1. education

Manual of
Policies & Procedures for
Graduate Medical Education
Programs
May 17, 2013
Chicago Medical School
at
Office of
Graduate Medical Education
Manual of Policies & Procedures for Graduate Medical Programs
Table of Contents
All of the following have been reviewed and reapproved as of May 17, 2013.
POLICY & PROCEDURES
EFFECTIVE
____________________________________________________________________________________
1.
The Office of GME
5/17/13
1a. Definitions
5/17/13
1b. Introduction
5/17/13
2.
Statement of Commitment to Graduate Medical Education
5/17/13
2a. Healthcare Industry Interactions with Graduate Medical Education
5/17/13
3.
Endorsements
4/20/12
4.
Resident Eligibility
4/20/12
5.
Selection of Residents and Fellows
4/20/12
5a. Acceptance of Residents or Fellows Transferring from Another Program
4/20/12
6.
Promotion Policy
5/17/13
7.
Resident Evaluations
5/17/13
8.
Deficiency in Performance or Progress
5/17/13
8a. Misconduct Policy
5/17/13
9.
Non-Renewal of Contract
5/17/13
9a. Dismissal from Residency Program
5/17/13
10.
Resident Supervision Plan
4/20/12
11.
Evaluations by the Trainees
4/20/12
12.
Attendance at Conferences
4/20/12
13.
Dress Code
5/17/13
14.
Duty Hours, On-Call Activities, Patient Loads & Service Obligations
4/20/12
15.
Ancillary Support
4/20/12
16.
Learning and Working Environment
4/20/12
17.
Quality Assurance and Administrative Activities
4/20/12
18.
Autopsies
4/20/12
19.
Competency-Based Curricula and Educational Goals
4/20/12
20.
Provisions for Program Closure or Reduction
4/20/12
21.
Scholarly Activity
4/20/12
22.
Professional and Personal Conduct
4/20/12
23.
Infection Control
4/20/12
24.
Immunization Recommendations
4/20/12
25.
Leave Policies
a. Educational Leave
4/20/12
b. Annual Leave
4/20/12
c. Maternity/Paternity/Adoption Leave
4/20/12
d. Sick Leave
4/20/12
e. Bereavement Leave
4/20/12
f. Military Leave
4/20/12
g. Leave of Absence
4/20/12
h. The Family and Medical Leave Act
4/20/12
26.
Salary and Benefits
4/20/12
27.
Malpractice Insurance
5/17/13
28.
Medical Records
4/20/12
29.
“Moonlighting” Policies
4/20/12
30.
Complaints and Grievances Rights and Procedures
5/17/13
30a. Appeal Rights and Procedures
5/17/13
31.
Impaired Physicians: Policies and Procedures
4/20/12
GME Policy Manual | May 17, 2013 | Page 1
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
Sexual Harassment
Counseling and Support Services
Orientation Programs
Residents’ Councils
Restrictive Covenants
Monitoring for Fatigue
Extension of Permissible Duty Hours
Actions Requiring the Approvals of the GME Committee and of the
the Dean or Associate Dean for GME
Actions Requiring DIO Countersignature
Technical Standards for GME Programs
Appendix I:
Appendix II:
Appendix III:
Appendix IV:
Appendix V:
Appendix VI:
Statement of Commitment to Graduate Medical Education
Salary Scale for Residents and Fellows for the AY 2013-14
Request for Permission to “Moonlight”
ACGME Requirements for Duty Hours and On-Call Activities
Sample Residency and Fellowship Agreement
Technical Standards for Graduate Medical Education Programs
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
4/20/12
5/17/13
4/20/12
4/20/12
5/17/13
5/17/13
Distribution and Review Form
GME Policy Manual | May 17, 2013 | Page 2
1. THE OFFICE OF GME
The Office of GME, under the direction of the Associate Dean for GME, is located in the Medical
School, Room L.152, 3333 Green Bay Road, North Chicago, IL 60064. Phone: (847)578-8509 and
(847) 578-3341; Fax: (847) 578-3320. Office personnel include:
Jeanette L. Morrison MD, Associate Dean for GME and Designated Institutional Official (DIO);
(847) 578-8509 and (847) 578—8646
Elsa Kurien, MA, MEd; Administrative Director for GME and CME; (847) 578-3341
Diane O’Gara; Senior Administrative Assistant; (847) 578-3329
The Office of GME may be able to assist you in matters common to all postgraduate residency
programs which include, but are not limited to:
a.
b.
c.
d.
e.
f.
University and Medical School policies and procedures, including grievances,
State of Illinois medical licenses,
Visas and IAP-66’s,
Residency program contracts,
Salaries and benefits for trainees paid by CMS, and
Graduation from postgraduate residency programs.
On most matters, your Residency Program Director and departmental education office should be
able to help you. If not, call the Office of GME at (847) 578-3341 and (847) 578-3329.
1a. DEFINITIONS.
Residency Program. Unless specifically distinguished in a particular section of this Manual, the
term “residency program” or simply “residency” refers to the program for specialty residents and
subspecialty fellows.
Resident. Unless specifically distinguished in a particular section of this Manual, the term
“resident” refers to both specialty residents and subspecialty fellows.
1b. INTRODUCTION.
This Manual is intended to promote compliance with the established standards and requirements
promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and is to be
interpreted in a manner consistent with those standards and requirements.
The italicized words below are excerpts of the ACGME Common Program Requirements and are
adopted as part of this Manual.
Residency is an essential dimension of the transformation of the medical student to the
independent practitioner along the continuum of medical education. It is physically, emotionally,
and intellectually demanding, and requires longitudinally-concentrated effort on the part of the
resident. The specialty education of physicians to practice independently is experiential, and
necessarily occurs within the context of the health care delivery system. Developing the skills,
knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires
the resident physician to assume personal responsibility for the care of individual patients. For the
resident, the essential learning activity is interaction with patients under the guidance and
supervision of faculty members who give value, context, and meaning to those interactions. As
residents gain experience and demonstrate growth in their ability to care for patients, they assume
roles that permit them to exercise those skills with greater independence. This concept--graded
GME Policy Manual | May 17, 2013 | Page 3
and progressive responsibility--is one of the core tenets of American graduate medical education.
Supervision in the setting of graduate medical education has the goals of assuring the provision of
safe and effective care to the individual patient; assuring each resident’s development of the skills,
knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing
a foundation for continued professional growth.
2. STATEMENT OF COMMITMENT TO GRADUATE MEDICAL EDUCATION
The Medical School’s Statement of Commitment to Graduate Medical Education May 17, 2013 is
given in Appendix I.
[Adopted by the GMEC on August 28, 2009; by the Faculty Executive Council on September 4,
2009; and by the Academic Assembly on October 23, 2009, approved April 20, 2012. Reviewed
and approved on May 17, 2013]
2a. HEALTHCARE INDUSTRY INTERACTIONS IN GRADUATE MEDICAL EDUCATION.
The University policy entitled “Healthcare Industry Interactions in Education” is applicable to
residents and is available on the University intranet (“Insite”) on the Office of Compliance page.
The following italicized words are selected excerpts from that policy:
For purposes of this policy, “health care industry” means a commercial entity (or one of its
representatives) that manufactures, sells, or otherwise provides medical devices,
pharmaceuticals, medical equipment, research equipment, health services, or other similar
products/services. Gifts to [a resident] from the health care industry are prohibited. A “gift to [a
resident]” means any payment to [a resident] or provision to [a resident] of free or discounted
items, medical samples for personal use, food, or travel when the [resident] is not providing, in
return therefore, a service of similar or greater value. For example: pens, notepads, free
textbooks, free meals, payment for attending a meeting, and samples are all considered gifts.
[Residents] may not attend or participate in any purported professional continuing education
program that is sponsored by the health care industry but that is not accredited [by the ACCME].
Each residency program must include within its curriculum, training on the University policy entitled
“Healthcare Industry Interactions in Education.”
3. ENDORSEMENTS
The Medical School endorses the “Essentials of Accredited Residencies in Graduate Medical
Education: Institutional and Program Requirements” as presented on the website of the
Accreditation Council for Graduate Medical Education (ACGME).
[Adopted by the GMEC on January 27, 2006 as a replacement for the policy of the same title,
approved June 27, 1997, approved April 20, 2012. Reviewed May 17, 2013]
4. RESIDENT ELIGIBILITY
Applicants with one of the following qualifications are eligible for appointment:
a. Graduates of medical schools in the U.S. and Canada accredited by the Liaison Committee
on Medical Education (LCME).
b. Graduates of medical schools in the U.S. and Canada accredited by the American
Osteopathic Association (AOA).
GME Policy Manual | May 17, 2013 | Page 4
c. Graduates of medical Schools outside the U.S. and Canada who meet both of the
following qualifications:
1. Have received a currently valid certificate from the Educational Commission for
Foreign Medical Graduates (ECFMG); and
2. Have a full and unrestricted license or a temporary license to practice medicine in
the State of Illinois.
d. Graduates of medical schools outside the U.S. and Canada who have completed a Fifth
Pathway program provided by an LCME accredited medical school.
[Adopted by the GMEC on October 25, 1996, approved April 20, 2012. Reviewed May 17,
2013]
5. SELECTION OF RESIDENTS AND FELLOWS
The Medical School’s postgraduate residency programs select candidates based on their
preparedness and ability to succeed in the program to which they have applied and to achieve the
stature of the complete physician envisioned by the Medical School in its Statement of
Commitment.
The policy of the School is to consider candidates regardless of race, gender, creed, nationality,
ethnic background or sexual orientation. Performance in medical school and on achievement tests,
character endorsements and official letters of recommendation, accomplishments, humanistic and
other qualities deemed important for the success of the candidate, will be used in the selection
process.
The Medical School participates in the Electronic Residency Application Service (ERAS). The
Medical School’s standard residency/fellowship ERAS application requires, among other items,
submission of a transcript from the applicant’s medical school [optional for fellowship applicants],
a Dean's letter [optional for fellowship applicants] and at least two letters of recommendation.
International medical graduates must also meet all the requirements for temporary licensure in
Illinois, minimum undergraduate college requirements, medical school basic science and core
clerkship requirements, ECFMG certification and other requirements for appropriate visa status. In
addition to academic, licensing and administrative credentials, the candidates’ personal
characteristics and ability to communicate are considered in the selection process. Invitations for
interview are sent out selectively after receipt and review of completed applications.
Applicants are responsible for ensuring that they meet all program prerequisites and institutional
policies regarding eligibility for appointment to a residency position prior to ranking a program
through the NRMP.
The Graduate Medical Education Committee reviews each program’s selection criteria on an annual
basis.
[Adopted by the GMEC on March 26, 2010 as a replacement for the policy of the same title of June
27, 1997, approved April 20, 2012. Reviewed May 17, 2013]
5a. ACCEPTANCE OF RESIDENTS OR FELLOWS TRANSFERRING FROM ANOTHER PROGRAM
Residents or fellows may be accepted in transfer from an extramural residency program if they are,
or may reasonably be expected to become, appropriately credentialed with respect to prior
education, training, visa status and licensing. Failure to confirm appropriate credentials, or to
acquire appropriate credentials within the timeframe anticipated by the CMS Program Director, will
GME Policy Manual | May 17, 2013 | Page 5
constitute adequate cause for voiding any verbal or written agreements to accept the individual in
transfer.
[Adopted by the GMEC on November 7, 2008, approved April 20, 2012. Reviewed May 17, 2013]
Before accepting a resident who is transferring from another program, the program director must
obtain written or electronic verification of previous educational experiences and a summative
competency-based performance evaluation of the transferring resident.
A program director must provide timely verification of residency education and summative
performance evaluations for residents who leave the program prior to completion.
6. PROMOTION POLICY.
1. Introduction. Residency is an essential dimension of the transformation of the medical student
to the independent practitioner along the continuum of medical education. It is physically,
emotionally, and intellectually demanding, and requires longitudinally-concentrated effort on the
part of the resident.
Within a residency program, there are formal levels of education. Each formal level of education in
the residency program is scheduled to coincide with each year the resident is in the residency
program and, accordingly, is normally signified by the label “PGY- #” where the # would be the
particular year of postgraduate training. Within each formal level of education in a residency
program, there are requirements to be fulfilled, which are consistent with the accreditation
standards and requirements established by ACGME. Those requirements include the resident
demonstrating proficiency in established competencies, as deemed appropriate for that formal
level of education in the residency program.
