Policies & Procedures

Resident reappointment and promotion to the next PGY level of training are contingent upon the adherence to requirements outlined in the “Rules and Procedures” set forth by the American Board of Orthopaedic Surgery, Inc. (ABOS) and the “ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery” set forth by the Accreditation Council for Graduate Medical Education (ACGME).

Resident should demonstrate proficiency in the following:

• Incremental increase in clinical competence, including performing applicable procedures
• Appropriate increase in the fund of knowledge; ability to teach others
• Clinical judgment
• Necessary technical skills
• Humanistic skills: communication with others, integrity
• Attendance, punctuality, availability, and enthusiasm
• Adherence to institutional standards of conduct, rules, and regulations, including program standards and hospital and clinic rules concerning infection control policies, scheduling, charting, record-keeping, and delegation to medical staff
• Adherence to rules and regulations in effect at each healthcare entity to which assigned
• Satisfactory performance on in-service examination

Supervision

To ensure oversight of resident supervision and graded authority and responsibility, the following levels of supervision are recognized:

• Direct Supervision: The supervising physician is physically present with the resident and patient.
• Indirect Supervision:
  • The supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision.
  • The supervising physician is not physically present within the hospital or other site of patient care but is immediately available to use telephonic and/or electronic modalities and come to the care site to provide Direct Supervision.
• Oversight: The Supervising Physician is available to review procedures/encounters with feedback provided after delivering care.

Attendings should consider following the SUPERB model when providing supervision. They should;

1. Set Expectations: When they should be notified about patient status changes.
2. Uncertainty is a time to contact: tell residents to call when they are uncertain of diagnosis, procedure, or care plan.
3. Planned Communication: Set a planned time for communication (i.e., each evening, on-call nights).
4. Readily available: Make your contact information and availability explicit for any questions or concerns.
5. Reassure the resident not to be afraid to call: tell the resident to call with questions or uncertainty.
6. Balance supervision and autonomy.

The Duke Orthopaedic Surgery Residency Training Program adopted the Duke University Hospital Graduate Medical Trainees and Attending Physicians Patient Care Activities and Supervision Responsibilities.

Duke University Hospital Graduate Medical Trainees and Attending Physicians Patient Care Activities and Supervision Responsibilities

Attending Physician: A licensed independent practitioner who holds admitting and/or attending physician privileges consistent with the requirements delineated in the Bylaws, Rules, and Regulations of the Medical Staff of Duke University Hospital or with the requirements delineated in the governing regulations of the assigned and approved off-site healthcare entity.

Trainee: A physician participating in an approved graduate medical education (GME) program. The term includes interns, residents, and fellows in GME programs approved by the Duke Institutional Committee on Graduate Medical Education. (A medical student is never considered a graduate medical trainee.)

Purpose

• Training graduate medical trainee physicians is a core mission of Duke Hospital, the Duke University School of Medicine, and the Duke University Health System. Teaching staff must supervise graduate medical trainees so that trainees assume progressively increasing responsibility according to their level of education, ability, and experience. This document describes the principles and general guidelines for supervising Duke University Health System trainees. Individual graduate medical training programs may require additional supervision, and the guidelines for supervision in such programs will be described in their separate program documents.
• The education of graduate medical trainees requires a partnership of teaching physicians, teaching hospitals, and educational organizations. The policies outlined here provide a framework that integrates the pertinent policies of the Private Diagnostic Clinic (PDC), the bylaws of Duke University Hospital, and the standards of educational accrediting agencies. In addition to providing an environment for outstanding trainee education and clinical experience, these policies are expected to support the goal of delivering high-quality patient care.

