives plus an assessment of the effectiveness in achieving them. Representative senior (PGY V and/or IV) residents attend and participate in these reviews. Documentation is provided in the Departmental Meeting minutes. At each Department meeting, the Program Director (PD) or the Associate Program Director (APD) report on residency update issues.

Quarterly, Surgery GME meetings are held and faculty discuss rotations and personnel issues. An annual review of the program is held each May or June.

Faculty and resident teaching development is supported through guest lectures, on-site presentations and workshops. The Vanderbilt Office for Teaching and Learning in Medicine is an importance resource. Attendance is encouraged at the ACS Surgeons as Educators and Residents as Teachers and Leaders courses.

 

5.             Policy on Duty Hours and Fatigue

Reporting duty hours on a regular and timely basis is a matter of professionalism and must be adhered to for personal development reasons as well as accreditation requirements.   ACGME duty hour guidelines, predicated on attaining a balance between the continuity of patient care and the patient's right to expect a healthy, alert, responsible, and responsive physician, mandate an 80-hour maximum work week averaged over four consecutive weeks. Resident education and patient care are both essential as are the avoidance of undue stress and fatigue among residents. Adherence to the following duty hour guidelines are mandatory in order that fatigue and sleep deprivation may be kept to a minimum or avoided altogether.  Vanderbilt Graduate Medical Education policy requires that residents and faculty complete the online educational module concerning duty hours and fatigue (‘VUMC Duty Hour Fatigue’ assigned through VandySafe at http://www.vandysafe.com). 

Signs of fatigue and sleep deprivation include:

•        repeatedly yawning and nodding off during conferences,

•        “microsleeps”…a few seconds of “Sleep” the “awake” resident may not even recognize

•        increased tolerance for risk,

•        passivity,

•        inattention to details,

•        decreased cognitive functions,

•        irritability,

•        motor vehicle collisions (or near misses),

•        increased errors,

•        impact on sleep process itself,

•        voluntary and involuntary latencies (the time to fall asleep) shorten,

•        increased number of “microsleeps”.

 

 

Summary of ACGME and S-RRC Hours Guidelines as of July 1, 2011
 

All Residents:

  • 320 hrs. or less for the 4-week block of 28 days, i.e., 80 hrs. per week averaged over four weeks
  • 4 days off in 4-week block of 28 days

 

PGY I:

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

Duty periods of PGY I resident must not exceed 16 hours in duration.

Minimum Time Off between Scheduled duty periods for PGY I:

    Should have 10-hr rest period between duty periods
    Must have 8 hours free of duty between schedule duty periods. 

 

PGY II-V:

24 + 4 Rule: Residents cannot stay beyond 28 consecutive hrs.; the 4 additional hrs. are for education or to complete work initiated. IF one stays > 28 hrs., the resident must report it to the PD who must investigate and log the occurrence.

 

PGY II-III (Intermediate Level Residents): Minimum Time Off Between Scheduled Duty Periods:

Should have 10-hr rest period between duty periods
Must have 8-hr rest period between scheduled duty periods
Must have at least 14-hrs free of duty after 24 hours of in-house duty.

 

PGY IV-V (Final Years of Education): Minimum Time Off Between Scheduled Duty Periods:

Must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.

Desirable: 8 hours free of duty between scheduled duty periods
There may be circumstances where these senior resident must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. The resident must report this to the PD who must investigate and log the occurrence.

 

Residents are responsible for informing their superiors when further hours and call will cause them to be out of compliance. Proactive attention should be paid to work hours and days off. The PGY1 rotations are 28 days. PGY 2-5s should check schedules regularly with the 28-day blocks in mind. Residents are required to submit a weekly log through the New Innovations online system. The Vanderbilt GME Duty Hours guidelines are found on page 12 of http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf

Educational activities in the form of Residents' Teaching Conference and Grand Rounds are integral to the educational mission of the program. Attendance is mandatory and residents are expected to be on time. Only post-call residents are exempt. Skeletal coverage at integrated hospitals will be the exception. Residents on assignments to specialty rotations are required to attend the 7 AM to 9 AM Friday morning Surgical Education Conference unless released by the PD or the APD. 