2. Promotion and Basis for Promotion. Promotion is a determination made by the Program
Director to advance a resident to the next formal level of education within the residency program.
This would be appropriate only when the Program Director determines, through the use of
academic judgment, that the resident has achieved the appropriate level of progress in the
residency program and has fulfilled the requirements associated with the current formal level of
education in the residency program. Promotions that occur as scheduled would be concurrent with
a renewal of the residency contract.
3. Non-Promotion of a Resident. A resident shall not be promoted if the Program Director
determines, through the use of academic judgment, that the resident has not achieved the
appropriate level of progress in the residency program or has not fulfilled the requirements
associated with the current formal level of education in the residency program. A decision to not
promote a resident as scheduled could lengthen the duration required to complete the residency
program.
a. Notice Requirement. In the event the Program Director determines that the resident
might not be promoted as currently scheduled, the resident will be so notified. This notice will be at
least four (4) months prior to the date of the promotion would have occurred as currently
scheduled. However, if the primary reason(s) for the non-promotion occurs or becomes apparent
within that four-month period, then this notice will be provided as soon as the circumstances allow.
This notice will be in writing and may be included within a written evaluation (as described in
paragraph 3 of Section 7 of this Manual), in a notice of deficiency (as described in paragraph 3 of
Section 8 of this Manual), or other written document signed by the Program Director.
GME Policy Manual | May 17, 2013 | Page 6
b. Appeal Rights. A resident has a right to appeal an action of the Program Director of nonpromotion to the next formal level of education within the residency program as scheduled. See
Section 30a describing the rights and procedures associated with this appeal.
7. RESIDENT EVALUATIONS.
1. Evaluation of Rotation or Similar Education Assignment. Assigned faculty shall evaluate the
performance and progress of each resident during each rotation or similar education assignment.
That evaluation shall be documented at the completion of that assignment and included in the
resident’s file.
2. Evaluation by Clinical Competency Committee. Each residency program shall have a Clinical
Competency Committee (CCC) that consists of core teaching faculty and the Program Director. That
committee shall meet on a regular basis for the purpose of evaluating the performance and
progress of the residents in that residency program. Candid comments from the membership of
the committee are essential in this evaluation process of residents in order for the Program
Director to identify any relevant issues that might not be reflected in rotation written evaluations.
3. Evaluation by Program Director. The Program Director shall, on at least a semi-annual basis,
evaluate the performance and progress of each resident within the residency program, document
that evaluation in a written document, and ensure delivery of that written evaluation to the
resident. In conducting this evaluation, the Program Director will consider evaluations from
multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff), the documented
rotation evaluations by faculty described in paragraph 1 of this Section, and the information
discussed during committee reviews described in paragraph 2 of this Section. A copy of the
evaluation by the Program Director shall be included in the resident’s file.
8. DEFICIENCY IN PERFORMANCE OR PROGRESS.
1. Policy. In the event the Program Director determines, through the exercise of academic
judgment, that a resident has not performed or progressed within the residency program in a
satisfactory manner or pace, the resident will be so notified and will be provided a reasonable
opportunity to address and correct that deficiency. Failure of the resident to then adequately
correct that deficiency in a timely manner, maintain proficiency, and progress in a satisfactorily
pace may result in non-promotion, non-renewal of the residency contract, or dismissal from the
residency program.
2. Examples. Examples of deficiencies in performance or progress in the residency program
include:
a. The failure to achieve or maintain proficiency in any component of any ACGME
competency that is deemed appropriate for the current formal level of education;
b. The failure to progress in the residency program at an appropriate pace;
c. The failure to timely achieve or maintain a prerequisite for any training activity in the
residency program; and
sites.
d. The failure to comply with University policies or policies of affiliated hospitals or other
Note: It is possible that a situation may reflect a deficiency in performance or progress but
also meet the definition of “misconduct” described in Section 8a of this Manual. In such a
GME Policy Manual | May 17, 2013 | Page 7
situation, the Program Director should use the process described in Section 8a of this
Manual.
3. Notification. This requirement will normally be accomplished by the Program Director issuing a
written notification to the resident that includes the following:
a. The nature and a brief description of the deficiency and a brief description of how this
deficiency was identified;
b. Statements that (i) the resident will be given a reasonable opportunity to address and
correct the deficiency; (ii) it is the responsibility of the resident to correct the deficiency; (iii) the
failure of the resident to correct the deficiency in a timely manner may result in non-promotion,
non-renewal of the residency contract, or dismissal from the residency program;
c. The specific date by which the resident is required to correct the deficiency;
d. If and when considered appropriate by the Program Director, a requirement for the
resident to participate in the development of a written plan of specific actions that the resident will
take in an effort to correct the deficiency (e.g. an academic action plan);
e. When applicable, a statement that, based on the current evaluation of the resident’s
performance and progress, the Program Director does not intend to promote the resident to the
next formal level of education and/or does not intend to renew the resident’s contract, but that this
intent will be reconsidered upon the receipt of additional information.
4. Meeting with the Resident and Program Director’s Determination. After notice of a deficiency
has been provided and after the expiration of the reasonable opportunity to correct the deficiency,
the Program Director shall meet with the resident and provide the resident the opportunity to
characterize his/her current status and explain what he/she considers to be the proper context. The
resident, upon request, will have access to his/her resident file; however, the resident’s file shall
always be under the supervision of the Program Director, faculty, or administrative staff of the
residency program. The Program Director will then determine, through the exercise of academic
judgment and based on the relevant information gathered (including resident’s entire file and any
information that was provided by the resident), whether or not the resident has timely corrected the
deficiency.
a. Deficiency Corrected. In the event the Program Director determines that the deficiency
had been corrected such that the resident is now expected to be eligible for promotion and renewal
of the residency contract, then the Program Director shall so notify the resident in writing and
include in that letter a statement that (1) the resident is required to perform and progress within
the residency program in a satisfactory manner and pace and (2) any failure to do so may result in
non-promotion to the next formal level of education within the residency program, non-renewal of
the residency contract, or dismissal from the residency program.
b. Continuing Deficiency. In the event the Program Director determines that the resident
has failed to timely correct the deficiency, the Program Director shall make one or more of the
following determinations:
(1) Extension of the Notification of Deficiency. The Program Director may decide to
extend the opportunity to correct the deficiency. This would normally be appropriate
when the Program Director determines that the resident acted in good faith, that
external factors beyond the control of the resident precluded or inhibited successful
GME Policy Manual | May 17, 2013 | Page 8
correction of the deficiency, and that a reasonable amount of additional time is
likely to result in the successful correction of the deficiency. This may be
appropriate in other circumstances, as determined by the Program Director. When
the determination is to extend the notification of deficiency, a new written notice
shall be issued to the resident.
(2) Non-Promotion. The Program Director may decide to not promote the resident
to the next formal level of education within the residency program, as further
explained in Section 6 of this Manual. In this situation, the Program Director shall
issue a written letter to the resident that notifies the resident of the Program
Director’s determination and of the resident’s right to appeal, as described in
Section 30a of this Manual.
(3) Non-Renewal of Residency Contract. The Program Director may decide to not
renew the resident’s contract in the residency program, as further described in
Section 9 of this Manual. In this situation, the Program Director shall issue a
written letter to the resident that notifies the resident of the Program Director’s
determination and of the resident’s right to appeal, as described in Section 30a of
this Manual.
(4) Dismissal. The Program Director may decide to dismiss a resident from the
residency program, as further described in Section 9a of this Manual. In this
situation, the Program Director shall issue a written letter to the resident that
notifies the resident of the Program Director’s determination and of the resident’s
right to appeal, as described in Section 30a of this Manual.
5. Administrative Leave. The Program Director may, at any time, summarily place
a resident on administrative leave, with or without pay, when the Program Director
determines that there is reason to believe any of the following:
a. There would be an unreasonable risk of harm to patients, to faculty, to
any resident (including the resident to be placed on administrative leave), or to the
administrative staff of the residency program, should the resident continue in the
specific rotation or generally in the residency program; or
b. There would be an unreasonable disruption of the residency program, of
the normal activities of the University, or of the normal activities of any affiliated
site, should the resident continue in the specific rotation or generally in the
residency program.
8a. MISCONDUCT POLICY.
1. Misconduct Defined. For purposes of this Section of the Manual, the term “misconduct” means:
a. any act or acts of a resident that amounts to or attempts to amount to:
(1) assault or other acts of violence toward a person, threat of harm to persons,
theft, intentional wrongful destruction of property, making deceptive false
statements or deceptive false documents, or acts of a similar nature;
(2) cheating, plagiarism, lying, or acts of a similar nature;
(3) patient abuse, child abuse or neglect, intentional breach of patient
confidentiality, diversion of controlled substances, sexual harassment or other
GME Policy Manual | May 17, 2013 | Page 9
forms of unlawful discrimination, boundary violation with medical students or
with faculty, or acts of a similar nature;
(4) violation of the University Code of Conduct; or
(5) violation of a condition of probation imposed from a prior finding of misconduct;
b. when such act or acts relate to the residency program.
Note: “Relates to the residency program” includes:
- the resident using his/her status as resident physician to facilitate the act or
- the resident engaging in any act that impacts, affects, or involves the residency program
curriculum, a University student, faculty, staff, or property, or an affiliated site patient,
medical staff, personnel, or property.
Note: It is possible that a situation may meet the definition of “misconduct” and also
appear to reflect a deficiency in performance or progress, as described in Section 8 of this
Manual. In such a situation, the Program Director should use the process in this Section.
2. Obligation to Report. Residents shall promptly report any known or suspected resident
misconduct to the Program Director. There shall be no retaliation, retribution, or reprisal for
making a good faith report of known or suspected resident misconduct.
3. Investigation. Upon becoming aware of an allegation of resident misconduct, the Program
Director shall take steps to gather the relevant information in a fair and reasonable manner (i.e. by
using methods deemed reasonably efficient in time and resources and that are reasonably likely to
result in reliable information within this learning and working environment); however, the factgathering efforts shall not be subject to any formal investigative or other criminal procedure
requirements that are applicable to government law enforcement officials. The Program Director
may do this by personally gathering information and/or by receiving information from another who
has conducted an investigation into the matter. This fact-gathering stage will normally include
seeking information directly from the resident.
4. Notice of Allegation of Misconduct. After completion of the investigation, if the Program
Director determines the process should continue, then the Program Director shall issue to the
resident a written notice of allegation of misconduct. This notice shall including the following:
a. The allegation in sufficient detail to enable the resident a meaningful opportunity to
respond, along with a brief description of how it was identified;
b. A statement that the resident will be given a reasonable opportunity to respond to this
allegation, to characterize his/her behavior, and explain what he/she considers to be the proper
context;
c. The specific date and time that has been scheduled to provide the resident the
opportunity to meet with the Program Director to respond to the allegation in person, and, if the
resident declines the opportunity to meet in person, the specific date and time before which any
information submitted in response to the allegation must be received by the Program Director; and
d. A statement that the Program Director will consider all relevant information, including
the resident’s entire file and information provided by the resident, to make a determination,
through the use of academic judgment, regarding the allegation of misconduct and the resident’s
future status in the residency program.
GME Policy Manual | May 17, 2013 | Page 10
5. Resident’s Opportunity to Respond. The resident has the opportunity to respond to the
allegation of misconduct, consistent with the Notice of Allegation of Misconduct (see paragraph 4
of this Section). The Program Director has discretion to conduct the meeting with the resident as
the Program Director deems fair and reasonable (i.e. by using methods deemed reasonably
efficient in time and resources and that are reasonably likely to result in reliable information within
this academic environment) in order to fairly resolve the matter; however, this meeting shall not be
bound by any legal procedural formality commonly utilized in formal legal proceedings, shall not be
bound by rules of evidence commonly utilized in formal legal proceedings, and shall not include the
presence of attorneys. The resident, upon request, will have access to his/her resident file;
however, the resident’s file shall always be under the supervision of the Program Director, faculty,
or administrative staff of the residency program.