Attending Physician Responsibilities

• In hospitals participating in a professional graduate medical education program(s), the medical staff has a defined process for supervising each participant in the program(s) in carrying out patient care responsibilities.
• Such supervision will be provided by an attending physician with appropriate clinical privileges, with the expectation that the graduate medical trainee will develop into a practitioner with the knowledge, skills, experience, and abilities to provide care to the patients with the disease states applicable to his/her training program.
• The medical staff is responsible for the quality of the professional services provided by individuals with clinical responsibilities. In a hospital, the management of each patient's care (including patients under the care of participants in professional graduate medical education programs) is the responsibility of a medical staff member with appropriate clinical privileges. Therefore, the medical staff assures that each participant in a professional graduate medical education program is supervised in his/her patient care responsibilities by a medical staff member who has been granted clinical privileges through the medical staff process.
• Each Program Training Director is responsible for providing the medical staff with written descriptions of participants' roles, responsibilities, and patient care activities in professional graduate medical education programs. Each attending physician must be knowledgeable of these responsibilities.
• The attending physician position entails the dual roles of providing quality patient care and effective clinical teaching. Although some learning is conducted in the classroom, most are through direct contact, mentoring, and role modeling with trainees. All patients seen by the trainee will have an assigned attending physician. The attending physician is expected to:
  • Exercise control over the care rendered to each patient under the care of a resident, either through direct personal care or through supervision of medical trainees and/or medical personnel.
  • Document the degree of participation according to existing hospital policies.
  • Effectively role model safe, effective, efficient, and compassionate patient care and provide timely documentation to program directors required for trainee assessment and evaluation as mandated by the program’s Residency Review Committee (RRC), where applicable.
  • Participate in the educational activities of the training programs, and as appropriate, participate in institutional orientation programs, educational programs, performance improvement teams, and institutional and departmental educational committees.
  • Review and co-sign the history and physical within 24 hours,
  • Review progress notes and sign procedural and operative notes and discharge summaries.
• In general, the degree of attending involvement in patient care will be commensurate with the type of care the patient receives and the training, education, and experience of any medical trainee(s) involved in the patient’s care.
• The intensity of supervision required is not the same under all circumstances; it varies by specialty, level of training, the experience and competency of the individual trainee, and the acuity of the specific clinical situation. When supervising a senior-level trainee, an attending may provide less direct personal care of a patient seen for routine care. It may provide more direct personal care for a patient receiving complex care when supervising a junior-level trainee. An Attending physician may authorize the supervision of a junior trainee by a more senior level trainee based on the attending physician’s assessment of the senior level trainee’s experience and competence, unless limited by existing or future hospital policies, such as the use of lasers.
• Medical care teams are frequently involved in managing patients, and many physicians may act as the attending physician at different times during a patient’s illness. However, within the medical care team, the faculty attending physician must provide personal and identifiable service to the patient and/or appropriate medical direction of the trainee when the trainee performs the service as part of the training program experience.
• The following are specific instances in which involvement of the attending physician is required:

For Inpatient Care:

• Review the patient’s history, the record of examinations and tests, and make appropriate reviews of the patient’s progress;
• Examine the patient within 24 hours of admission, when there is a significant change in patient condition, or as required by good medical care;
• Confirm or revise the diagnosis and determine significant changes in the course of treatment to be followed; Either perform the physician’s services required by the patient or supervise the treatment to assure that trainees or others provide appropriate services and that the care meets proper quality level;
• Be present and ready to perform any service an attending physician would perform in a non-teaching setting. For major surgical or other complex, high-risk medical procedures, the attending physician must be immediately available to assist the trainee who is under the attending physician’s direction;
• Make a decision(s) to authorize or deny elective and urgent admissions, discharge from an inpatient status, or release from observation or outpatient status.
• When an in-patient is to be transferred to another service, the attending physician or a designee of the referring service shall inform the patient of the service change as soon as possible before the transfer. The receiving service shall assign a new attending physician who shall accept responsibility for patient care. Confirmation of the transfer to another level of care or acceptance of patients in transfer is the attending physician's responsibility.
• An attending physician’s decision is required to authorize an inpatient’s discharge or release from observation or outpatient status.
• Issue all "No Code" or DNAR orders. "No Code" or DNAR orders shall be issued only by an attending physician. In extenuating circumstances, the attending physician may issue the order verbally, by telephone, while the responsible registered nurse and trainee listen to and witness the verbal-telephone order; such verbal-telephone order shall be signed within twenty-four hours of issuance by the attending physician.
• Assure a completed history and physical and a completed, appropriately signed, and witnessed consent form are placed in the patient’s record before performing an operative or invasive procedure involving substantial risk.
• Assure appropriate documentation is made immediately in the medical record when a procedure is completed on a patient.