 

Moonlighting

Residency training in surgery at Vanderbilt is a full-time responsibility. Residents in their research years must have the approval of their research advisor and show signs of academic productivity in the form of abstracts, presentations, and presentations.  PGY V, IV, and on occasion III residents who have the approval of the PD or APD may moonlight as long as they remain within hours guidelines and it does not detract from their academic productivity. All Moonlighting activities must be registered with the Vanderbilt GME Office, 2601 The Vanderbilt Clinic. No resident is required to engage in moonlighting. The PD or APD must provide a prospective, written statement of permission that is made part of the resident's file. The residents' performance will be monitored for the effect of Moonlighting activities upon performance and adverse effects may lead to withdrawal of permission. The Vanderbilt GME Moonlighting guidelines are found on page 15 of http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf      
ACGME link: (http://www.acgme.org/acWebsite/irc/irc_IRCpr703.asp)

After a thorough review of compliance with hours for the ACGME Resident Work Hours, it is clear that some, but not all, rotations have excess capacity that would permit one 12 hour shift q 28 days without adversely affecting resident rest, study, or performance.

 Accordingly, we will consider approving on a resident-by-resident, rotation- by-rotation basis senior residents (PGY V and IV and, on occasion, PGY III) to participate in Moonlighting under close monitoring. This privilege is earned; it is not a right. There are ground rules and stipulations.

1. Permission to moonlight applies to PGY V and IV residents and, on occasion, PGY III. PGY 1 and 2 residents are not permitted to Moonlight.

2. Residents applying to moonlight should be meeting or exceeding expectations on their clinical rotations. 

3. For clinical residents, permission is granted for two 12-hour shifts per 28 days.

4. VUMC/VCH needs take priority over other institutions (e.g., St. Thomas) in our integrated residency.

5. No permission will be granted for moonlighting in Davidson County at any medical center not in an affiliation agreement with Vanderbilt. Thus, moonlighting is limited to VUMC, VCH, NVAMC, and St Thomas.

6. Moonlighting hours must be reported in the 80/work week; the 80 hours/work week average for 28 day blocks may not be exceeded with or without moonlighting.

Drs. Terhune and Tarpley will be the reference individuals to grant permission by four-week blocks and rotations. A signed permission will be placed in the folders of residents who are granted permission for the specified period.

This was last updated in 2013.

Backup Plan for Coverage: For work hours compliance as well as vacations, professional meetings, and emergency absences, backup coverage is maintained through the use of laboratory residents, the VA research resident, service cross-coverage, and resident sharing. Residents who spend one to three years in the lab are encouraged to moonlight on services which need manpower coverage in addition to assigned residents. One resident spends a year as a VA research resident with specific responsibility to assist with vacation, meeting, and emergency coverage. The R3 & R5 on the White GS service can be utilized as well on occasion. As of July 2013 the PGY IV Jeopardy resident will assist with day time case and call coverage with their primary night and Saturday call obligations being the home-base on Pediatric Surgery for 2013-2014.

 

6.    Record Keeping

As residents rotate through specialties or through patient care activities, they should document exposure and experience by means of the ACGME Resident Case Log System, "an Internet-based data collection system utilizing CPT codes." Logging cases on a regular and timely basis is a matter of professionalism and must be adhered to for personal development reasons as well as accreditation requirements.   The system is designed to permit you to enter procedures on a regular basis at your convenience from any PC connected to the World Wide Web. Access is by User ID and Password: contact Stephanie Burnham for your User ID and Password. Log on at  Case Log.

You will need such information when you make application to the American Board of Surgery. Please see 1.C.5.b. of the Program Requirements for Residency Education in General Surgery.

 

Portfolios for All Categorical General Surgery Residents

a. Keep a list by date, name, ss#, diagnosis, etc., of all specialty surgery encounters at all years. The American Board of Surgery or a future employer may query you for this to "prove" your exposure to urologic, otolaryngologic, neurosurgical, orthopaedic, plastic, anesthetic, and gynecologic nonoperative experiences.

b. Keeping track of ALL surgical encounters such as central lines, complex suturing in the ER, cast applications, nonoperative management of patients with traumatic and nontraumatic (e.g., pancreatitis, GI bleeds, cellulitis, diverticulitis, etc.) is  important as you seek  credentialing whether for  academic or community practice. Endoscopic procedures, stereotactic and other biopsy procedures, and your ultrasound experiences should be recorded.

c. Keep a portfolio that includes your CV (curriculum vitae) with all your accomplishments (ATLS, FLS, course attendances such as Surgeons as Educators, etc.) as well as all your presentations such as PowerPoint teaching sessions, important journal articles, and other useful materials and any reflections you note as you read and work. This portfolio is the equivalent of a filing cabinet of everything you do and everything you collect that might be useful in the future.