6. Program Director Determination. The Program Director will make a determination, through the
exercise of academic judgment, based on the information gathered and the entire file of the
resident, of one of the following:
a. That there was no misconduct and no further action is warranted.
b. That there was no misconduct but there is a deficiency in performance or progress in the
residency program. In this situation, the Program Director shall take action consistent with Section
8 of this Manual.
c. That the resident committed misconduct and the resident should be placed on probation.
In this situation, the Program Director shall issue a letter to the resident that includes the
conditions of probation, a notification that a violation of any condition of probation would be
considered an act of misconduct, which may result in the dismissal from the residency program,
and a notification of the right to submit a grievance, as described in Section 30 of this Manual. The
duration of probation shall be the remainder of the time in the residency program and the
conditions of probation must include a condition that the resident not engages in misconduct.
d. That the resident committed misconduct and the resident’s contract in the residency
program should not be renewed, as further described in Section 9 of this Manual. In this situation,
the Program Director shall issue a written letter to the resident that notifies the resident of the
Program Director’s determination and of the resident’s right to appeal, as described in Section 30a
of this Manual.
e. That the resident committed misconduct and the resident should be dismissed from the
residency program, as further described in Section 9a of this Manual. In this situation, the Program
Director shall issue a written letter to the resident that notifies the resident of the Program
Director’s determination and of the resident’s right to appeal, as described in Section 30a of this
Manual.
7. Administrative Leave. The Program Director may, at any time, summarily place a resident on
administrative leave, with or without pay, when the Program Director determines that there is
reason to believe any of the following:
a. There would be an unreasonable risk of harm to patients, to faculty, to any resident
(including the resident to be placed on administrative leave), or to the administrative staff of the
residency program, should the resident continue in the specific rotation or generally in the
residency program; or
b. There would be an unreasonable disruption of the residency program, of the normal
GME Policy Manual | May 17, 2013 | Page 11
activities of the University, or of the normal activities of any affiliated site, should the resident
continue in the specific rotation or generally in the residency program.
9. NON-RENEWAL OF CONTRACT.
1. Introduction. Non-renewal of the residency contract means that, upon expiration of the current
term of the residency contract, a new contract would not be entered into as otherwise previously
scheduled and, accordingly, the individual would no longer be a resident in that residency program
and all terms and conditions that are incidental to the status of continuing to be a resident would
expire (e.g. financial support).
2. Bases for Non-Renewal of Contract. The Program Director may decide to not renew a resident’s
contract in either of the following situations:
a. As further described in Section 8 of this Manual, the Program Director may decide to not
renew the resident’s contract in the residency program when the Program Director concludes that
the resident has a continuing deficiency in performance or progress.
b. As further described in Section 8a, the Program Director may decide to not renew the
resident’s contract in the residency program when the Program Director concludes that the
resident has committed misconduct.
c. The Program Director may decide to not renew a resident’s contract in the residency
program when the Program Director concludes that the resident is not able, not qualified, or is not
eligible to perform or progress in the residency program and that the reason or basis could not be
affected by any reasonable corrective efforts by the resident.
3. Notice of Anticipated Non-Renewal of Contract. In the event the Program Director determines
that the residency contract for a particular resident might not be renewed as currently scheduled,
the resident will be so notified. This notice will be at least four (4) months prior to the date the
renewal of residency contract would have occurred as currently scheduled. However, if the primary
reason(s) for the non-renewal occurs or becomes apparent within that four-month period, then this
notice will be provided as soon as the circumstances allow. This notice will be in writing and may
be included within a written evaluation (as described in paragraph 3 of Section 7 of this Manual), in
a notice of deficiency (as described in paragraph 3 of Section 8 of this Manual), or other written
document signed by the Program Director.
4. Appeal Rights. A resident has a right to appeal an action of the Program Director of nonrenewal of the residency contract. See Section 30a describing the rights and procedures
associated with this appeal.
9a. DISMISSAL FROM RESIDENCY PROGRAM.
1. Introduction. Dismissal means the individual is immediately removed from the status of
resident in that residency program, results in the immediate termination of the residency contract,
and results in the immediate cessation of all terms and conditions that are incidental to the status
of continuing to be a resident (e.g. financial support).
2. Bases for Dismissal. The Program Director may decide to dismiss a resident in any of the
following situations:
a. As further described in Section 8, the Program Director may decide to dismiss a resident
GME Policy Manual | May 17, 2013 | Page 12
from the residency program when the Program Director concludes that the resident has a
continuing deficiency in performance or progress.
b. As further described in Section 8a, the Program Director may decide to dismiss a
resident from the residency program when the Program Director concludes that the resident has
committed misconduct.
c. The Program Director may decide to dismiss a resident from the residency program
when the Program Director concludes that the resident is not able, not qualified, or is not eligible to
perform or progress in the residency program and that the reason or basis could not be affected by
any reasonable corrective efforts by the resident.
3. Appeal Rights. A resident has a right to appeal an action of the Program Director of dismissal
from the residency program. See Section 30a describing the rights and procedures associated with
this appeal.
10. RESIDENT SUPERVISION PLAN
Each residency program will have a written plan for the graduated supervision of its residents. The
supervision plans will be reviewed annually by the GMEC.
[Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed May 17, 2013]
11. EVALUATIONS BY THE TRAINEES
The resident will be given the opportunity to complete an anonymous formal written evaluation of
each rotation and of his/her attending physicians and faculty preceptors, addressing among other
features of the rotation the provisions of clinical supervision, i.e. availability, responsiveness, depth
of the interaction and knowledge gained. The evaluations will be reviewed by the Program Director
and integrated into discussions with attending physicians and faculty members.
[Adopted by the GMEC on September 17, 2004 as a replacement for the policy of October 25,
1996, approved April 20, 2012. Reviewed May 17, 2013]
12. ATTENDANCE AT EDUCATIONAL CONFERENCES
Unless specified otherwise, attendance at conferences is mandatory. In recognition of the
occasional need to attend to simultaneous patient care emergencies, a percentage of mandatory
conferences at which the trainee is expected to be present, e.g. 80%, may be specified by the
residency program. Residents are required to attend all conferences that are not precluded by
emergencies, rather than to attend only the expected minimum percentage of conferences.
Documentation of attendance will be coordinated by the Chief Resident and, if the number of
absences is substantial, it will be reported to the Program Director. Attendance at less than the
expected minimum percentage of conferences should be addressed by the Chief Resident and/or
the Program Director. Trainees may be asked to account for absences from conferences regardless
of the percentage of conferences that they have attended. Disciplinary actions may be instituted for
unwarranted absences.
[Adopted by the GMEC on September 17, 2004 as a replacement for the policy of June 27,
1996, approved April 20, 2012. Reviewed May 17, 2013]
GME Policy Manual | May 17, 2013 | Page 13
13. DRESS CODE
The professionalism of the trainee is often projected by his/her appearance, including apparel,
hairstyle and grooming, and cleanliness. Trainees will maintain an appearance acceptable to their
residency programs and to the facilities in which they are assigned.
[Adopted by the GMEC on January 27, 2007 as a replacement for the policy of October 25,
1996. Reviewed and approved on May 17, 2013.]
14. DUTY HOURS, ON-CALL ACTIVITIES, PATIENT LOADS AND SERVICE OBLIGATIONS
Residencies and fellowships must comply with the current ACGME policies on Duty Hours and
On-Call Activities. The relevant policies are excerpted in Appendix IV.
Residents and fellows should be apprised of these policies at least annually. Training must
document this compliance. Statements by resident that they adhere to the policy are no longer
sufficient.
All residency and fellowship programs must monitor compliance to these policies at least
quarterly. A report on compliance and actions taken to remedy recurring episodes of noncompliance must be submitted to the Graduate Medical Education Committee semi-annually.
The Graduate Medical Education Committee will review the above reports semi-annually and
take appropriate actions to assure compliance.
Residencies and fellowships must maintain a policy specifying the maximum number of
admissions, inpatients and outpatients for rotations and clinics in which an excessive number of
patients may reasonably compromise the educational process or working environment.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012 as a replacement for
the policy of the same title of September 11, 2003. Reviewed May 17, 2013]
15. ANCILLARY SUPPORT
Each residency program will ensure that on-call residents are provided adequate sleeping quarters
and food services. The program will also ensure that its residents are provided sufficient radiology,
medical records, library, phlebotomy, transport and laboratory services to assure that the trainees’
time can be appropriately focused on education and patient care.
[Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed May 17, 2013]
16. LEARNING AND WORKING ENVIRONMENT
Each residency program will ensure that residents have access to:
a.
b.
c.
d.
a physician or resident lounge,
a locker for personal belongings,
a mailbox, and
parking facilities with adequate security.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the
policy of June 27, 1997. Reviewed May 17, 2013]
GME Policy Manual | May 17, 2013 | Page 14
17. QUALITY ASSURANCE AND ADMINISTRATIVE ACTIVITIES
Residents should be informed of the quality assurance activities of the affiliated medical centers to
which they are assigned and are expected, when possible, to participate in these activities.
Residents may be asked to participate on School committees, e.g. the Graduate Medical Education
Committee (GMEC) and the Faculty Executive Council. They may also be appointed to University
committees, departmental committees and committees of the affiliated medical centers.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the
policy of January 25, 2002. Reviewed May 17, 2013]
18. AUTOPSIES
If required for accreditation, autopsies will be sought for patients who die on teaching services. If
not required, autopsies may be sought when helpful to facilitate the maintenance of high quality
patient care and the advancement of medical science, and to contribute to the educational goals of
the residency program.
[Adopted by the GMEC on January 27, 2007, approved April 20, 2012, as a replacement for the
policy of September 17, 2004. Reviewed May 17, 2013]
19. COMPETENCY-BASED CURRICULA AND EDUCATIONAL GOALS
Each program will maintain a competency-based curriculum with appropriate curricular and
educational goals as well as administrative structures for implementing the curriculum and
assessing the achievement of these goals. The curricular and educational goals should be approved
by the program's education committee, or an equivalent body, at least annually. Changes in the
curriculum, educational goals or relevant administrative structures will be submitted for approval
by the GMEC at least annually.
The competency-based curricula should comply with current programmatic accreditation
requirements, to include the competencies of “Patient Care,” “Medical Knowledge,” “PracticeBased Learning and Improvement,” “Interpersonal and Communication Skills,” “Professionalism,”
and “Systems-Based Practice.”
[Adopted by the GMEC on March 26, 2010, approved April 20, 2012, as a replacement for the
policy of September 17, 2004. Reviewed May 17, 2013]
20. PROVISIONS FOR PROGRAM CLOSURE OR REDUCTION
In accordance with ACGME regulations, the sponsoring institution must notify the GME Committee,
the DIO and the affected residents/fellows as soon as possible whenever a decision is made to
close the institution or to close or reduce the size of a residency program. The Program Director
should notify the residents as early as reasonably possible of an anticipated programmatic closure
or reduction that would necessitate the release of residents before completion of their training.
Efforts should be made to maximize the number of residents who can complete the program and
to assist the released residents in finding alternative residency positions. A non-renewal (or
shortened term of renewal) of contract based on program closure or reduction is not eligible for
appeal or grievance.
[Adopted by the GMEC on November 7, 2008, approved April 20, 2012, as a replacement for the
policy of September 17, 2004.]
GME Policy Manual | May 17, 2013 | Page 15
21. SCHOLARLY ACTIVITY
Residents are expected to participate in scholarly activities which may include research projects
designed to generate, assemble and/or present new medical knowledge. Residents are also
expected to develop a basic capability for evaluating published research findings.
[Adopted by the GMEC on November 22, 1996, approved April 20, 2012.]
22. PROFESSIONAL AND PERSONAL CONDUCT
Conduct that is consistent with the dignity of the medical profession is required of all residents in
their interactions with School and medical center personnel as well as with patients and their
families. Residents are required to respect the ethical and legal rights of their patients and to
comply with the codes of conduct of the medical centers in which they are assigned. The
injudicious use of alcoholic beverages and the use of recreational drugs are strictly prohibited.
Smoking is permitted only in designated areas of the School and its affiliated medical centers.
Residents may not accept fees from patients for medical services.
[Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed May 17, 2013]
23. INFECTION CONTROL
The infection prevention and control programs at the affiliated medical centers provide a system
for the collection and analysis of data needed to determine areas of risk of infectious disease and
opportunities for improvements. Residents will be apprised of the existence and nature of infection
control programs and at times may be asked to participate in these programs.