For Outpatient Care:

The extent and duration of the attending’s physical presence will be variable, depending upon the nature of the patient care situation, the type, and the complexity of the service. The responsibility or independence of trainees depends on their knowledge, manual skills, and experience as judged by the responsible attending physician. The attending physician supervisor must be designated and available to all sites of training by the Accreditation Council for Graduate Medical Education (ACGME) institutional and program requirements and specific departmental policies.

Graduate Medical Trainee Responsibilities:

• Each graduate medical trainee physician must meet or may exceed the qualifications for appointment to Associate member of the Medical Staff of Duke Hospital, whether in an Accreditation Council for Graduate Medical Education (ACGME) or institutionally sponsored GME graduate medical education program.
  Graduate medical trainees are expected to:
• Participate in care at levels commensurate with their degree of advancement within the teaching program and competence under the general supervision of appropriately privileged attending physicians.
• Perform their duties by the established practices, procedures, and policies of the institution and those of its programs, clinical departments, and other institutions to which the trainee is assigned.
• Adhere to state licensure requirements, federal and state regulations, risk management and insurance requirements, and occupational health and safety requirements.
• Fulfill all institutional requirements, such as attending the Graduate Medical Trainee Orientation, maintaining BLS/ACLS certification, and completing required instructional exercises, as detailed in their annual Appointment agreement.

The Duke Orthopaedic Surgery Residency Training Program adopted the Duke Graduate Medical Education Clinical and Educational Work Hours Policy (Section II).

I.  Duke Orthopaedic Surgery - Subject to Exceeding Work Hours

a. If a Resident (PGY-1 and PGY-2-5) finds themself in jeopardy of exceeding the work hour requirement, they should immediately contact the Orthopaedic Administrative Chief Resident and the Program Director to discuss a resolution.

II.  Duke Graduate Medical Education Clinical and Educational Work Hours

Background

Providing graduate medical trainees (trainees) with sound academic and clinical education must be carefully planned and balanced with concerns about patient safety and trainee well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on trainees to fulfill service obligations and that the clinical demands on trainees are achievable without compromising patient safety during scheduled hours (i.e., avoidance of excessive work compression). Didactic and clinical education must prioritize the allotment of trainees’ time and energies. Clinical and Educational Work Hour (formerly Duty Hour) assignments must recognize that program directors, faculty, and trainees are responsible for patients' safety and welfare and adherence to this policy. The institution is committed to promoting an educational environment, supporting its graduate medical trainees' physical and emotional well-being, and facilitating safe, timely, high-quality patient care.

Policy

As a Sponsoring Institution for ACGME-accredited programs, DUH shall maintain compliance with ACGME requirements or ACGME's interpretation of such requirements; therefore, this policy will be superseded by any applicable revisions to ACGME institutional, standard, or specialty-specific program requirements. Programs must maintain compliance with this policy and any additional specifications provided by individual ACGME Review Committees to maintain sponsorship by DUH. Programs may develop more stringent policies. The Duke GME policy applies to all institutions at which trainees rotate and to all trainees in ACGME-accredited or internally sponsored programs. For this policy, the terms DukeHealth.org “resident,” “fellow,” and “trainee” are interchangeable, and these policies apply to all GME trainees, regardless of the training year, except when otherwise noted.

