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 coups are important components of this residency program. 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 that is strategically placed to make meaningful contributions to the advancement of medical knowledge across broad fronts.

The following paragraphs relate to the educational goals, supervisory levels of responsibilities, resident stress issues, and teaching staff evaluations as well as the educational goals for the various rotations.

1. Educational Goals

Vanderbilt University Surgical Residency Program Mission Statement: Our goal is to train surgical scholars. 
Our academic and clinical surgical curriculum is based on four pillars: 
a. Surgical Resident Curriculum, 4th Ed. (Edited by Sherralyn S. Cox and Walter J. Pories. Arlington, VA: Association of Program Directors in Surgery, 2002). Dr. James A. O'Neill, Jr., MD, the former Chairman of Surgical Sciences at Vanderbilt, was a contributor.  
b. The latest  Sabiston Textbook of Surgery,16th Ed. (Edited by Townsend, Beauchamp, Evers, Mattox. Philadelphia: Saunders, 2001).  This text is available to all Vanderbilt General Surgery residents on the web in the book section of MDConsult (http://www.mc.vanderbilt.edu/biolib/mdconsult.html ). Dr. Dan Beauchamp, Chief of Surgical Sciences, is an editor.  Argenta's Basic Science for Surgeons: A Review  is a supplementary text. 
c.  Evolving current information from the peer-reviewed surgical literature and information derived from presentations at national meetings.  Articles will be provided electronically and as copies for journal club and other information.
d. Basic science is addressed through the weekly Resident Teaching Conferences, grand rounds, attending walk rounds, and clinical conferences as well as the twice-monthly research conference.  All categorical residents are encouraged to participate in a research fellowship during residency.

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. There are 55 different surgery rotations spread amongst the five clinical years. The Educational Goals of each by rotation and level are enunciated in the pages that follow.
 

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 attending surgeon. The attending 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.  Attending faculty members will encourage and be open and receptive to calls from residents regarding patient care issues.  The service chiefs will state this explicitly at the beginning of each resident rotation and this practice will be supported by the actions of all faculty members. The hierarchical system as a rule pertains (attending, chief resident, senior resident, junior resident, intern) with graded levels of responsibility, supervision, guidance, communication, and accountability. When attendings or residents are away, off, or unavailable, specific attending and resident coverage arrangements will be communicated by the call duty roster and verbally. While the attending 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.
 

3. Resident Stress

Recognizing that a surgical residency can be a period of physical, mental and emotional stress, the Program Director and his/her designee will 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 performance will be done quarterly by the GME Committee of the department.

Should the resident perceive a need for assistance or counseling guidelines for independent, confidential assistance are provided in the Support Services section of the Vanderbilt University Medical Center Housestaff Manual. 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 Director 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, the Psychological and Counseling Center, the Hospital Chaplains Office, and a psychiatrist specializing in substance abuse 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" will be used to identify the more stress-prone rotations. Rotations and training situations which consistently produce undesirable stress will be reviewed adversely and actions taken to ameliorate, improve, and modify them.

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

4. Teaching Staff
   Quarterly, the monthly Departmental Meeting will devote time to a review of teaching program goals and objectives plus an assessment of the effectiveness in achieving them. A representative senior (PGY V) resident will attend and participate in these quarterly reviews. Documentation will be provided in the Departmental Meeting minutes.

5. Policy on Duty Hours

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 plus the avoidance of undue stress and fatigue among residents.