[Adopted by the GMEC on November 22, 1996, approved April 20, 2012. Reviewed May 17, 2013]
24. IMMUNIZATION RECOMMENDATIONS
Residents are at risk for developing infectious diseases from the patients they treat. Residents with
infectious diseases are conversely a potential hazard to their patients and co-workers. It is the
policy of the Medical School and its affiliated medical centers to provide the residents with the
same immunization panel offered to other employees at similar risk. The following measures are
recommended:
a. Hepatitis B vaccine is recommended for any resident who has not developed immunity
to Hepatitis B. Since there is evidence to suggest that anti-Hepatitis B titers begin to
wane approximately five years after immunization, previously immunized individuals
should obtain a Hepatitis B antibody titer and a booster injection if indicated.
b. Tetanus/Diphtheria (TD) vaccine should be provided to any resident who has not been
vaccinated or who has not received a booster vaccination within the last 10 years.
c. Influenza vaccination is recommended annually in the fall.
d. Mumps-Measles-Rubella vaccination (MMR) is recommended. A history of having
previously received 2 MMR injections should be sought. If documentation is not
available, appropriate antibody titers should be obtained on female residents. The
vaccine should be administered, if indicated, following screening for pregnancy. Male
residents may be offered the vaccine without a titer, at the discretion of the resident or
his primary care physician.
GME Policy Manual | May 17, 2013 | Page 16
e. Varicella vaccination is recommended and should be offered to any resident without a
known history of chicken pox. Female residents should be screened for pregnancy
before vaccination.
f.
Hepatitis A vaccine should be made available for those at risk of exposure to Hepatitis
A.
g. TB testing should be performed for all residents unless the resident has documentation
of TB testing within the past one year or documentation of significant reactivity to
tubercular antigen in the past. Routine annual testing should be done in those without
significant reactivity. Chest x-rays may be required by the medical centers at which the
residents rotate.
The affiliated medical centers at which residents rotate may not require all of the above
immunizations, in which case residents may obtain any non-required immunizations at their
own expense. Likewise, one or more affiliated medical centers may require immunizations or
tests not specified above. These requirements are ordinarily provided by the affiliated medical
center.
[Adopted by the GMEC on November 17, 2005, approved April 20, 2012, and replaces the policy of
the same title of October 25, 1996. Reviewed May 17, 2013]
25. LEAVE POLICIES
Leave for any reason may require that additional time in training be invested for successful
completion of the residency program and/or for board eligibility. The need for additional time in
training depends upon multiple factors that include the type of leave, its status as authorized or
unauthorized, and whether it can be incorporated into annual or sick leave. Types of leave include
the following:
a. Educational Leave: Residents may be granted educational leave, which may be paid or
unpaid, if and as approved by their Program Director and in accordance with the
policies and procedures of the residency program, of the Medical School, and of the
affiliated medical centers at which they are assigned and by which they are salaried.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for policy of the same title, approved November 16, 2005. Reviewed May 17, 2013]
b. Annual Leave: Residents receive up to 30 days of annual leave (vacation) per academic
year (July 1 through June 30), depending upon (a) the residency program, (b) the
methods of counting annual leave days used by the Medical School and its affiliated
medical centers, and (c) the methods of calculation of accrued annual leave used by the
Medical School and its affiliated medical centers.
Accrued annual leave is proportionate to the amount of the academic year served in
pay status by the resident. Paid annual leave cannot be carried over to a subsequent
academic year except in extraordinary circumstances, with the assurances of the
employer and the medical center on whose time the leave would be taken, and with the
written permission of the Program Director and the Associate Dean for GME. If annual
leave time is not used in the academic year in which it was accrued, it is subject to
forfeiture.
GME Policy Manual | May 17, 2013 | Page 17
Requests for a specific time for annual leave will be considered but approval remains at
the discretion of the Program Director. Requests should be submitted to the Program
Director as long in advance as is reasonably possible and in accordance with protocol
established by the residency program.
[Adopted by the GMEC on March 26, 2010, approved April 20, 2012, as a replacement
for the policy of same title of March 7, 2008.]
c. Maternity/Paternity/Adoption Leave: Maternity/Paternity/Adoption leave (paid, unpaid,
or a combination thereof) may be granted upon formal request and in accordance with
the policies of the organization directly employing the resident (e.g. an affiliated
medical center or the Medical School). When the Family and Medical Leave Act
(“FMLA”) is applicable, its provisions will be observed.
Annual and/or sick leave may be used in whichever order is specified by the employer
to continue salary and benefits during Maternity/ Paternity/ Adoption Leave.
Maternity/Paternity/Adoption Leave may also be taken in an approved leave-withoutpay status. The use of annual leave and leave-without-pay are subject to the FMLA, if
applicable, and may require the approval of the Program Director. Sick leave may only
be used for illness or as post-partum leave. A doctor's certificate verifying the status of
the resident may be requested by the Program Director.
The resident should notify the Program Director at least 30 days in advance of the time
anticipated for use of Maternity/Paternity/Adoption leave, or as soon as practicable.
The resident should also consult with the Human Resources Department of his/her
employer to determine the specific provisions of the applicable Maternity/ Paternity/
Adoption Leave currently in effect.
Absence from training greater than that acceptable to the residency program and/or to
the program’s specialty board may require compensatory training time for the resident
to be eligible for graduation and/or board eligibility. Except for FMLA leaves, retention in
the program after prolonged absence requires the approval of the Program Director.
Compensatory training time depends upon the availability of funding and residency
positions. The resident should discuss the anticipated need for compensatory training
time with his/her Program Director.
Programs are encouraged to arrange minimum night call duty around the expected
time of the birth of the resident’s child.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for the policy of the same title of November 16, 2005. Reviewed May 17, 2013]
d. Sick leave: If a resident calls in sick, it is the prerogative of the Program Director to ask
for verbal or written corroboration by the resident’s physician or by an independent
consultant. Residents must be aware that each specialty board allows only a certain
amount of excusable absence from training. Absence beyond that amount will ordinarily
require compensatory time in training in order to secure board eligibility. Except for
FMLA leaves, retention in the program after prolonged absence requires the approval of
the Program Director. Salary and benefits for compensatory training time depend upon
the availability of funding and residency positions. The resident should discuss the
anticipated need for compensatory training time with his/her Program Director.
GME Policy Manual | May 17, 2013 | Page 18
The amount of paid and unpaid sick leave is determined by the policies and practices of
the Medical School and of the medical centers at which the resident has been rotating
and/or by which he/she is salaried.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for the policy of the same title, approved November 16, 2005. Reviewed May 17, 2013]
e. Bereavement Leave: Bereavement leave (paid, unpaid, or a combination thereof) may
be granted for deaths in the immediate family. The amount of paid and unpaid
bereavement leave is determined by the policies and practices of the medical school
and of the medical centers at which the resident has been rotating and/or by which he
is salaried. If additional time is required, available vacation time may be used.
For purposes of Bereavement leave, the immediate family is defined as the resident's
or spouse’s grandparents, parents, siblings, children and grandchildren.
[Adopted by the GMEC on November 16, 2005, approved April 20, 2012, as a
replacement for the policy of the same title, approved December 20, 1996.]
f.
Military Leave: Residents who are members of the U.S. Armed Forces, including
reserves, and who are required to undergo training or are called to active duty, may be
granted a paid leave of absence for a specified period of time in accordance with the
policies of the Medical School and of the medical centers at which the resident is
salaried and at which he/she is rotating. Ordinarily, the salary paid to the resident will
be the difference between the resident’s regular salary and the salary received from the
military service. The resident may use accumulated vacation time to extend the period
of salaried absence. Local drills or training assemblies might not qualify for short-term
military leave, with or without pay. All legal obligations pertaining to the use of military
leave will be honored.
If a resident enters the Armed Forces of the United States while an employee of the
Medical School, or of its affiliated medical centers, he/she may have certain reemployment rights, as specified by Federal or State laws, applicable upon completion
of the military service.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for the policy of the same title, approved November 16, 2005. Reviewed May 17, 2013]
g. Leave of absence: A leave of absence (paid, unpaid, or a combination thereof) may be
granted only with the written permission of the Program Director and in accordance
with the policies of the Medical School and of the affiliated medical centers at which
the resident is salaried and at which he/she is rotating. Such leave may prolong the
duration of the residency training period required to complete graduation and/or board
eligibility requirements.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for the policy of the same title, approved January 27, 2007. Reviewed May 17, 2013]
h. The Family and Medical Leave Act: The above policies are subject to revision to
maintain compliance with the Family and Medical Leave Act and other applicable
Federal and State laws.
GME Policy Manual | May 17, 2013 | Page 19
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement
for the policy of the same title, approved November 16, 2005. Reviewed May 17, 2013]
26. SALARY AND BENEFITS
a. Salary: Each resident is assigned to the payroll of the Medical School or of an affiliated
medical center. The salary and benefits package is competitive with the regional
hospitals and is adjusted annually with the approval of the School’s GME Committee.
The current salaries are found in Appendix II. Salaries and Benefits may be updated
before publication of the next version of this manual.
b. Health Insurance: Subject to eligibility requirements of the plan and enrollment by the
resident, health insurance is available through the Medical School or medical center
that employs the resident. Details of the available insurance plans are presented and
discussed with each resident at the time of appointment.
c. Disability Insurance: Subject to eligibility requirements of the plan and enrollment by
the resident, disability insurance is available through the Medical School or medical
center that employs the resident. Details of the insurance plan, including when it goes
into effect, are presented and discussed with each resident at the time of appointment.
d. Extension of Training into a subsequent academic year: Residents who are late in
beginning their training, or who must make up for time lost due to illness,
unsatisfactory performance in one or more rotations, leave of absence, etc., may be
allowed to extend their training into a subsequent academic year at the discretion of
the residency program director. The salary and benefits for training extended into the
subsequent academic year, however, will be subject to the availability of residency
positions and funds in excess of those funds required for new and routinely continuing
residents.
[Adopted by the GMEC on March 7, 2008, approved April 20, 2012, as a replacement for the policy
of the same title of January 27, 2007. Revised May 17, 2013]
27. MALPRACTICE INSURANCE
Professional liability insurance is provided by the School or by the affiliated medical center to which
the resident is assigned. Each insurance plan provides at least $1,000,000 per occurrence and
$3,000,000 in annual aggregate.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the
policy of December 20, 1996. Reviewed May 17, 2013]
28. MEDICAL RECORDS
Complete and available medical records are a necessity for good patient care. Discharge
summaries, procedural reports, etc., must therefore be completed accurately and in a timely
manner. The original or official copies of the medical records or patient charts are not to be taken
from the hospital under any circumstances other than as required by law. Residents are expected
to comply with the policies and procedures of the affiliated medical centers regarding medical
records. Residents who do not comply with these policies and procedures may be disciplined or
discharged from the residency program.
GME Policy Manual | May 17, 2013 | Page 20
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the
policy of December 20, 1996. Reviewed May 17, 2013]
29. “MOONLIGHTING” POLICIES
Residency and fellowship programs generally require substantial time commitments from the
residents, allowing little if any time for outside employment, i.e. "moonlighting". The Program
Director may prohibit “moonlighting” for all residents in the program or may allow it on an
individual basis within specified limits depending upon the nature of the outside employment and
the academic standing of the resident. Residents will not be required to “moonlight.”
Residents without permanent Illinois licenses may not engage in "moonlighting". Residents holding
J-1 visas are not permitted to "moonlight". Other types of immigration status may similarly restrict
employment outside of the residency program. The resident who wishes to "moonlight" must
request the privilege from the Program Director and provide the following information: site of
"moonlighting", amount of time involved, schedule of the outside employment, and nature of the
employment. A sample "Moonlighting" Request Form is provided in Appendix III. Completed
“Moonlighting” Request Forms should be included in the resident’s file.
It is the resident's responsibility to obtain approval from the Program Director of any significant
increases in "moonlighting” hours.
The Program Director may prohibit or rescind approval of any "moonlighting" commitment if he
believes that the resident's performance or learning capability in the program has been, is, or
would possibly be compromised. The resident may challenge the decision in accordance with the
appeal processes of their department and of the School. The performance of “moonlighting”
residents will be monitored by the Program Director and, if the performance of the resident
appears to be compromised, permission to “moonlight” may be modified or withdrawn.
