LOMA LINDA UNIVERSITY
GENERAL SURGERY RESIDENCY
HANDBOOK
2008 – 2009

Welcome to the General Surgery Residency Program at Loma Linda University and affiliated hospitals.  It has taken much work and focused attention for your arrival at this point in your career - CONGRATULATIONS!  Your choice of a residency has been pivotal, for it will affect your future professional satisfaction and your contribution to medicine, as well as your personal and family life.  The residency years may be stressful and time consuming, but this intensity will be rewarded by accomplishment and the acquisition of technical skills and knowledge.

Our goal as surgery attending staff is to teach the knowledge and practice of surgery while reflecting true Christian empathy and compassion. Each of you has different long-term goals: some to serve as community surgeons, some as surgical missionaries, and some as academic surgical researchers and teachers.  There is ample opportunity, and we have developed a residency program that will satisfy the development of any of these goals. As Christian teachers, we want our graduates to be known for their outstanding capability and knowledge, their compassion and trustworthiness. We want you to be leaders in the specialty of surgery.

MISSION STATEMENT:

• To educate medical students and residents in the art and science of surgery.

• To recruit, support and retain faculty with high academic standards, who are committed to surgical education and are excellent role models to younger generations of surgeons.

• To maintain and foster a research environment that contributes to medical knowledge and stimulates innovative thinking in our residents and faculty.

• To foster an educational environment in which the mission of Loma Linda University Medical Center, “To make man whole,” is emphasized not only in the care of the patient but also by helping our residents to become excellent surgeons while they continue to cultivate their cultural, social and spiritual life.

GENERAL EDUCATIONAL OBJECTIVES:

1. To acquire a comprehensive knowledge base, clinical decision-making ability, and technical skills in the principal components of general surgery. These goals are fostered in an environment of progressively-graded clinical and operative experience and responsibility.

2. To acquire a broad experience in the additional components of general surgery, including acquisition of the appropriate knowledge base, the development of specific technical skills, and an understanding of the principles of decision-making particular to the specialty.

3. To acquire the ability to quickly and effectively assess, stabilize, and manage (operatively or non-operatively, as appropriate) the patient with severe multiple injuries, regardless of the organ systems involved.

4. To demonstrate the intellectual curiosity and commitment required to participate fully in the didactic curriculum of the residency program and to develop personal, life-long habits of self-study and continuing education.

5. To develop professional habits consistent with sound ethical medical practice, including:
• Effective interpersonal relationships with peers and other health professionals.
• A compassionate attitude toward patients and their families and friends.
• Clarity and timeliness of written communication in medical records and elsewhere.

6. To develop General Competencies in areas recommended by the ACGME
• Patient care
• Medical knowledge
• Practice-Based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-Based practice

7. To secure an environment in which the residents can develop mature surgical judgment and technical skills and, at the same time, be able to cultivate their cultural, social and spiritual life.

YEARLY EDUCATIONAL OBJECTIVES:

PGY-1 residents are expected to accomplish and maintain the following objectives:
1. Establish basic proficiency in the evaluation of patients under routine and emergency circumstances (recognizes surgical emergencies, performs a history and physical examination, orders appropriate basic ancillary studies, effectively communicates findings to other physicians).
2. Establish basic proficiency in providing pre-operative and post-operative care (writes appropriate pre-op and post-op orders for floor patients, handles nursing calls appropriately, and manages most routine postoperative care with minimal intervention by supervisors).
3. Develop a working knowledge of common problems in general surgery, vascular surgery, neurosurgery, orthopedics, plastic surgery, gynecology and urology (achieves acceptable grade on rotation evaluation).
4. Establish a working knowledge and familiarity with common procedures of the surgical specialties (achieves acceptable grade on rotation evaluation).
5. Acquire basic operative skills necessary to perform less complex surgical procedures, such as hernia repair, central line procedures and minor outpatient surgery.
6. Acquire proficiency in surgical endoscopy (successfully performs colonoscopy, EGD, sigmoidoscopy).
7. Acquire basic skills to perform endotracheal intubation and administer conscious sedation.
8. Develop personal values and interpersonal skills appropriate for the surgical resident (is available at required times, gives patient care needs highest priority).
PGY-2 residents are expected to accomplish and maintain the following objectives:
1. Develop enhanced proficiency in the provision of pre-operative and post-operative care (manages pre-operative and post-operative care of complex patients with minimal intervention by supervisors).
2. Establish a knowledge base and skill proficiency for the management of the critically ill surgical patient and the burned patient (achieves acceptable grade on rotation evaluation, can place endotracheal tube, S-G catheters, arterial lines, and perform escharotomy).
3. Develop organizational and teaching skills necessary for basic management of a surgical service (attends to organizational duties of service such as organizing rounds and teaching sessions).
4. Acquire proficiency in surgical endoscopy (successfully performs colonoscopy, EGD, sigmoidoscopy).
5. Acquire basic skills to perform ultrasound evaluations of breast, thyroid and trauma.
6. Develop a working knowledge of and familiarity with the management of common problems in thoracic surgery and transplant surgery (achieve specific goals & objectives on these services).
7. Increased skill in operative technique required for procedures of increasing surgical complexity, such as skin grafting, more complex hernia repairs and complex soft-tissue surgery (is able to perform these operations with minimal assistance).
PGY-3 residents are expected to accomplish and maintain the following objectives:
1. Continues to develop technical skills necessary for the performance of more complex surgical procedures in general, pediatric and minimally invasive surgery (performs laparoscopic cholecystectomy, small bowel resection, and other procedures of similar complexity).
2. Establish a knowledge base, judgment and interpersonal skills necessary to function as a surgical consultant (successfully manages simple consults with minimal help).
3. Develop enhanced skills in the management of a surgical service (manages service administrative duties assigned by chief resident or faculty).
4. Proficiency in the rational use of surgical literature and evidence-based medicine (defends discussions and recommendation with scientific evidence).
PGY-4 residents are expected to accomplish and maintain the following objectives:
1. Continue to develop knowledge and skills necessary for the complete management of common problems in general surgery, pediatric surgery, vascular surgery and surgical oncology (manages most common problems with minimal assistance).
2. Develop knowledge and skills necessary to function as the trauma team leader for both adult and pediatric patients (successfully directs trauma resuscitation).
3. Satisfactory performance as a teacher of junior residents and medical students (receives acceptable feedback from students and peers).
PGY-5 residents are expected to accomplish and maintain the following objectives:
1. Develop knowledge and skills necessary to assume complete responsibility for the management of the surgical patient, including mastery of the fundamental components of surgery as defined by the American Board of Surgery (achieves acceptable score on written and oral examinations and receives acceptable evaluations).
2. Proficiency in management of complex problems in general surgery, vascular surgery, surgical oncology and trauma (treats complex problems in the discipline with minimal help).
3. Demonstrates personal and professional responsibility, leadership skills and interpersonal skills necessary for independent practice as a specialist in surgery (successfully manages the chief resident services)