Residents must have at least one day (24 hours minimum) out of seven or two days (48 hours minimum) out of  fourteen out of the hospital and free from responsibility including beeper call.  Call in the hospital should be no more often than every third night averaged over a four-week period. A distinction is made between on-call time in the hospital and on-call availability at home. Hours worked when a resident comes into the hospital from home call are counted in the 80-hour work week. No duty period can exceed 30 hours straight.  Between 24-hour work periods there should be a minimum of a 10-hour rest period (i.e., coming off all-night call at 7 a.m. means the next work day cannot start before 5 p.m. the following day: 24 plus 10). Residents on-call continually at home should, as above, be off beeper at least one day in seven or one weekend in two. In every 28-day block the resident must have at least 4 days off and must not work more than 320 hours total. Residents are responsible for informing their superiors when further hours and call will cause them to be out of compliance. Proactive attention to work hours and days off is advised; check your schedule regularly with the 28-day blocks in mind.  A 28-block calendar is found at the end of this manual. Click here.  Residents are required to submit a weekly log each Monday. A copy is found by clicking here.

Educational activities in the form of Residents' Teaching Conference and Grand Rounds are integral to the educational mission of the program.  Attendance is required. 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. 

Moonlighting
Residency training in surgery at Vanderbilt is a full-time responsibility. "Moonlighting," is proscribed except for residents in their research years and senior residents meeting ABSITE criteria below  with the approval of their supervisor and the departmental Chairman. All "Moonlighting" activities must be registered with the Vanderbilt GME Office, 2601 The Vanderbilt Clinic. No resident is required to engage in moonlighting. The program director 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 these activities upon performance and that adverse effects may lead to withdrawal of permission (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, as from now, we will consider approving on a resident-by-resident, rotation- by-rotation basis senior residents (PGY V and IV) 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 only.

2.  Residents applying to moonlight must have scored at the 60^th %tile or higher on their previous year's ABSITE to earn this privilege (i.e., scored  60^th %tile in 2006 to moonlight in 2006-2007).

3.  Permission is granted for one 12 hour shift per 28 days, (i.e., one shift for our four week blocks).  Two-hour weekend shifts at VCH CT may be permitted on a case by case basis.

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, MNGH, 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. Dattilo 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.

Note: this permission is granted reluctantly and not entered into enthusiastically by all leadership.  This is being floated on a trial basis to those who are eligible.  The residents have a great deal of say in the running of this department.  Your input is listened to and- on occasion-acted on, as in this instance.  We will review this quarterly.  Continuity of care for our patients, compliance with work hours, and adequate rest for our residents remain priorities.

This is effective from 1 Feb 2006.

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 as the R 4 on GI Lap.
 

6. Continuity of Care Policy


Residents must have a weekly outpatient  experience on most rotations of at least one day or two half days of clinic.

In the ACGME Program Requirements for Residency Education in Surgery (11/2005), the following guidelines occur:

h. Outpatient Responsibilities
Residents must be provided, on average, with at least 1 day each week of outpatient experience during assignments in the principal components of surgery. Each resident should have the opportunity to examine patients preoperatively, consult with the attending surgeon, participate in the operation and in the immediate postoperative care until release from the facility, and to see patients personally in an outpatient setting and consult with the attending surgeon regarding follow-up care.

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

5. Record Keeping
   Residents to a large extent will determine their own training and education. Some residents will avail themselves of all opportunities on a service and reap an outstanding experience. Others, on the same service, may perform the minimum, not make it to the operating room, be more interested in getting off earlier, etc., and adjudge the rotation educationally deficient. Plan to make the most of each rotation. 
   
   Additionally, as residents rotate through specialties or through patient care activities, document your exposure and experience by means of  the ACGME Resident Case Log System, "an Internet-based data collection system utilizing CPT codes." RDCS 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:
         Username is the initial of your first name plus the initial of your last name plus the last four digits of your Social Security number (e.g., John Bob Doe=JD9999). 
         Password is the same as your WIZ order ID login.
         a. Log on to www.acgme.org 
         b. Select "Resident Case Log System"
         c. Select "Login"
         d. Enter Username and password.
   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 traumatic and nontraumatic (e.g., pancreatitis, GI bleeds, cellulitis, diverticulitis, etc.) is mandatory as you look forward to credentialing whether in academic or community practice. Endoscopic procedures, stereotactic and other biopsy procedures, and your ultrasound experiences should be recorded.