The professional liability insurance provided by the School or an affiliated medical center covers
only the activities of the residency program and does not cover "moonlighting" activities. The
resident is therefore responsible for securing adequate professional liability insurance coverage
and may be required by the Program Director to provide written evidence of such insurance.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012, as a replacement for the
policy of September 11, 2003. Reviewed May 17, 2013]
30. COMPLAINTS AND GRIEVANCES RIGHTS AND PROCEDURES.
1. Scope. These grievance procedures apply to all complaints and grievances regarding the
resident are academic, clinical, or research learning and working environment, except decisions of
the Program Director that are cognizable under Section 30a of this Manual.
2. Timing and Submission Procedures. Any complaint or grievance cognizable under this Section
of the Manual:
a. Shall be submitted to the Program Director (or, if the complaint or grievance is against
the Program Director, then it shall be submitted to the Associate Dean for GME of the Chicago
Medical School).
b. Should be submitted in a prompt manner in order to enable a prompt and fair resolution
(any undue delay in submitting a complaint or grievance could adversely impact its resolution).
GME Policy Manual | May 17, 2013 | Page 21
c. Shall be submitted in writing and include (i) the relevant facts and circumstances giving
rise to the complaint or grievance and (ii) the desired action to be taken on the complaint or
grievance.
3. Inquiry into the Complaint or Grievance. Upon receipt of a complaint or grievance cognizable
under this Section of this Manual, the Program Director shall take steps to gather the relevant
information in a fair and reasonable manner (i.e. by using methods deemed reasonably efficient in
time and resources and that are reasonably likely to result in reliable information within this
learning and working environment); however, the fact-gathering efforts shall not be subject to any
formal investigative or other criminal procedure requirements that are applicable to government
law enforcement officials. The Program Director may do this by personally gathering information
and/or by receiving information from another who has conducted an inquiry into the matter. If the
complaint or grievance is against the Program Director, then these steps shall be taken by the
Associate Dean for GME of the Chicago Medical School, in lieu of the Program Director, and the
Associate Dean for GME shall consult with the GMEC during the inquiry.
4. Resolution. The Program Director shall take steps to resolve the complaint or grievance in a
prompt and fair manner and such resolution shall be consistent with University policies and the
ACGME standards and requirements that are applicable to the specific residency program. The
Program Director shall notify the resident making the complaint or grievance of its resolution,
subject to the privacy rights of others and other applicable University policies. If the complaint or
grievance is against the Program Director, then these steps shall be taken by the Associate Dean
for GME of the Chicago Medical School, in lieu of the Program Director, and the Associate Dean for
GME shall consult with the GMEC prior to making the resolution decision.
5. Appeal of Resolution Decision Made by Program Director. The resident may appeal the
resolution made by the Program Director. This appeal must be submitted in writing to the
Associate Dean for GME of the Chicago Medical School within 14 days of receiving the written
resolution from the Program Director. The written appeal must describe the complaint or
grievance, the resolution decision of the Program Director, and the desired action to be taken. The
Associate Dean for GME shall take steps to gather additional information in a fair and efficient
manner and shall consult with the GMEC in this effort. The Associate Dean for GME shall take
steps to decide the appeal in a prompt and fair manner and shall consult with the GMEC prior to
making the decision on the appeal. Such decision shall be consistent with University policies and
the ACGME standards and requirements that are applicable to the specific residency program. The
Associate Dean for GME shall notify the resident making the complaint or grievance of its
resolution, subject to the privacy rights of others and other applicable University policies. There is
no appeal of any decision made by the Associate Dean for GME described in any paragraph of this
Section 30 of this Manual.
30a. APPEAL RIGHTS AND PROCEDURES.
1. Scope. These appeal procedures apply to actions of a Program Director to (i) not promote a
resident to the next formal level of education within a residency program, (ii) not renew a residency
contact, (iii) dismiss a resident from the residency program, or (iv) any action that would lengthen
the duration required to complete the residency program.
2. Timing and Appeal Authority. An appeal submitted under this Section of the Manual must be
submitted and received by the Dean of the Chicago Medical School of Rosalind Franklin University
of Medicine and Science no later than the expiration of fourteen (14) calendar days from the
resident receiving the written letter of the Program Director announcing the action taken. In
situations where date of receipt by the resident has not been acknowledged by the resident or has
not otherwise documented, then an appeal submitted under this Section of the Manual must be
GME Policy Manual | May 17, 2013 | Page 22
submitted and received by the Dean of the Chicago Medical School of Rosalind Franklin University
of Medicine and Science by the expiration of twenty-one (21) calendar days from the date that
written letter was sent by mail to the last known address of the resident.
3. Grounds For Appeal. An appeal submitted under this Section of the Manual may be made on
any of the following grounds:
a. There was a violation of the procedures in this Manual relating to the Program Director’s
decision;
b. The Program Director’s decision clearly exceeded the bounds of discretion associated
with the proper exercise of academic judgment; or
c. The Program Director had a conflict of interest such that the Program Director should
have been recused.
4. Format and Content. An appeal submitted under this Section of the Manual must be submitted
in writing and clearly state (a) the grounds of appeal; (b) the facts and circumstances that support
the grounds for appeal; and (c) the desired action to be taken by the Dean.
5. Decision of Dean. The Dean shall consider the appeal submitted by the resident, consider the
resident’s entire file, and consult with the GMEC prior to making a decision on the grievance. The
Dean shall determine (a) whether or not any of the grounds for grievance exist and (b) the final
resolution of the appeal. The final resolution of the appeal shall be consistent with University
policies and the ACGME standards and requirements that are applicable to the specific residency
program.
31. IMPAIRED PHYSICIANS: POLICIES AND PROCEDURES
The Impaired Physician policy is intended to assist in the identification and treatment of the
impaired resident in order to reduce any compromise of patient care and to restore the resident to
health and effective practice.
Procedure:
a. An impaired resident is a resident or fellow, involved in training or research, licensed to
practice medicine in the State of Illinois, who is unable to practice medicine with
reasonable skill and safety to patients because of mental or physical illness or shortcoming.
b. Whenever a resident, fellow or staff member observes behavior in a resident that indicates
that the resident may be impaired, the Program Director should be notified immediately.
c. Upon notification, the Program Director will conduct a preliminary investigation. If he
concurs that there is a reasonable belief that such impairment exists, he will report such
information to the appropriate departmental chairman and to the Associate Dean for GME.
d. The resident may be placed on paid or unpaid leave [including annual leave, sick leave or
leave of absence] at the discretion of the Program Director until evaluation of the situation
is complete. During these proceedings, the resident will have access to the current
grievance procedures of the School.
e. In conjunction with the leave, the Program Director, at his discretion, may notify the
Impaired Physicians Program of the Illinois State Medical Society.
GME Policy Manual | May 17, 2013 | Page 23
f.
If a resident is placed on leave because of drug or alcohol abuse, the resident will be
required, at a minimum, to complete successfully an appropriate rehabilitation program
approved by the Program Director. Such programs may include those approved by the
Impaired Physicians Program of the Illinois State Medical Society, programs under the
auspices of affiliated medical centers, programs utilized by the University, and programs
specifically arranged by the Program Director in consultation with appropriate health care
professionals. The resident must document his compliance to the rehabilitation program.
g. If the resident fails to comply with the rehabilitation program, he will be terminated from
the residency program and a notice to that effect will be placed in his permanent record.
Appropriate state and national agencies will be notified in accordance with state and
federal laws. Termination for this reason is not eligible for appeal.
h. Upon completion of a rehabilitation program, the resident may be required by the Program
Director to enter an aftercare program. The resident must document compliance to the
aftercare program to the satisfaction of the Program Director. Failure to comply or to
adequately document compliance will result in termination. Termination for this reason is
not eligible for appeal.
i.
The Associate Dean for GME and the departmental chairman will be notified when the
resident is eligible for resumption of training pursuant to the recommendation of the
resident’s physician or therapist. If the resident is participating in an aftercare program, the
resident must provide the Program Director, the departmental chairman, and the Associate
Dean for GME acceptable documentation of compliance to the aftercare program.
j.
The Program Director will notify the departmental chairman and the Associate Dean for
GME when a resident has completed the aftercare program. Training time lost to
accommodate participation in rehabilitation and aftercare programs may require the
completion of additional compensatory training to secure satisfactory completion of the
residency program and board eligibility requirements.
k. If, after successful completion of the aftercare program, the resident subsequently
relapses, termination from the program may be recommended unless there are
extenuating circumstances. Retention of the resident will require the concurrence of the
Program Director, the departmental chairman and the Associate Dean for GME. If the
resident claims that he/she has a mental or physical disability accounting for the
impairment or for the failure of rehabilitation, adequately documented substantiation of the
claims by one or more qualified health care professionals acceptable to the University may
be required by the Medical School or University.
l.
The participation of the resident in a rehabilitation program will be acknowledged as
requested by state licensing agencies, hospital credentialing bodies, and any other
organizations or individuals authorized to be so informed.
m. Health and disability insurance benefits will remain in effect according to the terms and
limitations of the policy.
[Adopted by the GMEC on January 27, 2007, approved April 20, 2012, as a replacement for the
policy of September 17, 2004. Reviewed May 17, 2013]
GME Policy Manual | May 17, 2013 | Page 24
32. SEXUAL HARASSMENT
Federal law (Title VII of the Civil Rights Act of 1964) provides that it shall be an unlawful
discriminatory practice for any employer, because of the sex of any person, to discharge without
just cause, to refuse to hire, or otherwise discriminate against that person in any matter directly or
indirectly related to employment. Harassment of an employee on the basis of sex violates the
federal regulations implementing this law.
In accordance with the federal Equal Employment Opportunity Commission, sexual harassment
consists of repeated, unwelcome sexual advances, requests for sexual favors, and other verbal or
physical conduct of a sexual nature which is unlawful when:
a. submission to sexual conduct is an explicit or implicit term or condition of an individual's
employment,
b. submission to or rejection of sexual conduct by an individual is the basis for any
employment decision affecting the individual, or
c. sexual advances, requests for sexual favors or other verbal or physical conduct of a sexual
nature have the purpose or effect of unreasonably interfering with an individual's work
performance or creating an intimidating, hostile or offensive working environment.
The University does not tolerate sexual harassment and will pursue appropriate disciplinary action
against any member of the faculty of the University found to have engaged in sexual harassment.
At the same time, it is recognized that, because of cultural and social variances which exist among
members of a heterogeneous community, there may be differing views of what constitutes sexual
harassment. It is suggested, consequently, that anyone who is distressed by the perceived sexual
attentions of another person seek, in the first instance, to have an open and direct discussion of
the behavior with the person involved.
Allegations of sexual harassment are taken seriously. If you believe that you are the victim of
sexual harassment, you should do the following:
a. Document each incident of alleged sexual harassment, including date, time, place,
what was said or done, and the surrounding circumstances.
b. If possible, clearly communicate to the offending individual that his or her conduct is
unwelcome, and request that the offensive behavior stop.
c. At the same time, you should file a complaint in accordance with Section 30 of this
Manual
All such matters will be treated with the utmost discretion. The University will actively investigate all
sexual harassment complaints and, if it is determined that sexual harassment has occurred, the
University will take appropriate disciplinary action against the offending party, up to and including
discharge.
The Program Director will make available counseling for persons who have concerns related to
sexual harassment and will investigate complaints where such investigations are warranted.
Individuals who feel that they are targets of sexual harassment should understand that they may
also utilize a variety of other resources on campus for seeking informal counseling or an informal
resolution of the perceived problem.
The resources of the affiliated medical centers and their specific policies and procedures will be
coordinated with those of the University when appropriate. The Office of GME is available to assist
the resident with the processing of any complaints.
GME Policy Manual | May 17, 2013 | Page 25
[Adopted by the GMEC on December 20, 1996, approved April 20, 2012. Reviewed May 17, 2013]
33. COUNSELING AND SUPPORT SERVICES
Confidential counseling and support services may be available through the University Clinic, the
University Counseling Center or the departments of Psychology and Psychiatry. If preferred, a
referral to an outside provider can be made. In general, the cost of these services is the
responsibility of the resident. The cost of some intramural services, however, may be deferred by
the University.