ACGME COMPETENCIES: 

The Accreditation Council for Graduate Medical Education (ACGME) has implemented a requirement that residents must obtain competence in the six areas listed below to the level expected of a new practitioner.  Accreditation of a given residency is contingent on this requirement being met.  Your residency program defines the specific knowledge, skills, behaviors, and attitudes required and provides educational experiences as needed in order for residents to demonstrate the following:

1. Patient care that is compassionate, appropriate, and effective for the treatment of health programs and the promotion of health;
2. Medical knowledge about established and evolving biomedical, clinical, and cognate sciences, as well as the application of this knowledge to patient care;
3. Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in patient care;
4. Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals;
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds;
6. Systems-based practice, as manifested by actions that demonstrate an awareness of responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

RESIDENT PERFORMANCE EVALUATIONS:

An evaluation of resident performance is completed by your attending at the end of each rotation.  YOU ARE TO REVIEW YOUR ROTATION PERFORMANCE WITH YOUR ATTENDING STAFF MEMBER AT THIS TIME.  PLEASE MAKE AN EXTRA EFFORT TO MEET WITH YOUR CHIEF FOR THIS FINAL EVALUATION.  THE EVALUATION MUST BE REVIEWED BY YOU AND THE ATTENDING STAFF SURGEON.  Rotation evaluations are reviewed by the Program Director and counseling performed when indicated.  The evaluations are kept in each resident’s file and are available for review at any time.

ATTENDING AND ROTATION EVALUATIONS:

Each attending is very interested in an evaluation of his/her performance. At the close of each rotation, you will be expected to complete the faculty and rotation evaluation forms.  Faculty/Rotation evaluation reminders will automatically be sent to you via e-mail and pager when you complete the rotation.  Reminders will continue to be sent to you through your e-mail address until you submit the evaluation.  These evaluations are completely anonymous; this anonymity is guaranteed.  The residency office does not have access to, nor can we obtain, your password.  These evaluations are reviewed by the Program Director, the Department Chairman, the appropriate section Chairman, and are used in Faculty Evaluations.  These evaluations are used to improve the content and quality of the residency program.

RESIDENT REPRESENTATION:

When a resident has a particular problem/concern with the program, he/she has three avenues in which to discuss the problem/concern.  First, the General Surgery Residency Council is an elected group of surgery residents who meet on a quarterly basis with the Program Director to discuss issues, concerns, and changes with the program.  Residents at each level of training select two representatives from their level to represent them on this council.  Second, all of the Chief Residents represent the residents on the Residency Committee.  This Committee is comprised of the Program Director, Associate Directors, and attending representatives from each hospital.  Please contact your resident council representative or the Chief Residents if you have issues you would like discussed.  Third, the resident can bring the problem directly to the Program Director.

PERSONAL FILES:

A personal file is maintained for each resident.  Information kept on file consists of applications, correspondence, leave requests, and other miscellaneous items.  Rotation evaluations will be reviewed with you at your bi-annual interview.

BI-ANNUAL INTERVIEWS:

The Director and Associate Directors of the Residency Training Program will conduct bi-annual interviews for each resident.  These interviews are meant to provide personal feedback regarding a resident's performance, future goals, and to identify areas of concern and need.  We recognize that a residency can be a significant stress for not only the resident but also his/her spouse.  We welcome the concerned spouse to the interview meetings.

HOUSE STAFF OFFICE:

The House Staff Office is the hospital's representative to oversee that all residencies are approved and functioning appropriately.  HSO is located in Coleman Pavilion (CP) Room 21005.  Dr. Daniel Giang is Director of Graduate Medical Education and Nancy Wheeler is the Executive Director of the HSO.  Other House Staff Office personnel include Theresa Meinken, Lynne Wendtland and Martie Parsley, PhD.  They can be reached at ext. 88131.

The House Staff Office will assist you in obtaining your California Medical License and Drug Enforcement Administration Certificate (DEA) during your first year.  Subsequently, each resident will then be responsible for providing an updated copy of his/her California Medical License, DEA Certificate and CPR card to both the House Staff Office and the residency office.  No third year resident will be employed without a California Medical License.  It is important to obtain your license early in the second year to avoid unforeseen problems.

The House Staff Office also coordinates all payroll activities and the House Staff Association (which functions to assist residents in negotiations with the hospital and in planning social activities).  Representatives to the House Staff Association are elected annually.

USMLE STEP 2 AND 3:

USMLE Step 2 or COMLEX 2 must be passed by the end of the PGY-1 year (12 months of ACGME training) or it will result in automatic NONRENEWAL OF THE TRAINING AGREEMENT.

Residents in the first year of postgraduate training at LLUMC are REQUIRED to take the USMLE Step 3 and submit results to the House Staff Office (HSO) by the end of the 8th month of training.  HSO will reimburse fees for USMLE Step 3 if successful results are submitted to HSO by this deadline.  Funds are void after the deadline.  If Step 3 is NOT PASSED, no funds will be available. 