8.     Travel Policy

·                   The Department encourages residents to submit their clinical and basic science research efforts to significant meetings in the United States 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 for faculty or residents.  International travel and expenses are the responsibility of the submitter or sponsors.

9. Vacation Policy:  
Vanderbilt policy stipulates that PGY I  are entitled to two weeks of vacation. Residents PGY II and above 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. 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. Per Departmental policy, interviews constitute "vacation" time. Assigned vacations may not be changed without the consent of the administrative chief resident as well as the surgery education office.

9A. 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.

10. Leave Policy including Maternity Leave policy and Family and Medical Leave Policy: Go to http://www.mc.vanderbilt.edu/root/pdfs/gme/04_05_Manual2.pdf in the 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 unpaid leave in a rolling twelve month period for certain family or medical reasons. 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. Paid leave time, if available, is required to be substituted in accordance with the Vanderbilt policy on FMLA. A copy of the detailed policy may be found at http://www.mc.vanderbilt.edu/root/vumc.php?site=gme&doc=4204  and the request forms at http://hr.vanderbilt.edu/forms/index.htm.
2. Maternity Leave
Maternity leave is available to eligible residents for the birth or adoption of a child under the FMLA and the Tennessee Maternity Leave Act (TMLA). Pursuant to the TMLA, if certain conditions are met, a female resident may be eligible for maternity leave related to pregnancy, childbirth, and nursing an infant for a period of up to four months. Time off under the TMLA 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 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.

11.  Criteria for Selection, Evaluation, Promotion, and Dismissal of Residents:
General Surgery  Residency  Program, Vanderbilt U. School of Medicine.

I. Selection.

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

Categorical (C)

Designated preliminary (DP)

Non-designated preliminary (NDP).

Designated preliminary PGY I residents are recruited by the various specialties of surgery (ENT, Neurosurgery, Orthopaedics, Urology, and Oral-maxillofacial Surgery) and assigned to General Surgery for their basic introduction and experience in surgery. Categorical candidates apply for positions through the Match process. Applications are read, screened, and graded on a 55-point screening grid by a single individual, the Program Director . Of the many applications received, approximately 70 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/or 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.

The sum of  scores plus comments are produced and presented to a faculty and senior resident ranking session. Each person 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 Chairman and Program Director generate the final rank list which is submitted to the NRMP.

Non-designated preliminary residents can apply for preliminary positions and go through the above interview process. Additionally, on Scramble Day, unfilled NDP positions may be filled through a process involving program directors, faculty, and candidates who employ the phone, e-mail, and fax for interviews and recommendations.

II. Evaluation.

Residents have formal evaluations of their performance on each rotation by attendings and, at times, chief/senior residents.  The Chairman and Program Director review these evaluations as they are returned. 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 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 Chairman gives feedback to residents regarding their performance on the ABSITE with follow-up conferences for counseling as indicated. The newly developed on-line ACS/APDS Resident Evaluation System is being used presently by faculty and residents.

III. Promotion.

The Chairman and Program Director conduct regular reviews of residents at departmental GME 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 Attachment). Promotion is based on performance, maturity, judgment, and mastery of the skills expected for each level as well as interpersonal skills, integrity, and collegiality.

IV. 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 House Staff Manual Section IV: “VUMC-Graduate Medical Education Evaluation and Disciplinary Guidelines”.

John Tarpley
Surgical Education Office 
June 2007

 

WEEKLY LOG OF RESIDENT WORK HOURS Resident’s Name:  PGY Level: Service:  Week of:   Arrive Leave Return for Night call--hours worked Daily Total Monday         Tuesday         Wednesday         Thursday         Friday         Saturday         Sunday                                                             Weekly Total   CLINIC Service   Day(s), Date(s) & Hours _________ _________ _________ Attending(s)     Did you get 24 Hours straight off this week or 48 hours off in the past 14 days?

Return to Surgical Education Information

27 Jun 2007