[Adopted by the GMEC on January 27, 2007, approved April 20, 2012, as a replacement for the
policy of the same title, approved January 25, 2002. Reviewed May 17, 2013]
34. ORIENTATION PROGRAMS
Residents will be oriented to the relevant policies and procedures of each medical center at which
they train. Orientation to their residency program in general and to specific rotations within their
residency program will also be provided in accordance with residency program policy. The
curriculum, objectives and goals of each rotation, when appropriate, will likewise be provided to the
residents during the course of their residency program.
[Adopted by the GMEC on June 27, 1997, approved April 20, 2012. Reviewed May 17, 2013]
35. RESIDENTS’ COUNCILS
Residency programs of sufficient size shall encourage and support “residents’ councils” or similar
organizations, administered and attended exclusively by residents, to which residents may voice
their concerns anonymously or in the absence of members of the faculty or administration.
“Residents’ Council” leaders shall have the opportunity to bring concerns of the Council to the
administration of the program, of the department or of the institution.
[Adopted by the GMEC on January 29, 1999, approved April 20, 2012. Reviewed May 17, 2013]
36. RESTRICTIVE COVENANTS
Residents and fellows will not be required to agree to practice outside of a specified locale after
completion of training. Likewise, other forms of restrictive covenants intended to reduce or
eliminate competition by former residents will not be required.
[Adopted by the GMEC on April 23, 1999, approved April 20, 2012. Reviewed May 17, 2013]
37. MONITORING FOR FATIGUE
A list of the major signs and features of excess fatigue in residents and fellows will be
distributed annually to the residents, fellows and principal teaching faculty of the residencies
and fellowships. The residents, fellows and faculty will be advised to be aware of these
indicators of fatigue and, if a resident or fellow exhibits findings suggestive of excess fatigue,
they should notify the resident’s Program Director. The Program Directors will evaluate such
reports to assess if a significant problem with fatigue does exist. If so, the Program Directors will
take appropriate actions to remedy the problem.
The Program Directors will report to the GMEC on their monitoring programs on a semi-annual
basis.
GME Policy Manual | May 17, 2013 | Page 26
[Adopted by the GMEC on September 11, 2003, approved April 20, 2012. Reviewed May 17,
2013]
38. EXTENSION OF PERMISSIBLE DUTY HOURS
The 80-hour maximum for duty hours may be extended by up to 10% (8 hours) if the extension
is approved by the GMEC and, subsequently, by the program’s RRC. A department seeking an
extension must submit a written request for the extension, and the reasons justifying the
extension, to the GMEC. If approved by the GMEC, the request will be forwarded to the RRC over
the signatures of the Program Director, the Chairman of the GMEC, and the Designated
Institutional Official.
[Adopted by the GMEC on September 17, 2004, approved April 20, 2012. Reviewed May 17,
2013]
39. ACTIONS REQUIRING THE APPROVALS OF THE GME COMMITTEE AND OF THE DEAN OR
ASSOCIATE DEAN FOR GME
The following actions require review and approval by the GME Committee and by the Dean or
Associate Dean for GME before the actions can be implemented:
(a) Additions or deletions of training sites.
(b) Increases, decreases, or redistribution among training sites of 3 or more Psychiatry or Internal
Medicine residents.
(c) Increases, decreases, or redistribution among training sites of 1 or more Internal Medicine
subspecialty fellows.
(d) Application to establish a new residency program or to reinstate an inactive residency program.
(e) Application to voluntarily withdraw a residency program or reduce an active residency program
to an inactive residency program.
(f) Appointment or change of Residency Program Director.
(g) Submission of a progress report or a response to a proposed adverse action to a Residency
Review Committee (RRC).
(h) Submission of a request for appeal, or presentation of a written or verbal appeal, to the ACGME.
(i) Submission of a request to the ACGME for increases in permissible Duty Hours [qv. Policy 38 in
the “Manual of Policies & Procedures for Graduate Medical Programs.”]
(j) Significant increases in the stringency of programmatic policies or practices for resident
promotion, graduation, suspension, dismissal or threshold for allowing resident grievances, to
greater than that established in Medical School policy. Relaxation of stringency to less than
that established in Medical School policy is not permitted.
(k) Modification of the official residency program’s [not individual resident’s] start date (July 1) or
completion date (6/30). Residents may present prior to July 1 on non-pay status for orientation
or administrative processing, without prior GME Committee approval.
(l) Modification of the salaries of Chief Residents. Modification of the salaries of non-Chief
Residents are not acceptable except in unusual circumstances, e.g. reductions of salary
associated with the completion of additional training time beyond the initially anticipated
graduation date.
(m) Major changes in program structure or length of training.
The above list is not intended to indicate that no other actions require approval of the GME
Committee and/or of the Dean or Associate Dean for GME. If there is any question that a
considered action should appropriately require GME Committee approval and/or Dean’s Office
GME Policy Manual | May 17, 2013 | Page 27
approval, the question should be addressed to the Chairman of the GME Committee or to the
Associate Dean for GME.
[Adopted by the GMEC on November 7, 2008, approved April 20, 2012, as a replacement for the
policy of the same title of November 7, 2005. Reviewed May 17, 2013]
40. ACTIONS REQUIRING DIO COUNTERSIGNATURE
The following actions require the countersignature of the DIO (Designated Institutional Official):
(a) Submission of information or requests to the ACGME unless the requests are programmatically
innocuous, e.g. requests for clarification of ACGME requirements or policies, inquiries about
dates of site visits or deadlines, inquiries about completion of documents or on-line surveys or
databases.
(b) Submission of a Program Information Form (PIF), progress report, response to a proposed
adverse action, request for appeal or written appeal, to the ACGME.
(c) Notification of the ACGME of an appointment or change of Program Director.
(d) Notification of the ACGME of the addition or deletion of a training site.
(e) Notification of the ACGME of changes in the numbers or distributions of residents among
training sites.
The above list is not intended to indicate that no other correspondence with the ACGME requires
DIO countersignature. If there is any question that considered communication with the ACGME may
require DIO countersignature, the question should be addressed to the DIO before submission.
[Adopted by the GMEC on November 7, 2005, approved April 20, 2012. Reviewed May 17, 2013]
41. TECHNICAL STANDARDS FOR GRADUATE MEDICAL EDUCATION
The Americans with Disabilities Act (ADA), enacted in July of 1990, protects any individual with a
physical or mental impairment that substantially limits that person in some major life activity and
any individual who has a history of, or is regarded as having, such an impairment. Under the ADA,
as with Section 504 of the Vocational Rehabilitation Act, universities and colleges are prohibited
from discriminating against an otherwise qualified person with a disability in all aspects of
academic life. Schools must make reasonable accommodations to accommodate the known
physical or mental disabilities of otherwise qualified individuals. The University need not make an
accommodation that would cause an undue burden. The philosophical basis of the ADA, that of
judging persons on their abilities and achievements rather than their potential disabilities runs
parallel to the traditional philosophy of this University.
In order to define the "essential requirements" of its graduate medical curriculum, the Chicago
Medical School has developed a list of Technical Standards of physical, mental, and behavioral
skills and capabilities essential for training and functioning in a residency or subspecialty
fellowship program (Appendix VI). In decisions on admission, evaluation, promotion, and graduation
of any person, and especially an applicant or resident with a disability, it is the obligation of the
individual to meet these technical standards, with or without reasonable accommodation.
For further information on these Technical Standards and the procedures for their implementation,
interested persons are encouraged to contact Ms. Rebecca Durkin, ADA Coordinator (at [847] 5788351 or [email protected]), or Jeanette Morrison, MD, FACP, Associate Dean
for GME (at [847] 578-8509 or [email protected]).
[Adopted by the GMEC on November 7, 2008, approved April 20, 2012. Reviewed May 17, 2013]
GME Policy Manual | May 17, 2013 | Page 28
Appendix I
STATEMENT OF COMMITMENT TO
GRADUATE MEDICAL EDUCATION
May 17, 2013
Chicago Medical School is committed to supporting Graduate Medical Education (GME) programs
of the highest caliber. The goal of these programs, consistent with the strategic goals of Chicago
Medical School and Rosalind Franklin University of Medicine & Science, is the training of highly
skilled, scholarly physicians whose practices will engender the highest ideals of compassion and
professionalism.
To this end, the Medical School commits to:
I.
Support an Office of GME headed by an Associate Dean serving as the ACGME’s Designated
Institutional Official and charged with the administrative oversight and management of the
School’s GME programs,
II.
Support a Graduate Medical Education Committee, composed of the Associate Dean for GME
/Designated Institutional Official, selected faculty, residents and administrators, which has
responsibility for monitoring, advising and establishing policies as defined by the Accreditation
Council for Graduate Medical Education,
III.
Establish an effective, competency-based curriculum, the efficacy of which is continually monitored
and improved through the use of outcomes-based methodology,
IV.
Establish partnerships with medical centers sharing the same goals and offering academic,
educational environments for residents, and
V.
Provide the monetary, space, material and human resources to support the GME programs and
their administrative infrastructure in collaboration with the affiliated medical centers.
GME Policy Manual | May 17, 2013 | Page 29
Approvals:
_______________________________________________________
Jeanette L. Morrison, MD
Date
Designated Institutional Official (DIO)
Associate Dean for GME
_______________________________________________________
Russell Robertson, MD
Date
Senior Institutional Executive (SIE)
Vice President of Medical Affairs and Dean of the Chicago Medical School
_______________________________________________________
Margot A Surridge, MA
Date
Governing Body
Executive Vice President and Chief Operating Officer
GME Policy Manual | May 17, 2013 | Page 30
Appendix II
Basic Salary Scale for Residents
2013-2014 Academic Year
PGY 1:
$47,887
PGY 2:
$49,830
PGY 3:
$51,763
PGY 4:
$54,095
Basic Salary Scale for Fellows
2013-2014 Academic Year
PGY 4:
$53,570
PGY 5:
$55,419
PGY 6:
$57,170
GME Policy Manual | May 17, 2013 | Page 31
Appendix III
Request for Permission to “Moonlight”
Name: _____________________________________________ Date: _________________________
Training Program: ___________________________________________________________________
____________________________________________________________________________________
I understand the following conditions of “moonlighting”:
1. I do not expect that my “moonlighting” activities will interfere with or compromise either my
performance as a resident or as a physician.
2. I understand that if my academic standing, clinical performance or learning capacity is felt to
be compromised by “moonlighting”, or reasonably expected to be compromised, permission to
“moonlight” may be withdrawn.
3. I understand that the professional liability insurance provided by the Medical School and its
affiliated medical centers does not provide coverage for activities outside of the training
program, for example “moonlighting.” I must therefore obtain my own professional liability
insurance or assure that my outside employer will provide adequate insurance coverage for me.
4. I understand that it is unlawful for non-U.S. citizens in several types of visa status, including J-1
visa status, to engage in employment activities outside of their training programs.
5. I understand that the permission to “moonlight” applies only to the activities, facilities and
amounts of time described below. I will seek permission from my Program Director to engage
in other types of “moonlighting” activities, or at other facilities or in significantly greater
amounts.
____________________________________________________________________________________
I am requesting permission to “moonlight” in the following capacities:
Facility: _____________________________________________________________________________
Location: ____________________________________________________________________________
Nature of the Outside Employment: ______________________________________________________
____________________________________________________________________________________
Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total
hours/week):
____________________________________________________________________________________
____________________________________________________________________________________
GME Policy Manual | May 17, 2013 | Page 32
Facility: _____________________________________________________________________________
Location: ____________________________________________________________________________
Nature of the Outside Employment: ______________________________________________________
____________________________________________________________________________________
Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total
hours/week):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Facility: _____________________________________________________________________________
Location: ____________________________________________________________________________
Nature of the Outside Employment: ______________________________________________________
____________________________________________________________________________________
Usual Employment Commitment (Days of the week; Time of the day; Hours/shift; Total
hours/week):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(Attach additional sheets if necessary)
____________________________________________________________________________________
I understand the conditions of “moonlighting” described above and attest that there are no
prohibitions against my engagement in “moonlighting.”