Clinical and Educational Work Hours
a. Clinical and Educational Work (CEW) hours are defined as all clinical and academic activities related to the graduate medical education program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. CEW hours do not include reading and preparation time away from the work site.

b. CEW hours must be limited to 80 hours per week, averaged over four weeks (when averaging is allowed by the relevant RRC), inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting or Temporary Special Medical Activity (TSMA). Resident schedules should be created with a targeted maximum of 72 hours per week, averaged over four weeks, to allow residents flexibility to partake in unique clinical or educational activities that promote their sense of professionalism without exceeding the 80-hour-per-week limit.

c. When averaged over four weeks, trainees must receive one day in seven free from all clinical work and required education. At-home calls must not be assigned on these free days. One day is a continuous 24-hour period free from all clinical, educational, and administrative activities, including at-home calls.

d. Adequate time for rest and personal well-being activities must be provided. This should consist of 10 hours (8) provided between scheduled CEW periods. All trainees must have 14 hours free of duty after 24 hours of in-house call.

On-Call Activities
a. Residents must be scheduled for in-house calls no more frequently than every third night, averaged over four weeks.

b. Trainees must not be scheduled for more than six consecutive nights of night float. Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.

c. Continuous on-site duty, including in-house calls, must not exceed 24 hours. Residents may remain on-site for no longer than four additional hours for effective care transitions and didactic learning. Trainees must not be assigned additional patient care responsibilities after 24 hours of continuous in-house duty.

At-Home Call
a. At-home calls must not be as frequent or taxing as to preclude each trainee's rest and reasonable personal well-being time.

b. The frequency of at-home calls is not subject to the every-third-night limitation. Trainees taking at-home calls must be provided with one day in seven completely free from all educational and DukeHealth.org clinical responsibilities, averaged over four weeks (if allowed by the relevant Review Committee). At-home calls cannot be assigned on these days.

c. When trainees are called into the hospital from home, the hours trainees spend in-house are counted toward the 80-hour limit.

d. The program director and the faculty must monitor the demands of at-home calls in their programs and make scheduling adjustments to mitigate excessive service demands and/or fatigue.

Moonlighting and Temporary Special Medical Activity (TSMA)

a. Because graduate medical education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the trainee's ability to achieve the educational program's goals and objectives. The PTD must monitor the effect of moonlighting and TSMA activities on CEW hour compliance and trainee well-being.

b. All TSMA and moonlighting activities must be voluntary.

c. Moonlighting and TSMA hours must be counted towards the 80-hour maximum hour limit.

d. PGY-1 trainees are not permitted to moonlight or participate in TSMA.

e. Other Special Situations: Eligibility for TSMA moonlighting is affected by visa and active military status. Trainees who are visa holders or active military should check with their PTD and, if relevant, visa services and their military supervisor to determine eligibility.

Oversight

a. Each program must have written policies and procedures consistent with the Institutional, Common, and Specialty Program Requirements for trainee CEW hours and the working environment. These policies must be distributed to the trainees and the faculty annually. Trainees are required to log CEW hours using MedHub. Program directors must monitor CEW hours sufficiently to ensure an appropriate balance between education and service. Still, all program directors should review their trainees’ CEW and CEW violations at least monthly, detailing their reviews in MedHub.

b. Institutional CEW hours are reviewed monthly by the DIO and the MedHub Administrator.

c. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care.

d. Exceptions to CEW hours policy are not allowed.

e. Violations of the CEW hour standards may result in program or institutional sanctions, such as withdrawal of program sponsorship or Corrective Actions for Associate Members of the Medical Staff.

“Hand-Off” Checklist

1. Name/Gender/Age
2. Diagnosis
3. Procedure/DOS/Day Post-Op
4. Vital Signs/Neurovasc Exam
5. HCT/Urine out-put/Hemovac Drainage/Lytes
6. Dressing
7. Co-Morbidities
8. Anti-Coag/Antibiotics
9. Other Sig. Meds.
10. Ambulation/ Aides
11. PT/OT
12. Image Studies
13. Consults Pending/PMRO
14. Psycho-Social
15. Anticipated D/C Date
16. Plan of Care
17. Return Appt/Where/When
18. Pending Task(s)
19. DNR