 

7.      Continuity of Care Policy

In the ACGME Program Requirements for Residency Education in Surgery, the following guidelines occur:

Outpatient Responsibilities—“Each program is required to provide residents with an outpatient experience to evaluate patients both pre-operatively, including initial evaluation, and post-operatively. At least 75% of the assignments in the essential content areas must include an outpatient experience of 1/2 day per week. (An outpatient experience is not required for assignments in the secondary components of surgery or surgical critical care, p. 17, Surgery PR 2008).

 It is our expectation that residents will adhere to the guidelines of the RRC.

 

8.     Residents Travel Policy

  • The Department encourages residents to submit their clinical and basic science research efforts to significant meetings in the United States and Canada for presentation. The Department will endeavor to help fund domestic travel for residents who are first authors to present their paper or their poster, providing certain provisions and expectations are met. Papers and posters may be submitted to international meetings, but the department does not fund expenses for foreign travel. International travel and expenses are the responsibility of the submitter or sponsors.
  • Travel assistance is a privilege, not a given. We need residents to be good stewards of the Department's resources, to treat departmental funds as if they were personal resources, and to meet the Department at least halfway in using common sense and cost-saving measures.
  • For insurance to cover residents on their travel, requests and notification for meetings and travel need to be done in advance in writing (e-mail encouraged) with Stephanie Rowe Burnham or her designee. Tickets need to be purchased in advance to optimize savings; days of travel may need to be adjusted to take advantage of fares; coach fare only can be reimbursed, etc. Searching for the best prices for hotels is encouraged.
  • If you prefer, Stephanie will be happy to make the travel arrangements (booking flight & hotel and taking care of registration) for you. The department procurement card can be used in this situation.
  • To confirm travel status and for insurance purposes, the traveler MUST sign a travel form before leaving on the trip.
  • Surgery Education requests that – when residents are dining together – residents pay individually. Please ask that the check be broken up by individual. If the residents do not pay individually, it is the responsibility of the paying resident to obtain reimbursement from fellow dining residents. The resident who turns in the group receipt will only be reimbursed by Vanderbilt for up to $75 per day.

Specific guidelines and limits:

  • Receipts are mandatory. Original, itemized, detailed receipts are required. All receipts must be submitted to Stephanie Rowe Burnham or her designee within ten calendar days of the return date.
  • There is a $75 reimbursement limit per day on meals. Alcohol is excluded and is not reimbursable.  Meal tips are reimbursable up to 20%.
  • Time up to one week total spent at meetings is considered departmental not vacation time. If an individual is at meetings for a total of greater than seven days then the days in excess of seven are subtracted from vacation days.
  • Hotels selected will be reimbursed at the base rate. Many hotels offer discounted rates for educational institutions. Such rates should be requested upon registration.
  • Car Rental – reimbursable when deemed more cost effective than taxi/cab or flight. Vanderbilt will not reimburse for upgrades (satellite radio, car seat, etc.). Staff who rent cars while on University business should decline any optional insurance offered by the rental agency. Automatic liability coverage for bodily injury, property damage and physical damage to a rental automobile is provided by the University.
  • Entertainment, health club expenses, video rentals, etc., are at the expense of the traveler.
  • Tips for maids and valet parking are considered personal expenses and are not reimbursable.
  • For the full Vanderbilt travel policy, please see:

http://www.vanderbilt.edu/procurement/travel/forms/VU%20Travel%20Policy.pdf

 

9.     Membership

Categorical General Surgery Residents are provided yearly memberships to the American College of Surgeons (ACS) for the duration of residency; and to the Society of American Gastrointestinal and Endoscopic Surgeons (SAFES) for PGY 2-5. 

The Department of Surgery will also cover membership to any societies where residents are presenting.  This membership will be maintained by the mentor or the resident (if interested, or the Department will continue the membership if the resident has another paper/abstract accepted to the meeting the following year. 

Also, during the chief year, the Department will provide membership to the Society the chief is using for their "chief meeting", but has not yet joined.

 

10.     Vacation Policy and Schedule Changes: 

Vanderbilt policy stipulates that residents are entitled to three weeks of vacation annually. The American Board of Surgery Booklet of Information states that residents are required to spend a minimum of 48 weeks/yearly in full-time surgical experience at the medical center. These are averaged over the first three clinical years and then over the last two clinical years.  The American Board of Surgery stipulates that absences of two days or more must be reported and count against your vacation ceiling.  For definition purposes five working days constitute a week.  We in the Surgery Education Office have obligations to CMS and the Department of Veterans Affairs which pay your salary as well as to you and the American Board of Surgery to make sure your eligibility is not compromised by too many absences. Thus, between vacations, interviews, meetings, workshops, there are four weeks available in a flexible manner for the residents. If one will be away for two weeks for various meetings plus interviews, then the vacation ceiling would be two weeks.