_______________________________________________ Date: _______________________________
Signature
APPROVAL
_______________________________________________ Date: _______________________________
Program Director
GME Policy Manual | May 17, 2013 | Page 33
Appendix IV
ACGME REQUIREMENTS FOR DUTY HOURS AND ON-CALL ACTIVITIES
Effective July 1, 2011
The program director and the faculty must monitor the demands of at-home call in their programs
and make scheduling adjustments as necessary to mitigate excessive service demands and/or
fatigue.
Resident Duty Hours in the Learning and Working Environment
Professionalism, Personal Responsibility, and Patient Safety
1. Programs and sponsoring institutions must educate residents and faculty members
concerning the professional responsibilities of physicians to appear for duty appropriately
rested and fit to provide the services required by their patients.
2. The program must be committed to and responsible for promoting patient safety and
resident well-being in a supportive educational environment.
3. The program director must ensure that residents are integrated and actively
participate in interdisciplinary clinical quality improvement and patient safety programs.
4. The learning objectives of the program must:
4. a) be accomplished through an appropriate blend of supervised patient care
responsibilities, clinical teaching, and didactic educational events; and,
4. b) not be compromised by excessive reliance on residents to fulfill non-physician
service obligations.
5. The program director and institution must ensure a culture of professionalism that
supports patient safety and personal responsibility. Residents and faculty members must
demonstrate an understanding and acceptance of their personal role in the following:
5. a) assurance of the safety and welfare of patients entrusted to their care;
5. b) provision of patient- and family-centered care;
5. c) assurance of their fitness for duty;
5. d) management of their time before, during, and after clinical assignments;
5. e) recognition of impairment, including illness and fatigue, in selves and peers;
5. f) attention to lifelong learning;
5. g) the monitoring of their patient care performance improvement indicators;
5. h) honest and accurate reporting of duty hours, patient outcomes, and clinical
experience data.
6. All residents and faculty members must demonstrate responsiveness to patient
needs that supersedes self-interest. Physicians must recognize that under certain
circumstances, the best interests of the patient may be served by transitioning that
patient’s care to another qualified and rested provider.
Transitions of Care
1. Programs must design clinical assignments to minimize the number of transitions in
patient care.
2. Sponsoring institutions and programs must ensure and monitor effective, structured
hand-over processes to facilitate both continuity of care and patient safety.
3. Programs must ensure that residents are competent in communicating with team
members in the hand-over process.
4. The sponsoring institution must ensure the availability of schedules that inform all
members of the health care team of attending physicians and residents currently
responsible for each patient’s care.
GME Policy Manual | May 17, 2013 | Page 34
Alertness Management/Fatigue Mitigation
1. The program must:
1. a) educate all faculty members and residents to recognize the signs of fatigue
and sleep deprivation;
1. b) educate all faculty members and residents in alertness management and
fatigue mitigation processes; and,
1. c) adopts fatigue mitigation processes to manage the potential negative effects
of fatigue on patient care and learning, such as naps or back-up call schedules.
2. Each program must have a process to ensure continuity of patient care in the event
that a resident may be unable to perform his/her patient care duties.
3. The sponsoring institution must provide adequate sleep facilities and/or safe
transportation options for residents who may be too fatigued to safely return home.
Supervision of Residents
1. In the clinical learning environment, each patient must have an identifiable, appropriatelycredentialed and privileged attending physician (or licensed independent practitioner as approved
by each Review Committee) who is ultimately responsible for that patient’s care.
1. a) This information should be available to residents, faculty members, and patients.
1. b) Residents and faculty members should inform patients of their respective roles in
each patient’s care.
2. The program must demonstrate that the appropriate level of supervision is in place for all
residents who care for patients. Supervision may be exercised through a variety of methods. Some
activities require the physical presence of the supervising faculty member. For many aspects of
patient care, the supervising physician may be a more advanced resident or fellow. Other portions
of care provided by the resident can be adequately supervised by the immediate availability of the
supervising faculty member or resident physician, either in the institution, or by means of
telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc
review of resident delivered care with feedback as to the appropriateness of that care.
3. Levels of Supervision - To ensure oversight of resident supervision and graded authority and
responsibility, the program must use the following classification of supervision:
3. a) Direct Supervision – the supervising physician is physically present with the
resident and patient.
3. b) Indirect Supervision:
3.b).(1) with direct supervision immediately available – the supervising physician is
physically within the hospital or other site of patient care, and is immediately
available to provide Direct Supervision.
3.b).(2) with direct supervision available – the supervising physician is not physically
present within the hospital or other site of patient care, but is immediately available
by means of telephonic and/or electronic modalities, and is available to provide
Direct Supervision.
3. c) Oversight – the supervising physician is available to provide review of
procedures/encounters with feedback provided after care is delivered
4. The privilege of progressive authority and responsibility, conditional independence, and a
supervisory role in patient care delegated to each resident must be assigned by the program
director and faculty members.
4. a) The program director must evaluate each resident’s abilities based on specific
criteria. When available, evaluation should be guided by specific national standardsbased criteria.
4. b) Faculty members functioning as supervising physicians should delegate
portions of care to residents, based on the needs of the patient and the skills of the
residents.
GME Policy Manual | May 17, 2013 | Page 35
4. c) Senior residents or fellows should serve in a supervisory role of junior residents
in recognition of their progress toward independence, based on the needs of each
patient and the skills of the individual resident or fellow.
5. Programs must set guidelines for circumstances and events in which residents must
communicate with appropriate supervising faculty members, such as the transfer of a patient to an
intensive care unit, or end-of-life decisions.
5. a) Each resident must know the limits of his/her scope of authority, and the
circumstances under which he/she is permitted to act with conditional independence.
5. a). (1) In particular, PGY-1 residents should be supervised either directly or
indirectly with direct supervision immediately available. [Each Review Committee
will describe the achieved competencies under which PGY-1 residents’ progress to
be supervised indirectly, with direct supervision available.]
6. Faculty supervision assignments should be of sufficient duration to assess the knowledge and
skills of each resident and delegate to him/her the appropriate level of patient care
authority and responsibility.
Clinical Responsibilities
The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident
education, severity and complexity of patient illness/condition and available support
services. [Optimal clinical workload will be further specified by each Review Committee.]
Teamwork
Residents must care for patients in an environment that maximizes effective communication. This
must include the opportunity to work as a member of effective interprofessional teams that are
appropriate to the delivery of care in the specialty. [Each Review Committee will define the
elements that must be present in each specialty.]
Resident Duty Hours
1. Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, averaged over a four week period,
inclusive of all in-house call activities and all moonlighting.
1. a) Duty Hour Exceptions - A Review Committee may grant exceptions for up to 10% or a
maximum of 88 hours to individual programs based on a sound educational rationale.
1.a).(1) In preparing a request for an exception the program director must follow the duty
hour exception policy from the ACGME Manual on Policies and Procedures.
1. a). (2) Prior to submitting the request to the Review Committee, the program director
must obtain approval of the institution’s GMEC and DIO.
2. Moonlighting
2. a) Moonlighting must not interfere with the ability of the resident to achieve the goals and
objectives of the educational program.
2.b) Time spent by residents in Internal and External Moonlighting (as defined in the ACGME
Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit.
2. c) PGY-1 residents are not permitted to moonlight.
3. Mandatory Time Free of Duty - Residents must be scheduled for a minimum of one day free
of duty every week (when averaged over four weeks). At-home call cannot be assigned on these
free days. Common Program Requirements 17
4. Maximum Duty Period Length
4. a) Duty periods of PGY-1 residents must not exceed 16 hours in duration.
4. b) Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24
hours of continuous duty in the hospital. Programs must encourage residents to use alertness
management strategies in the context of patient care responsibilities. Strategic napping,
GME Policy Manual | May 17, 2013 | Page 36
especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00
a.m., is strongly suggested.
4. b). (1) It is essential for patient safety and resident education that
effective transitions in care occur. Residents may be allowed to remain on-site in order
to accomplish these tasks; however, this period of time must be no longer than an
additional four hours.
4. b). (2) Residents must not be assigned additional clinical responsibilities after 24
hours of continuous in-house duty.
4. b). (3) In unusual circumstances, residents, on their own initiative, may remain
beyond their scheduled period of duty to continue to provide care to a single patient.
Justifications for such extensions of duty are limited to reasons of required continuity
for a severely ill or unstable patient, academic importance of the events transpiring, or
humanistic attention to the needs of a patient or family.
4. b). (3). (a) Under those circumstances, the resident must:
4. b). (3). (a). (i) appropriately hand over the care of all other patients to the
team responsible for their continuing care; and,
4. b). (3). (a). (ii) document the reasons for remaining to care for the patient in
question and submit that documentation in every circumstance to the program
director.
4. b). (3). (b) The program director must review each submission of additional service, and
track both individual resident and program-wide episodes of additional duty.
5. Minimum Time Off between Scheduled Duty Periods
5. a) PGY-1 residents should have 10 hours, and must have eight hours, free of duty
between scheduled duty periods.
5. b) Intermediate-level residents [as defined by the Review Committee] should have 10
hours free of duty, and must have eight hours between scheduled duty periods. They must have
at least 14 hours free of duty after 24 hours of in-house duty.
5. c) Residents in the final years of education [as defined by the Review Committee] must
be prepared to enter the unsupervised practice of medicine and care for patients over irregular
or extended periods.
5. c). (1) This preparation must occur within the context of the 80- hour, maximum duty
period length, and one-day-off-in seven standards. While it is desirable that residents in
their final years of education have eight hours free of duty between scheduled duty periods,
there may be circumstances [as defined by the Review Committee] when these residents
must stay on duty to care for their patients or return to the hospital with fewer than eight
hours free of duty.
5.c).(1).(a) Circumstances of return-to-hospital activities with fewer than eight hours
away from the hospital by residents in their final years of education must be monitored
by the program director.
6. Maximum Frequency of In-House Night Float - Residents must not be scheduled for more
than six consecutive nights of night float. [The maximum number of consecutive weeks of night
float, and maximum number of months of night float per year may be further specified by the
Review Committee.]
7. Maximum In-House On-Call Frequency - PGY-2 residents and above must be scheduled for inhouse call no more frequently than every-third-night (when averaged over a four-week period).
8. At-Home Call
8. a) Time spent in the hospital by residents on at-home call must count towards the 80hour maximum weekly hour limit. The frequency of at-home call is not subject to the everythird-night limitation, but must satisfy the requirement for one-day-in-seven free of duty,
when averaged over four weeks.
8. a). (1) At-home call must not be as frequent or taxing as to preclude rest or reasonable
personal time for each resident.
GME Policy Manual | May 17, 2013 | Page 37
8. b) Residents are permitted to return to the hospital while on at-home call to care for new or
established patients. Each episode of this type of care, while it must be included in the 80hour weekly maximum, will not initiate a new “off-duty period”.
Innovative Projects
Requests for innovative projects that may deviate from the institutional, common and/or
specialty specific program requirements must be approved in advance by the Review
Committee. In preparing requests, the program director must follow Procedures for Approving
Proposals for Innovative Projects located in the ACGME Manual on Policies and Procedures.
Once a Review Committee approves a project, the sponsoring institution and program are
jointly responsible for the quality of education offered to residents for the duration of such a
project.
ACGME-approved: September 26, 2010 Effective: July 1, 2011, approved April 20, 2012. Reviewed
May 17, 2013
GME Policy Manual | May 17, 2013 | Page 38
Appendix V
Chicago Medical School at
Residency and Fellowship Agreement
«FIRSTNAME» «LASTNAME», M.D. (hereinafter, "RESIDENT/FELLOW") and Chicago Medical School
(hereinafter, "SCHOOL") hereby enter into this AGREEMENT as of «DATE», and hereby agree as
follows:
1. The term of this AGREEMENT shall be from «TERM» unless terminated or modified for good
cause or by mutual agreement between the parties to the agreement.
2. The RESIDENT/FELLOW shall participate as a postgraduate year «PGY» trainee in the «Year»
year of the «Residency» Training PROGRAM.
3. During the term of this AGREEMENT, the RESIDENT/FELLOW shall be paid at the annual rate of
$«Annual_Salary_Rate».00 with provisions for a benefits package that includes up to four weeks’
vacation per academic year, professional liability (malpractice) insurance, medical insurance, life
insurance, and disability insurance.