Residents in the PGY-1 year at LLUMC are allowed 2 days off with pay to take USMLE Step 3 for the first time. If it is necessary to re-take USMLE Step 3, vacation time must be used.  Residents at all other year levels are required to use vacation time when taking USMLE Step 3. You are not allowed to take boards in December, January, May, June or the first two weeks in July; please plan accordingly.  Please make sure the testing facility is available prior to requesting time off.  You are required to complete a vacation request and turn it in to the residency office prior to taking the boards.  If insufficient notice is given to the service, your request to be off may be denied.

CALIFORNIA MEDICAL LICENSE:

Residents are required to obtain and maintain a current non-restricted California Medical License within the time frame required by LLUMC and the Medical Board of California (MBC).  It is the resident's responsibility to obtain information concerning licensing requirements, examinations, and to meet established deadlines.

ACLS:

The Department of Surgery requires that all first year residents complete an ACLS course prior to beginning their first year of training.  ACLS courses are conducted free of charge by the Life Support Educational Group at LLU.  For more information concerning the ACLS course, please contact Life Support Education at x44977 for a schedule of classes.  ACLS training is valid for two years.

LLUMC requires that all residents be in possession of either a valid BLS or ACLS certificate at all times during residency

ATLS:

Advanced Trauma Life Support is offered at the beginning of the second year of residency.  This course will assist in rotations where you are involved in running trauma.  The cost of the course is paid for by the residency program.  You will be contacted by the residency office regarding dates for the course. The residency program will pay for the ATLS course one time only per resident.

BLS:

LLUMC requires that all residents be in possession of either a valid BLS or ACLS certificate at all times during residency.  It is the responsibility of the resident to maintain this credential. 

LIBRARY:

The Department of Surgery currently maintains a core resident library in the Coleman Pavilion 21110.  No books are to be taken from the library.  Cardkey access allows you into the library.

The LLU Medical Center Library is located in Coleman Pavilion on the first floor.  The library is not open after hours but access can be gained by calling Security at x44320.  Access is limited to 15-20 minutes after hours.  Please contact the library assistants regarding online and med line searches.  Additional textbooks and journals are available at the Del Webb Library located across the University campus.

LECTURES:

Important in the training of a surgeon is the acquisition of basic surgical facts.  You are encouraged to develop your own study program of regular reading. To facilitate your learning, we have set up a lecture schedule.

All PGY-1 and PGY-2 residents are required to attend weekly Basic Science lectures held Wednesday, at 6:00 a.m. in A-level Amphitheater.  The course is based on “The Physiologic Basis of Surgery,” Fourth Edition, by Patrick O’Leary and Arnold Tabuenca.

A required lecture series for PGY 3, 4, 5 is also given on Wednesday at 6:00 a.m., and is based on Cameron's “Current Surgical Therapy”.  This is designed to review current surgical practice and serve as a forum for clinical case discussions.  Oral examination-type discussion is encouraged.

The schedule is distributed in July and posted on the llusurgery.org website.  Revisions are also posted there as necessary.  Attendance is taken at each lecture, and residents must be present at, or have an excused absence for, all lectures. Excused absences include vacation, sick all day, on call, and post call.  If you will be on vacation or are sick, please notify the residency office of this. Any absence from these meetings must be explained.  If a resident’s attendance falls below 85%, he or she will give a Grand Rounds presentation at the next available opening in the schedule and will be placed on Academic Warning.

JOURNAL CLUB/ONLINE JOURNAL CLUB

Residents are required to participate in both Journal Club (moderated by Dr. Mark Reeves) and the Online Journal Club (moderated by Dr. Gerry Gollin).  The journal clubs operate in alternate months beginning each August with Journal Club and alternating with Online Journal Club in September and so on until ending with Journal Club in May.

ORAL EXAMINATIONS:

Oral examinations are given to all fourth and fifth year residents in May or June.  These will be conducted in the same format as the American Board of Surgery Certifying (oral) Examination.  Participation is required, as this simulates the Certifying Exam in Surgery, and will point out areas upon which the resident can concentrate study in preparation for this exam.

IN-TRAINING EXAMINATIONS:

The American Board of Surgery In-Training Examination (ABSITE) will be held this year on February 1.  This exam tests knowledge and is graded according to level of training.  It is a good indicator of surgical knowledge and gives the resident exposure to the type of testing given by the American Board of Surgery.  The following guidelines are used by the Residency Committee to evaluate test results:
  A.   A resident scoring less than 30th percentile on the ABSITE will be counseled and placed on academic warning; a resident scoring less than 40th percentile will have a study program for the next year outlined.
B. A resident that continues a pattern of poor academic performance will be discontinued from the program.  Academic performance is based on a combination of conference participation, oral examinations and the ABSITE.
C. To be recommended to the American Board of Surgery Qualifying Examination from LLUMC, the fifth year resident needs to score above the 30th percentile in his/her last year or have achieved an average of 45th percentile or above over the third, fourth and fifth year ABSITE scores.

The residency hopes, by these actions, to provide a motivation for study, a monitoring process for evaluation of knowledge, and an avenue by which residents can prepare and ultimately pass the American Board of Surgery Qualifying and Certifying Examinations.

AMERICAN COLLEGE OF SURGEONS:

This organization is the official representative of surgeons in the United States of America. A member of this organization is called a Fellow of the American College of Surgeons.  This honor is granted to those who have completed a general surgery residency, have become board certified, have practiced in a local area for two years, and have satisfactorily completed the official interview, (which reviews personal and professional attitudes and standards).  Residents can benefit from the privileges and opportunities of the ACS by becoming a member of the Resident and Associate Society of the American College of Surgeons (RAS-ACS). 

Resident membership status:

The Resident Membership of the American College of Surgeons to extend the educational and professional advantages of the college to surgical residents.  The Candidate Group is composed of graduates from medical schools who are:  A) Enrolled in approved surgical residency programs or, B) Fully trained surgeons who recently have entered into surgical practice and aspire to Fellowship in the American College of Surgeons.

The Department of Surgery requires each resident to make application to and participate in the Candidate Group.  The fee for filing an application is $20.00; however, the fee is waived during the intern year.  To download an application, go to the American College of Surgery web site at facs.org.The residency will be happy to provide the letter from the department verifying your resident status in an approved residency program.