·         Assigned vacations may not be changed without the consent of the administrative vacation chief resident or Program Director and the Associate Program Director as well as written permission from the surgery education office.

·         Per Departmental policy, interviews constitute "vacation" time.  

Schedules and Schedule Changes: A monthly schedule is a carefully crafted and delicate instrument. Any changes, no matter how small or seemingly trivial, cause ripples across the entire hospital and the surgical residency from the hospital operators to the nursing service to the hours and days-off compliance. On-call responsibilities or days off may not be traded or adjusted without the consent of the administrative chief resident as well as the senior resident of the service.

 

11.    Leave Policy including Parental Leave policy and Family and Medical Leave Policy:

Go to http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf  in the current Vanderbilt House Staff Manual quoted as follows:

1. Family and Medical Leave Act (FMLA)

As required by the FMLA, Vanderbilt allows eligible residents to take up to twelve weeks  leave in a rolling twelve-month period for certain family or medical reasons (they must use sick days and/or vacation days to maintain these days as paid leave prior to going into unpaid status). These reasons include childbirth and care for the resident’s child after birth or placement for adoption or foster care; care for the resident’s spouse, son or daughter, or parent who has a serious health condition; or a serious health condition that makes the resident unable to perform his/her job. Residents are eligible for FMLA leave (if they meet the defined family or medical reasons) if they have:

been employed by VUMC for at least 12 months and

­been employed for at least 1250 hours of service during the 12-month period immediately preceding the commencement of the leave. If a resident is on FMLA leave, his/her health insurance continues. More information on FMLA leave can be obtained through the Office of Graduate Medical Education. The current Vanderbilt House Staff Manual is at http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf and the request forms at http://hr.vanderbilt.edu/forms/index.htm .

2. Parental Leave

Parental leave is available to eligible residents for the birth or adoption of a child under the FMLA and the Tennessee Parental Leave Act (TPLA). Time off under the TPLA and the FMLA runs concurrently. Contact the Benefits Office or the Office of GME for more information about qualifying conditions and the provisions for maternity leave under these laws.

3. Medical Leave

Medical leave is available at the discretion of the Program Director or Associate Program Director in 30-day increments up to a maximum of 52 weeks. Medical documentation is required if the resident is away from work for more than 5 calendar days. Residents will be required to exhaust other forms of leave for which they may qualify prior to being eligible for medical leave. If paid sick time is available, it must be used prior to going into unpaid status.

 

12.     Criteria for Selection, Evaluation and Promotion

I. Eligibility and Selection Policies and Procedures.

Eligibility to be selected as a surgical house officer is based on the criteria found in the current Vanderbilt House Staff Manual starting on page 28 and found at http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf. Eligible candidates include graduates of accredited medical and osteopathic schools as well as graduates of medicals schools outside the US & Canada who hold valid certificates from the ECFMG.

The selection criteria for first year (intern) residents are based in large part on the applicant’s record from medical school. All applicants that are granted interviews will be interviewed in person, or if extenuating circumstances make that impossible, by telephone. The Program Director or Associate Program Director evaluating residents or fellows attempting to transfer from other educational programs (prior to completion of training offered in that discipline in that institution) will directly contact the referring program director, chair, and/or other appropriate references to assess the educational qualifications of the resident or fellow prior to making any offer of employment. A final letter of evaluation and recommendation must be obtained from the referring program for all residents or fellows entering Vanderbilt programs after completing some phase of training in another institution. Appointments are made for a one-year term, with renewal of the appointment based on satisfactory performance by the house officer and the availability of a position.

There are two types or designations of residents in the General Surgery Residency:

Categorical (C)

Preliminary (P)

Preliminary PGY I residents include three groups:1) those recruited by specialties and assigned to General Surgery for their basic introduction and experience in surgery; 2) others who have guaranteed positions for the following year (radiology, PM&R, ophthalmology, etc.); and 3) persons who are seeking categorical positions after the PGY 1 year. Categorical candidates apply for positions through the Match process. Applications are read, screened, and graded on a 55-point screening grid by the Program Director or Associate Program Director or designee. Of the many applications received, approximately 80 candidates are invited for interviews in Nashville, the majority on scheduled Saturdays in December and January. In addition to formal presentations regarding Vanderbilt and tours of the institution, the candidates have three thirty-minute interviews with two faculty members and a senior resident. Each candidate will have a brief interview with a Chair and the Program Director. Candidates are given opportunities to interact with many residents. The interviewing faculty members evaluate and rank the candidates for performance and also pen narrative comments for further review.