Faculty Contact Protocol

1. ER Admission/Emergency Transfer
2. Transfer to ICU
3. Significant Clinical Adverse Event
4. Infection, Embolus, Dislocation, MI, CVA, Neurologic Deterioration
5. Dynamic Premorten Course/ DNR
6. Patient Death
7. Angry Team Member/ Family Member

The Duke Department of Orthopaedic Surgery supports high-quality education and safe and effective patient care. The program is committed to meeting the requirements of patient safety and resident well-being. Excessive sleep loss, fatigue, and resident stress are serious matters. Appropriate backup support will be provided when patient care responsibilities are challenging and prolonged and if unexpected needs create resident fatigue sufficient to jeopardize patient care during or following on-call periods.

All attendings and residents are instructed to observe other residents closely for signs of undue stress or fatigue. Faculty and other residents are to report concerns of sleepiness, tardiness, resident absences, inattentiveness, or other possible fatigue or excessive stress to the supervising attending or program director. The resident will be relieved of duties until the effects of fatigue or stress are no longer present.

An in-house Chief Resident is always available every night to provide relief.

The GME Office provides all GME residents and fellows with taxi service to manage fatigue. This service picks up residents and fellows who experience fatigue and provides transportation home and back to work the following day.

The Accreditation Council for Graduate Medical Education (ACGME) requires that, on average, there be at least four (4) hours of formal teaching activities each week.

Each resident is required to take the OITE examination each year. 

The exam is remotely proctored and computer-based. Residents should have their laptop and be prepared to perform hardware systems check before the exam date. 

Residents will be notified regarding logistics closer to the examination timeline, including but not limited to the primary test date, systems checklist, and OITE Resident Guide.

Residents scoring below the 10th percentile are recommended to develop a study plan using Orthobullets.

Resident performance is evaluated two weeks after the start of each clinical service and again two weeks before the end. Evaluation includes resident strengths and areas for improvement, followed by milestone assessments. 

Evaluation criteria include the resident’s self-evaluation, evaluations by peers/staff/students, and milestone assessments by faculty.

Progress is monitored at the biannual meeting with Program Director, including:

• Conference attendance: Residents are expected to attend 80 percent of required conferences
• Compliance with hospital policies: ACLS certification, training modules, HIPAA compliance, current medical licensure, USMLE passage
• Record-keeping: Up-to-date maintenance of surgical case logs in the ACGME database and duty hours

Residents are strongly encouraged to anonymously evaluate the faculty after each assignment. The results are collected twice yearly and distributed to the program director and individual faculty to assist in improving the quality of our education program.

Leave Policy

The American Board of Orthopaedic Surgery (ABOS) stipulates that programs may provide individual leave and vacation times for a resident by overall institutional and program policy. However, one year of credit must include no more than 50 weeks of full-time graduate medical education per year and at least 46 weeks of full-time graduate medical education per year, averaged over five years. Graduation before 60 months from initiation of training is not allowed.

Parental Leave

Duke employees, including trainees, are eligible for six weeks of paid parental leave to care for your newborn or adopted child after one year of employment at the institution. Trainees in their first employment year can use maternity or sick leave.

Time-off

Residents may take paid time off during orthopaedic rotations. In addition to their chosen meeting or vacation, residents may present a paper at a meeting.

• PGY1 residents receive two weeks per year
• PGY1 residents receive a few days for the USMLE Step 3
• PGY2-PGY5 residents receive three weeks per year
• All receive Christmas or New Year's holiday time off

To provide an additional, nonexclusive system of communication, exchange of information, and confidential concerns of individual Graduate Medical Trainees regarding their educational programs. Graduate Medical Trainees may contact their resident or faculty representative on the Institutional Committee for Graduate Medical Education, who have full access to the committee and any ad hoc committees necessary to explore and address Trainee’s concerns, complaints, or grievances not covered under the Corrective Action and Hearing Procedures for Associate Medical Staff of Duke University Hospital. The names of the Graduate Medical Trainee and Faculty representatives will be made available to all Graduate Medical Trainees annually. Any records regarding these issues will have a protected status of peer review.