SESAP:

The Surgical Education and Self-Assessment Program present current information that many surgical authorities consider important.  The program provides a means of assessing your knowledge as you prepare for your board examinations (including the ABSITE).  The Surgery Department strongly recommends your participation in SESAP.  A copy of this ACS-authored publication is offered in the library as well as a CD ROM version for the computer.

RESEARCH:

Residents are encouraged to join their attending staff in pursuing basic science and clinical research studies.  Several physicians in the department conduct research projects and should be contacted months in advance to arrange research projects.  Research time at institutions outside Loma Linda University can be arranged.  Specific areas of interest should be outlined as soon as possible, as these usually must be arranged more than a year in advance.  For residents interested in dedicated research time, it is suggested that one to two years be taken for this after the 2nd year.  See the Program Director for further details and suggestions.  Please point out areas of particular interest or previous work to the Program Director or attending so work in these areas can be encouraged.  Residents must accumulate four research points over the course of the residency program in order to meet one of the qualifications for recommendation to the American Board of Surgery.  Submit completed presentations / publications to the surgery resident office for research credit.  Points can be accumulated at follows:

1.  Published manuscript     4 points
2.  Oral presentation at national meeting   3 points
3.  Oral presentation at regional meeting   2 points
4.  Submission of manuscript for publication   2 points
5.  Poster presentation     1 points

The involvement of residents in travel related to professional (educational) activities is necessary and encouraged.  To facilitate resident research participation, the policy is as follows:

RESIDENT TRAVEL FOR PROFESSIONAL ACTIVITIES:

Criteria for approved travel:

• The reason for traveling is to present the results of original investigative work conducted while at LLU or for participation in educational activities approved by the Program Director.
• The traveler will be personally making the presentation of the investigative work.
• Time away from clinical duties is minimized.  Residents presenting a paper or a poster at a scientific meeting can use one day for a local meeting and can use up to 3 days for an out-of-town meeting. (one day travel time to the meeting, one day for the presentation, and one day for return travel).  Residents may utilize vacation time to stay longer at a scientific meeting where they are presenting a paper. 

The residency program will assist the resident with travel expenses when the resident has a poster or paper accepted at a scientific meeting. Expenses will not be reimbursed if the approval for travel was not obtained prior to the date of departure or if a Leave Request is not completed and submitted within the usual time frames. The residency will reimburse the resident up to $750 in travel expenses (with valid receipts) and subject to the guidelines of LLUHC’s Accounting Department. Allowable expenses include: 
 
• Domestic economy class airfare (includes the United States and Canada)
• Single hotel room
• Usual and customary meeting registration fees
• Meal allowance at LLUHC-approved per diem rate
• Mileage charges and/or ground transportation fees

Additional funding for residents presenting papers is at the discretion of the section from which the paper originates, and each resident must apply to the Section Chief for funding prior to the meeting.

 

COMPETENCY EDUCATION:

Per the Graduate Medical Education office, residents are required to demonstrate instruction in the ACGME competencies, among other areas.  The General Surgery Residency program offers these units through educational DVDs from the American College of Surgeons.

The following courses are required of all residents:
 
ACS DVD courses: 
• Disclosing Surgical Error;
• Communicating with Patients about Surgical Errors and Adverse Outcomes
• Professionalism in Surgery;
• Practice Management Course for Residents and Young Surgeons (parts I and II);
• Personal Financial Planning and Management.

Residents must complete the above courses, as evidenced by satisfactory post-tests and, from the ACS, a certificate of completion in order to successfully complete the residency program.  Residents will be monitored to see that they are completing the courses during each year.

INVASIVE PROCEDURES:

All residents must perform a minimum number of invasive procedures under direct supervision.  These include, but are not limited to, central line placement, pulmonary artery catheterization, arterial line placement, endotracheal intubation, etc.  Junior residents who are not “privileged” to perform a given procedure must be supervised by an attending or senior resident.  Residents are “privileged” to perform invasive procedures after satisfactory completion of the minimum number of procedures are signed off by an attending or senior resident and verified by the Program Director. 

Please document the date, hospital, and patient’s medical record number for the procedure performed and have an attending or senior resident print and sign his/her name in the “Invasive Procedure Log Book” provided by the residency office.  After the number of procedures indicated is satisfactorily completed, submit the Invasive Procedures Book to the General Surgery Residency office for the Program Director’s signature. 

The procedures and the required minimum number that must be supervised are as follows:

Central Line Placement – Subclavian  10
Central Line Placement – Internal Jugular  5
Central Line Placement – Femoral  5
Arterial Line Insertion     5
Chest Tube Insertion    10
Endotracheal Intubation    10
Foley Catheterization    5 
Pulmonary Artery Catheterization   5

DRESS CODE:

YOUR DRESS IS A DEMONSTRATION OF THE QUALITY OF YOUR PROFESSIONAL SKILLS.  It is expected that surgery residents appear well-groomed and professional at all times.  White clinical coats and name tags are required at all institutions.  It is expected the men will wear ties and all personnel will dress in a professional way that represents the Department of Surgery.  Linen service on "B Level" at LLUMC will clean and store white coats for residents.  When you are in clinic, you are expected to be in professional attire, not surgical scrubs.

MAILBOXES:

Mailboxes are located in the Resident Library, Coleman Pavilion, 21110.  Please check them regularly for important program information and notices, even if you are on an off-site rotation.

CLINICAL ROTATIONS:

Clinical rotations form the core of surgical training.  We have developed clinical rotations that allow for the progressive development of skill and responsibility of a surgical specialist.  Every effort is made to insure that residents have a basic core of clinical rotations with some allowances made to those who wish to pursue special interests or research time.

The rotation schedule is created on a yearly basis in May or June.  Improvements in the residency may result in unexpected changes in the rotation schedule. If you have a specific request regarding your rotation schedule, please submit it in writing and schedule an appointment to discuss this request with the Program Director.