T The sum of scores plus comments are produced and presented to a ranking session attended by faculty and senior residents involved in the interview process. Each interviewer has the opportunity to lobby for or against any candidate. The input from the ranking session, the ERAS file data, and the faculty interview scores are all collated. After further deliberation the Chairmen, and the PD, and APD generate the final rank list which is submitted to the NRMP.

Preliminary residents without guaranteed positions for the following year can also apply for preliminary positions and go through the above interview process. Unfilled preliminary positions are filled through the Supplemental Offer and Acceptance Program (SOAP) (administered by the National Resident Matching Program) involving program directors and candidates via an online system.  Note that there is now an “All In” policy by the NRMP and all residency positions must go to individuals in the NRMP system until the close of SOAP on the Friday afternoon of Match Week.

 

II. Evaluation.

Residents have formal evaluations of their performance on each rotation by attendings and, at times, chief/senior residents. The Program Director and Associate Program Director review these evaluations as they are returned via New Innovations (https://gme.mc.vanderbilt.edu/NI-Authentication/login.aspx?ReturnUrl=%2fni-authentication%2fDefault.aspx ) or paper forms. At faculty meetings and Surgical Graduate Medical Education (GME) meetings “Resident Issues” are discussed. Specific input is sought whenever notations on evaluations have raised concerns. Faculty are queried about any residents who might be experiencing difficulty, not progressing, exhibiting stress, or performing below expectations. Residents have in-depth interviews with the Program Director or Associate Program Director at six- monthly intervals. Where difficulties or concerns are noted, more frequent conferences are held. Each categorical resident takes the American Board of Surgery In-service Training Examination (ABSITE) in January. The Program Director or Associate Program Director gives feedback to residents regarding their performance on the ABSITE with follow-up conferences for counseling as indicated. The New Innovations online system is used by faculty and residents.

 

III. Promotion

The PD and APD conduct regular reviews of residents at Clinical Competence Committee meetings. GME meetings are held quarterly or more often as needed. During the winter meeting a detailed discussion takes place concerning any resident who has failed to make progress, who is struggling, or about whom evaluations have raised alarms or concerns. The resident’s entire folder is reviewed and a decision is then made regarding promotion to the next level of training, repetition of the year, dismissal, redirection, or other alternatives. If non-retention is recommended, written notification is given by 1 March. Specific expectations for each level of training and each posting are presented to residents in July at the commencement of the academic year (See Goals and Objectives above) and are available at   http://www.mc.vanderbilt.edu/root/vumc.php?site=gsr&doc=12132 on the Vanderbilt General Surgery Education Web site. Promotion is based on performance, maturity, judgment, and mastery of the skills expected for each level as well as interpersonal skills, integrity, and collegiality. Two promotions committees will meet to make final decisions on resident advancement.

 

13.     Disciplinary Guidelines including Suspension and Dismissal

A full discussion of these guidelines can be found in the current Vanderbilt House Staff Manual starting on page 46 and seen at http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf.   Whenever problems are observed or reported, counseling is offered by the Program Director and the Associate Program Director and referrals to the Employee Assistance Program are made when deemed necessary. If problems escalate, the following steps (outlined in the current Vanderbilt House Staff Manual) can be taken: Warning(s), Probation, Summary Suspension, Dismissal or Non-renewal. Every attempt will be made to bring about corrected behavior before any of these steps are taken. The rights of the resident to appeal are also spelled out in this section. The House Staff Complaint/Grievance Procedures are outlined from page 54 onward.  

Suspension and Dismissal: Expectations are that each categorical resident recruited to the General Surgery Residency will eventually complete the program and pass the American Board of Surgery qualifying and certifying examinations. Dismissal can be for reasons of academic deficiency, failure to mature as a surgeon, personal failure, or violations of institutional rules, policies, bylaws, and/or procedures. Dismissals, when necessary, follow the documentation and due process guidelines of the current Vanderbilt House Staff Manual Section IV: “Graduate Medical Education Evaluation and Disciplinary Guidelines” found at http://www.mc.vanderbilt.edu/documents/gme/files/HSmanual.pdf   

Where individuals have failed in their efforts to complete the residency in the past, these failures have not been primarily because of lack of intelligence but rather for personal, social, or psychological reasons. A five-year residency program with several years of research can be a stressful period, but this endeavor can develop the competent clinician who is strategically placed to make meaningful contributions to the advancement of medical knowledge across broad fronts.

 

John Tarpley, MD and Kyla Terhune, MD

Surgical Education Office

June 2013

 

 

 

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