CALL SCHEDULES:

Requests for changes in the call schedule must be coordinated as early as possible with the person responsible for making the call schedule.  Requests are usually honored on a first come, first served basis. "On Call" days differ on each rotation and hospital:

Loma Linda University Medical Center: the residency office coordinates the call schedule and may be contacted at 558-4289 or 44289.  There will be no changes to the General Surgery/Trauma call schedule, except those of a true emergency nature, later than one week before the beginning of the month.

VA Medical Center: Dr. Kristine Zmaj and the Chief Administrative Resident coordinate the call schedule and may be contacted at 583-6064 or 76064.

Riverside County Regional Medical Center: Dr. Afshin Molkara and Michele Lynn coordinate the call schedule and may be contacted at 951-486-4175.

Arrowhead Regional Medical Center: the General Surgery Chief Resident coordinates the call schedule and may be reached at 580-6220 or 580-6222.

CONSULTS:

Consults are an important part of surgical training and are to be done in a timely manner.  The resident is responsible for all consults on the day he/she is listed on the call schedule.

RESIDENT WORK HOURS:

The duty hours restrictions and on-call activities as determined by the ACGME are as follows:

• Duty hours are defined as all clinical and academic activities related to the residency program (patient care, 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).  Duty hours do not include reading and preparation time spent away from the duty site.
• Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
• Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call.  One day is defined as 1 continuous 24 hour period free from all clinical, educational and administrative activities.
• Adequate time for rest and personal activities must be provided between all daily duty periods.  This should consist of a 10 hour time period provided between all daily duty periods and after in-house call.
• In-house call must occur no more frequently than every third night, averaged over a 4 week period.
• Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours.  Residents may remain on duty for up to 6 additional hours to participate in didactic activities, maintain continuity of medical and surgical care, transfer care of patients, or conduct outpatient continuity clinics.
• At-home call (or pager call) is defined as call taken from outside the assigned institution. The frequency is not subject to the every third night limitation.  Residents must still be provided with 1 day in 7 completely free of clinical responsibilities, averaged over a 4-week period. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80 hour limit.

• The Program Director and the faculty monitor the demands of the at-home call in their programs, and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
• Assessment of the compliance with these requirements will be done through the resident’s feedback on the Internet Evaluation Program and through time studies by the residency office.

A report of the previous week’s work hours (for purposes of hours reporting, the work week runs Friday – Thursday) is due each Friday in the residency office.  Hours are considered delinquent as of 8 a.m. Monday morning, and residents who are delinquent in reporting hours will be immediately suspended from duty.   The purpose of reporting hours is for the residency office to monitor work hours and keep them within the ACGME guidelines.

The residency uses New Innovations (new-innov.com) to track duty/work hours to verify residents are in compliance with ACGME guidelines as noted above.  Residents are required to record work hours on New Innovations on a weekly basis.  This includes hours worked at each facility/location.  It is extremely important that hours are accurately reported.  Under- and over-reporting of hours is not allowed; it is required that all residents accurately report work hours. 

MOONLIGHTING:

The Loma Linda Department of Surgery prohibits moonlighting during residency training.

ADMINISTRATIVE CHIEF

The Administrative Chief at LLUMC is the Chief Resident on Surgical Oncology.  The Administrative Chief at the VAMC is the Chief Resident on the Green service.  The Administrative Chief at RCRMC is the Chief Resident on the Blue service.

 

OPERATIVE EXPERIENCE:

A RECORD OF YOUR OPERATIVE EXPERIENCE IS OF UTMOST IMPORTANCE.  You should keep a personal record of all operations you do, the date and whether you were surgeon, first assistant, second assistant or teaching assistant. Recording of operative cases is done through the ACGME Resident Data Collection web-site (https://www.acgme.org/residentdatacollection/).  You will receive your password and user name to enter your cases from the Surgery Residency office.  Residents are required to enter their operative cases on a daily basis. Failure to enter cases may result in suspension from your service.  It is important that the dictating surgeon designates your position in the operation as you desire (i.e. 1st assistant, teaching assistant, etc) as this is how medical records will accumulate your experience.  You may print your operative experience record at any time to verify correct data entry of cases.  Also of importance are your critical care cases where no procedure is done but you are the primary physician during the hospital stay.  It is important that these cases be tracked, as the board asks for a total number of these cases.

The final five year record is a summation of your operative experience and must be turned in before June 30.    This report must be mailed to the Residency Review Committee for Surgery by July 15th.  This form will also be submitted to the American Board of Surgery once you have completed residency.

MEDICAL RECORDS:

Chart completion is an important part of your work as a physician.  It is imperative that you complete all operative reports, discharge summaries and signatures in a TIMELY MANNER.

Each hospital has its own guidelines, but as a general rule ALL operative reports and discharge summaries must be dictated WITHIN 24 HOURS. If you do not complete the medical records per the hospital policy, you will be suspended.  During suspension, you are not permitted to participate in ANY aspect of patient care, including on-call or operative activities.  IF A RESIDENT ACCUMULATES 45 DAYS ON SUSPENSION, HE/SHE IS REPORTED TO THE CALIFORNIA MEDICAL BOARD AND THIS CAN AFFECT LICENSE RENEWAL.  The Department requires timely completion of all medical records. We keep records of chart completion and include this in letters of recommendations to hospitals.

MEDICAL STUDENT TEACHING:

Medical student teaching is a very important part of the residency, as it encourages the resident to know the material about which she/he is teaching, and is a valuable resource for the student who may have limited time on a given service.

It is important to provide the students with supervised responsibility in patient care and documentation.  Students that show interest and ability should be allowed to make decisions about patient care and should be given responsibility to follow and present their patient.

Students should be involved in seeing what typically occurs on a surgical service including: patient care, decisions to operate, and discussions with the patients' families.  Junior and senior medical students are not required to work longer hours than the house staff (i.e., 80 hours per week).  However, students may opt to work longer hours should they choose to do so to learn.  Students are not required to stay for lectures or formal didactic activities if they have been on duty for more than 30 consecutive hours.  However, students who have worked more than 30 hours may opt to attend lectures/didactic activities if they wish to do so to learn.  Junior medical students are in lecture for most of the morning on Friday.

Common sense and the guidelines above will hopefully encourage the residents to be better teachers who are more knowledgeable about the subject of surgery and help make surgical rotations better learning experiences for students as well.

AUTHORIZED ABSENCE:

Resident Physicians are encouraged to apply for fellowship positions.  To support this process, the residency will allow 5 days of authorized absence (in addition to vacation) per academic year to interview for fellowships.  Any additional days spent on interviews will come from the resident’s vacation bank.  Additionally, if a resident has vacation scheduled and also schedules interviews during a particular rotation, the vacation may have to be adjusted.  The level of care in the rotation cannot be allowed to suffer due to absences.  A “Leave Request” must be completed for time off to apply for a fellowship, even though the time off is not taken from the resident’s leave bank.

VACATION AND LEAVE POLICY:

Resident Physicians are granted the following vacation and leave time.
PGY 1   Resident - 3 weeks (15 working days)
PGY 2-5 Resident - 4 weeks (20 working days)

The Chief Residents are given the option to attend the American College of Surgeons meeting either in the Fall or Spring.  A maximum of 3 residents can attend the meeting in the Fall, and a maximum of 3 can attend the meeting in the Spring.  Chief Residents are allowed 3 days of Authorized Absence to attend this conference or another pertinent conference or to attend a board review course.  Vacation time cannot be carried over from one Academic Year to another.

Vacations are not approved for the following periods except under the most unusual extenuating circumstances:

• June - last 2 weeks
• July - first 2 weeks
• January - for 3 weeks immediately preceding the ABSITE Exam

Requests for leave must be submitted to the Residency Office no later than 30 days prior to the beginning of the month in which leave is requested.  For example, if leave is desired during the month of September, the request must be in the Residency Office by August 1.

No service can deny a resident vacation time, but a maximum of 1 week (5 working days) may be taken per rotation by senior residents (PGY 3-5), and a maximum of 3 working days per rotation may be taken by junior residents (PGY 1-2) . A resident desiring a longer vacation, e.g., two weeks, should arrange it around the transition time between two service rotations so that one week is taken off from each service.

Vacation requests must be spread out over the Academic Year, preferably one week in each quarter, and must not be allowed to bunch up toward the end of the Academic Year.  By September 1, all vacation requests for the entire academic year - except for one week  - must be submitted to the residency office.  Residents may hold one week in abeyance for a later decision but need to be aware that vacation requests submitted early in the year are more likely to be honored. 

Vacation may only be taken in rotations that last at least 1 month. 
Vacation requests may not be approved if 2 or more residents assigned to the same Service request the same vacation time.  In that case the earliest request will have priority.  All vacation requests go through the Residency Office.

This vacation and leave policy will also apply to residents rotating on the surgical services from other residency programs in the Medical Center i.e. Emergency Medicine, Family Practice, etc.

Arrowhead Regional Medical Center requires vacation requests 2 months in advance, as they make their call schedule 2 months in advance.

During the months in which there are legal holidays (July, September, November, December, January, February, May), residents will be given one additional day off, for a total of 5 days off duty that month.  (In November, where there are 2 holidays, residents will receive 2 additional days off.)  There are no more “comp” days, per se.  If a resident works on the actual legal holiday, an additional day off will have already been scheduled by the person making the call schedule.

SICK LEAVE:

Residents are provided with ten (10) Monday-Friday days of paid sick leave.
- Resident must notify the assigned service, the Program Director’s office (ext. 44289) and the House Staff office if they are unable to work due to illness.
- Residents are responsible for keeping their residency/department aware of their status
- The Program Director will determine whether sick leave used will have to be made up in compliance with program and Board requirements.

In the event of an extended leave, the House Staff Office (ext. 88131) must be notified if a resident is hospitalized or is ill/disabled on an outpatient basis for more than seven days so that disability benefits, if any, can be applied for. Application for State Disability is required by the Medical Center if either of these situations arises.  It is imperative that a disability application be submitted as soon as possible in order to avoid interruption of pay.  Application for benefits must be made no later than the 20th day after the first day for which benefits are payable.

MATERNITY LEAVE:

The American Board of Surgery requires that a resident be involved in the residency program at least 48 weeks out of a year.  Thus, Maternity Leave will be limited to 4 weeks in a given year.  The Program Director will determine whether time off for maternity leave will have to be made up, in compliance with program and Board requirements.  Resident must inform the Program Director of anticipated delivery within six (6) months prior to the expected delivery to allow the program to plan for the resident’s absence to minimize disruption to the program.

FUNERAL LEAVE:

Three (3) regularly scheduled work days off, with pay, for funeral leave are granted in the case of a death in the resident’s immediate family.  Immediate family includes spouse, children, stepchildren, parents, stepparents, father-in-law, mother-in-law, brothers, sisters, stepbrothers, stepsisters, only living relative, foster parents and legal guardians.  The resident must notify the Program Director’s office and HSO in the event funeral leave is required.

JURY DUTY:

LLUMC continues compensation for up to 15 days per calendar year, provided court verification of jury duty served is provided to the HSO.  The HSO, the residency office, and your attending must be notified of both potential and actual jury duty.

SUPERVISION POLICY:

The General Surgery Residency Program adheres to the basic resident supervision policy established by the Graduate Medical Education Committee of Loma Linda University Medical Center and to the Bylaws of the Medical Staff of Loma Linda University Medical Center.

1. Only members of the Medical Staff who have been granted appropriate privileges and who have been selected by the Residency Program Director shall supervise residents.

2. Documentation of supervision shall be demonstrated by counter-signature of the resident’s note or by referring to the resident’s documentation in a separate attending note.

3. The supervising physician shall personally interview and examine the patient each day to confirm the resident’s finding and to evaluate and educate the resident’s clinical care.

4. The supervising physician shall be physically present for any procedure for which the resident is not capable of performing without direct supervision.  This responsibility may be shared with another resident who has been designated as being capable of performing the procedure without direct presence of the supervising physician.

5. The designated member of the Medical Staff must approve any admission of a patient to the service.  This will allow discussion of the resident’s preliminary medical decision making.

6. The designated member of the Medical Staff shall be informed of any unexpected transfer of a patient to another service, to another level of care (ICU, intermediate, etc.), unexpected transfer of a patient or death of a patient.

7. The designated member of the Medical Staff must approve any recommendation to discharge a patient from the Emergency Room.

8. The resident shall order consultations and testing on behalf of the attending physician following discussion with the attending physician.  This may be documented by the resident or by the attending in the order or in the physician’s notes.

9. Any consultations requested by another service may be initially seen by the resident.  The resident shall immediately discuss the consultation with the designated member of the Medical Staff for critically ill patients.  The consulting physician shall personally evaluate the patient within one day of the request for consultation.

10. Residents in General Surgery will not operate independently.  All cases taken to the operating room will be discussed with the attending physician and all operations performed under the supervision of the attending physician.  In addition, JACHO requires that all hospital nurses be able to determine whether a physician, including a resident, is capable of performing a given procedure in the ER or on the ward without direct physician supervision.

11. The GME office has instituted a system (the “MSO”) allowing nurses and staff to track resident capabilities to perform procedures without direct attending supervision.

12. The resident’s profile is updated as progression through the program and acquisition of skills is acquired.  In addition, the residency program has a program to monitor interns in the acquisition of skill for invasive procedures.  Once a predetermined number of specific procedures have been completed satisfactorily, the resident may then perform such procedures with attending approval but without direct supervision.

13. The first year of training emphasizes surgical diagnosis, pathophysiology and pre- and post- operative care.  The intern, along with the more senior resident, is involved in the daily presentation of the patient to the attending surgeons where treatment decisions are finalized.  The intern follows the patient to surgery, where he acts as one of the surgical assistants.  In less complicated cases, such as hernia or appendectomy, the intern often performs the operation as directed by the attending surgeon.

14. Residents who perform well can be given responsibility for independent judgment and surgical decision-making with continued attending supervision.  By the third year, residents are also given more responsibility for evaluating surgical patients in the emergency room, initiating preoperative treatment and arranging for further surgical care.  In addition, they are more involved with the technical aspects of the surgery in the operating room.

15. During the fourth and fifth years of residency, residents are considered the senior/chief of the service and supervise junior residents and medical students.  Senior residents are expected to exercise increasing degrees of independent responsibility for surgical decision-making and perform more advanced surgical procedures, while attending surgeons monitor their progress and continue to supervise the service. Senior residents are allowed and encouraged to exercise independent surgical judgment to the degree that is consistent with good patient care.

16. Residents must be aware of the supervisory lines of responsibility.  If there is a serious concern related to supervision or any other aspect of the training, any resident can bypass the supervisory lines and communicate directly with the Program Director of the Chairman of the Department of Surgery.

DEPARTMENT OF SURGERY DISCIPLINARY METHODS:

These disciplinary measures are designed to help the failing resident.  To accomplish this, all problem areas are documented and communicated between resident and attending staff.  These guidelines apply to General Surgery residents at each of the integrated institutions.  Representatives from the appropriate hospitals will be involved in the decision-making process.  The Department of Surgery has a real commitment to working with the resident to resolve problem areas.

A.  WARNING:

1. A warning is given to a resident at the decision of the Program Director (PD) or the Surgery Residency Review Committee (RRC).
2. Examples of situations resulting in a warning:
 a.  Poor academic performance or attendance to academic functions
 b.  Poor clinical performance or attendance to academic functions
 c.  Poor medical records completion
3. Warning is communicated to the resident by a meeting with the PD and a follow-up letter outlining the problem and expected solution.
4. Further follow-up at the PD or RRC's discretion.  Repeat similar poor performance by the resident may result in him/her being put on probation.

EXAMPLE:

- Resident with documented poor academic performance on evaluations and poor performance on ABSITE or quarterly tests.
- PD or RRC reviews evidence and decides if a warning is appropriate.
- PD meets with resident and reviews situation.
- Follow-up letter from PD to the resident reviewing steps later and warning given.
- Further follow-up at discretion of PD or RRC.

B. PROBATION:

1. Probation is instituted by the RRC or the PD.
2. Examples of situations resulting in probation are as follows:
 a.   Repeated poor evaluations from clinical services.
 b.   Repeated poor academic performance.
 c.   A consistent problem with medical record completion.
3. Probation usually follows a warning, but may be instituted without an initial warning if the PD or RRC feels that such a course is dictated by the severity of the problem.
4. Probation is communicated to the Resident by a personal visit with the Program Director and a follow-up letter outlining the problem and the expected solution - including time frame.  Appeal of the case may be taken to the RRC if the Resident so chooses.  Copies of the probation letter will be sent to the Chairman, Graduate Medical Education Committee and Dean, School of Medicine.
5. Probation cannot continue for greater than six months without review by the PD or RRC and resident.
6. Completion of the probation period will be documented by a letter from the PD to the resident.  Copies of this letter will be sent to the Chairman, Graduate Medical Education Committee and Dean, School of Medicine.
7. The resident may appeal a decision for probation to the Graduate Medical Education Committee

EXAMPLE:

- Resident with repeated poor performance or extremely poor performance.
- Placed on PROBATION by RRC.  Communicated by meeting and letter.
- Review of Resident's performance at the end of the probationary time period.
- Letter to remove Resident from PROBATION.

C. DISMISSAL:  FOR CASES OF INCOMPETENCE OR POOR PERFORMANCE.

1. The Resident has already been placed on probation or given a warning.  This implies documentation of the problem and communication with the Resident and possibility of appeal.
2. If the problem recurs or continues, the poor performance will once again be documented and discussed with the Resident by the PD.  In discussion with the PD, the Resident will sign that evaluation form or discussion summary.
3. Review of the Resident's case by the RRC with possible recommendation of initiation of dismissal.  This action will be documented with a formal letter to the Resident, Chairman, Graduate Medical Education Committee and Dean, School of Medicine.
4. Resident may appeal the initiation of dismissal action with Graduate Medical Education appointed committee consisting of:
  a. GME Representative
  b.  LLUMC Administration Representative
  c.  Chairman, Department of Surgery
  d. Resident's choice of attending to represent him.

EXAMPLE OF COURSE IN SUCH A CASE:

- Failing to meet the RRC or PD's requirements of the probationary time period.
- At the discretion of the RRC or PD for a Resident who is placed on probation twice or more for the same or similar problem.
- Resident on Probation.
- Repeat poor performance or failing to satisfy probationary terms.
- Meeting with Program Director.
- Residency Committee recommends dismissal, refers case to GME.
- Resident informed by meeting with PD, Chairman, GME and formal letter.
- Optional Case Review Committee.

D. IMMEDIATE SUSPENSION:

For the worst case situations. (i.e., patient harm).
In agreement with the complete Article X from the House Staff contract.

1.    Gross act not commensurate with good medical practice.
2. An inability of the Physician to fulfill responsibilities.
3. Disciplinary action imposed by the California Medical Board.
4. In the event the Physician is convicted or pleads guilty or nolo contendere to a felony or any crime involving moral turpitude.
5. Conduct not commensurate with good moral standards.
6. When capacity is diminished by use of drugs or alcohol.
7. When responsible Attending Staff, in conjunction with the Head of the Department and the Chairman of the Graduate Medical Education Committee, feels that the Physician's effective capacity has been seriously diminished by emotional, mental or physical factors.

In the event the physician is suspended for any reason, the physician may request a hearing before the Graduate Medical Education Committee or Sub-Committee thereof, pursuant to such grievance procedures as may be adopted by the Graduate Medical Education Committee.  Hearing shall be arranged by the Chairman of the Committee where a review of the facts shall be made and the physician may be heard.

1. Any dispute concerning the Physician's eligibility to receive the certificate referred to an ARTICLE XI, or with regard to termination of this Agreement prior to its expiration date, shall be reviewed and adjudicated, if Physician so requests, by the Committee on Graduate Medical Education after a hearing before said Committee at this Physician shall have the right to appear and present any evidence he/she may have regarding his/her right to continue to participate in the Program or receive said certificate.  Physician may select a member of the Hospital's Medical Staff to accompany and represent him/her at such a hearing.
2. The decision reached by the Committee on Graduate Medical Education in concurrence with Hospital Administration, which shall be rendered in the form of a written opinion designating the basis for such decision, shall be final between the parties to this Agreement.  A copy of the decision shall be made available to Physician if he/she so request.

EXAMPLE:

-  Severe resident misconduct or action documented by attending.
- Cases reviewed by RRC and PD and subsequent meeting with resident.
- Graduate Medical Education, LLUMC Administration, Chairman of Department and resident's choice of attending will review case.  Decision reached will be final.
- Resident will be suspended immediately from clinical duties and will receive full pay and benefits for 30 days, at which time he/she will be dismissed.

CONTINUATION IN RESIDENCY:

Continuation in the residency program is determined by clinical and academic performance and the number of positions available.  Clinical performance is based on  attending evaluations of the residents. These evaluations are completed after each rotation and are reviewed and signed by both the resident and attending.  Academic performance is based on a combination of conference participation, quarterly tests, oral examinations and the ABSITE.

THE AMERICAN BOARD OF SURGERY ALLOWS SIX RESIDENTS TO FINISH OUR PROGRAM EACH YEAR AND BE RECOMMENDED TO TAKE THE SURGERY BOARDS.

The residency contract is issued for one year only.  Admittance to the program in the first year does not guarantee a full five years of residency training.  Continuances are year by year based on overall performance.  Those residents whose poor performance does not allow them to complete even a single year will be given consideration under the terms for due process.

 

RESIDENT HANDBOOK ACKNOWLEDGEMENT FORM - 2008-2009

• I have received the General Surgery Residency Program handbook for academic year 2008-2009, and I understand that it is my responsibility to read and comply with the policies contained in this handbook and any revisions made to it.  The handbook describes important information about the General Surgery Residency Program, and I understand that this handbook replaces any previous understanding, practice, manual, handbook or workplace addenda, policy, or representation concerning the terms and conditions of the General Surgery Residency Program.
• I am aware of the residency program’s disciplinary policy.
• I agree to abide by the policies and procedures contained within the handbook.  I understand that the policies and benefits contained in this handbook may be changed, modified, or deleted at any time. 
• I understand that it is my responsibility to retain a copy of this handbook and to request a new copy if mine is lost or damaged.
• I certify that I will accurately and completely report my work hours.

 

      
RESIDENCY PROGRAM REQUIREMENTS:

Category	Expected Level of Participation	Consequence
Lecture	100%	Write paper on week’s topic.  < 85% participation means resident will give the GR presentation at the next opening + academic warning
Grand Rounds	100%	< 85% participation means resident will give the GR presentation at the next opening + academic warning
Anatomy Lab	100% participation in labs assigned to pertinent PGY level	If lab missed, additional labs will be assigned + academic warning
Online Journal Club	100%	Present a 5-minute summary on papers at Grand Rounds
ABSITE Scores (Chiefs)	Score >  30 percentile in last year or have an average of >45th percentile for third, fourth, fifth year scores	Denied ability to sit for exams upon graduation
ABSITE Scores (Others)	Scores < 30th percentile	Study program outlined + academic warning.
Online attendings evaluations	80% at quarterly check	Give GR presentation on topic of own choosing at next opening
Online rotation evaluations	80% at quarterly check	Give GR presentation on topic of own choosing at next opening
ABS Chief application	100% by May 1 deadline; extended deadline is June 1	Extended deadline costs more; failure to register = no exam
Timekeeping	100%	Miss 3 in 8 week period = academic warning
Mock orals	100%	Personal oral exam with Dr. Reeves
Log cases with ACGME	100%	Academic warning

Annual Advancement Requirement Summary
Lecture attendance
Anatomy lab attendance
Journal club
Grand Rounds
Online journal club
ABSITE score
On-line evaluations
On-line rotation evaluations
Research
Surgery Residency/Resident Review Committee evaluation
Medical Records at each site
USMLE
Case entry
ABS-Chief application