4. It is the responsibility of the RESIDENT/FELLOW to take all necessary steps to enroll in the
insurance programs and to so inform the Human Resources Department. Vacation time allotted
during an academic year (July 1 through June 30) is based upon the amount of time worked (i.e. in
pay status) during the same academic year and cannot be carried over to a subsequent academic
year except in extraordinary circumstances and with the written permission of the Program Director
and the Associate Dean for GME. If the vacation time is not used in the academic year in which it
was accrued, it is subject to forfeiture.
5. The professional liability insurance coverage is limited to activities that occur during, and are
components of, the training PROGRAM. Protection for covered activities occurring during the
training PROGRAM extends beyond the completion of the PROGRAM. The liability insurance
provides coverage of at least one million dollars per occurrence and three million dollars in annual
aggregate. In the event of a claim, the RESIDENT/FELLOW agrees to cooperate fully with the
professional liability insurance carrier.
6. Living quarters, meals and laundry are not offered in this agreement although at times and
under certain circumstances, e.g. nights on call, one or more of these benefits may be offered by
an affiliated medical center.
7. Promotion and reappointment within the tenure of this AGREEMENT is contingent upon
multiple factors, including (a) satisfactory completion of the expected educational and other
training requirements of the PROGRAM, (b) adequate attitudinal and professional growth and
behavior, (c) demonstrated ability to function at a level appropriate for the level to which he/she
would be promoted or reappointed, and (d) compliance with the rules and regulations of the
GME Policy Manual | May 17, 2013 | Page 39
PROGRAM, the SCHOOL, the University, the affiliated medical centers, and with the terms of this
AGREEMENT.
8. In the event of significant alterations of salary and/or benefits, e.g. associated with a
promotion or other change of status, the alterations will be specified in an updated AGREEMENT or
in an amendment to this AGREEMENT.
9. The SCHOOL, in conjunction with its affiliated medical centers, shall strive to provide the
RESIDENT/FELLOW a training program that meets the standards of the Accreditation Council for
Graduate Medical Education.
10.
The RESIDENT/FELLOW agrees to perform all appropriate duties and assignments to the
best of his/her ability. He/she further agrees to complete all assigned rotations, to devote clearly
sufficient time to the PROGRAM, and to abide by all the rules and regulations of the PROGRAM, the
SCHOOL, the University, the affiliated medical centers, and with the terms of this AGREEMENT.
11.
The RESIDENT/FELLOW may be subject to disciplinary action for the pursuit of any
unauthorized outside employment ("moonlighting"). This specifically includes, but is not limited to,
(a) outside employment that interferes with his/her learning, teaching, patient care or other
programmatic commitments, (b) outside employment conducted without a permanent Illinois
medical license or in violation of his/her visa regulations (e.g. "moonlighting" on a J-1 visa), (c)
outside employment without adequate professional liability insurance, or (d) outside employment
that jeopardizes the reputation of the SCHOOL or its affiliated medical centers. The professional
liability insurance provided by the SCHOOL or its affiliated medical centers does not cover the
RESIDENT/FELLOW during "moonlighting."
12. The RESIDENT/FELLOW agrees to comply with the DUTY HOUR regulations of the PROGRAM,
the SCHOOL, and the ACGME, and to cooperate with the mechanisms for implementing and
monitoring compliance to the DUTY HOUR regulations.
13. Non-competition agreements (restricted covenants) are not required of, or permitted for,
RESIDENTS/FELLOWS.
14. The RESIDENT/FELLOW, by signing below, acknowledges receipt of the current copy of the
"Manual of Policies and Procedures for Graduate Medical Education Programs," (MANUAL) with this
AGREEMENT. The MANUAL contains the most relevant policies and procedures common to the
SCHOOL's graduate medical programs, including those for leaves (including leaves of absence,
annual leave, sick leave, maternity/paternity/adoption leave, military leave, bereavement leave,
and leaves covered under the Family & Medical Leave Act); counseling/medical/psychological
support services; physician impairment; promotion; dress code; notification and consequences of
unacceptable performance, skills, knowledge, professional and personal conduct or attitude;
dismissal; suspension; remedial training; fatigue monitoring and duty hour policies; patient loads;
service obligations; working environment; attendance at conferences; graded supervision plans;
evaluations of and by trainees; immunization recommendations; “moonlighting” policy; residents'
councils; sexual and other forms of harassment; residency closure policy; restrictive covenants;
gifts from industry; grievance resolution procedures; Technical Standards and compliance to the
Americans with Disabilities Act; and the potential effects of leave on delaying graduation and board
eligibility. The RESIDENT/FELLOW agrees to comply with the policies described in this AGREEMENT
and in the accompanying and subsequent editions of the MANUAL.
15. The RESIDENT/FELLOW acknowledges that subsequent MANUALs and contracts may contain
revisions, and that the current MANUAL, and it’s as yet unpublished revisions, will be posted on the
University’s website at
GME Policy Manual | May 17, 2013 | Page 40
http://www.rosalindfranklin.edu/cms/GMEOffice/GMEManualofPoliciesandProcedures.aspx.
The RESIDENT/FELLOW also agrees that his/her retention in the program depends upon his/her
compliance to the rules and regulations of his specific training program, the SCHOOL, the
University, and the medical centers or organizations that will employ and train him/her. The
RESIDENT/FELLOW acknowledges that he/she has read the MANUAL and this AGREEMENT and
will read subsequent editions as they become available, and that he/she is bound thereby.
16. The RESIDENT/FELLOW attests that he/she has completed, as stated, all of the training and
administrative requirements claimed in the application process and grants permission to the
SCHOOL to seek verification of any or all documents and claims attending the application process.
Likewise, the RESIDENT/FELLOW grants the SCHOOL access to all information related to
determining eligibility for specialty board examinations. He/she acknowledges that any false or
misleading statements presented verbally or in the application or board eligibility-related materials
or in other supporting documents, are sufficient cause for termination of this AGREEMENT.
17. This AGREEMENT may also be terminated by the SCHOOL if the RESIDENT/FELLOW (a) does
not obtain and keep current an Illinois Medical License or (b) (if not a U.S. citizen) does not obtain
and keep current appropriate visa or resident alien status, enabling him/her to work in the United
States, or (c) would not be successful in obtaining clearance to work in an affiliated medical center
essential for the successful completion of the training program (e.g. non-compliance to Selective
Service regulations) or (d) becomes incapacitated or otherwise cannot or will not perform
satisfactorily the essential functions of a RESIDENT/FELLOW.
18. This agreement will not take effect until and unless signed by all of the designated signatories,
or their delegates, within two months of the date of the agreement (indicated in the first sentence).
If the agreement is not signed by all signatories, or their delegates, within this interval, the offer of
a training position is considered withdrawn. This time restriction may be waived only by the
Associate Dean for GME or by the Dean of the Medical School or by their delegates.
19. The RESIDENT/FELLOW must be ready to start his/her training by August 30st of the academic
year or this agreement will be terminated. This time restriction can be waived only by the Associate
Dean for Graduate Medical Education or by the Dean for the Medical School or his designee.
SIGNATURES
________________________________________________
«FIRSTNAME» «LASTNAME», MD
Date
Resident/Fellow
________________________________________________
Jeanette L. Morrison, M.D.
Date
Designated Institutional Official (DIO)
Associate Dean for GME
________________________________________________
Russell Robertson, MD
Date
Senior Institutional Executive (SIE)
Vice President of Medical Affairs and Dean of the Chicago Medical School
GME Policy Manual | May 17, 2013 | Page 41
Appendix VI
TECHNICAL STANDARDS FOR GRADUATE MEDICAL EDUCATION
The Americans with Disabilities Act
The Americans with Disabilities Act (ADA), enacted in July of 1990, protects any individual with a
physical or mental impairment that substantially limits that person in some major life activity and
any individual who has a history of, or is regarded as having, such an impairment. Under the ADA,
as with Section 504 of the Vocational Rehabilitation Act, universities and colleges are prohibited
from discriminating against an otherwise qualified person with a disability in all aspects of
academic life. Schools must make reasonable accommodations to accommodate the known
physical or mental disabilities of otherwise qualified individuals. The University need not make an
accommodation that would cause an undue burden. The philosophical basis of the ADA, that of
judging persons on their abilities and achievements rather than their potential disabilities runs
parallel to the traditional philosophy of this University.
In order to define the "essential requirements" of its graduate medical curriculum, the Chicago
Medical School has developed a list of Technical Standards of physical, mental, and behavioral
skills and capabilities essential for training and functioning in a residency or subspecialty
fellowship program. In decisions on admission, evaluation, promotion, and graduation of any
person, and especially an applicant or trainee with a disability, it is the obligation of the individual
to meet these technical standards, with or without reasonable accommodation.
For further information on these Technical Standards and the procedures for their implementation,
interested persons are encouraged to contact Ms. Rebecca Durkin, ADA Coordinator (at [847] 5788351 or [email protected]), or Jeanette Morrison, MD, FACP, Associate Dean
for GME (at [847] 578-8509 or [email protected]).
An applicant for a position in a residency or subspecialty fellowship position, or a trainee already in
such a position, must possess abilities and skills which include those that are observational,
communicational, motor, intellectual-conceptual (integrative and quantitative), and behavioral and
social. The use of a trained intermediary is not acceptable in many clinical situations in that it
implies that the applicant’s or trainee’s judgment must be mediated by someone else's power of
selection and observation, or implemented through someone else’s physical, mental or other
relevant skill sets.
The applicant or trainee must also be able to utilize these abilities and skills effectively over
frequent and long periods of duty, e.g. up to 30 continuous hours of duty, up to 88 hours duty per
week, in-house call as often as every third day, potentially no more than 10 hours between shifts,
and on average up to 6 workdays per week, in accordance with accepted duty hour limitations.
I. Observation:
The applicant or trainee must be able to acquire appropriate information as presented through
didactic group or individual teaching methods, self-learning, and experience with patients.
Furthermore, the applicant or trainee must be able to:

observe a patient accurately, at a distance and close at hand, with or without standard
medical instrumentation, to acquire information from written documents, and to visualize
information as presented in images from computer and telemetry monitors, projections,
paper, films, slides or video.
GME Policy Manual | May 17, 2013 | Page 42

interpret x-ray and other graphic images, and digital or analog representations of
physiologic phenomenon (such as EKGs) with or without the use of assistive devices.
Such observation and information acquisition necessitates the functional use of visual, auditory
and somatic sensation while being enhanced by the functional use of other sensory modalities. In
any case where a candidate's ability to observe or acquire information through these sensory
modalities is compromised, the applicant or trainee must demonstrate alternate means and/or
abilities to acquire and demonstrate the appropriate information in a realistic clinical setting and
within a time interval sufficient for proper patient care. If the alternatives are acceptable, it is
expected that obtaining and using such alternate means and/or abilities shall be the responsibility
of the student. Costs of necessary accommodations should be reasonable and will be properly
borne by the University or affiliated medical center(s) when not the responsibility of the student or
otherwise funded.
II. Communication:
An applicant or trainee must be able to speak, to hear, and to observe patients by sight in order to
elicit information, describe changes in mood, activity and posture, and perceive nonverbal
communications. An applicant or trainee must be able to communicate effectively and sensitively
with patients and their families. Communication includes speech and writing. The applicant or
trainee must be able to communicate effectively and efficiently in oral and written form with all
members of the health care team. If the applicant’s or trainee’s ability to communicate is
compromised, the applicant or trainee must demonstrate satisfactory alternate means and/or
abilities to communicate the appropriate information within a realistic clinical setting and within a
time interval sufficient for proper patient care.
III. Motor:
It is required that an applicant or trainee possess the motor skills necessary to directly perform
palpation, percussion, auscultation and other diagnostic and therapeutic maneuvers, basic
laboratory tests and diagnostic and therapeutic procedures. The applicant or trainee must be able
to execute motor movements reasonably required to provide general and emergency medical care
such as airway management, placement of intravenous catheters, cardiopulmonary resuscitation,
application of pressure to control bleeding, suturing of wounds and the performance of simple
obstetrical maneuvers. Such actions require coordination of both gross and fine muscular
movements, equilibrium and functional use of the senses of touch and vision. If the applicant’s or
trainee’s ability to perform motor skills is compromised, the applicant or trainee must demonstrate
satisfactory alternate means and/or abilities to accomplish the same tasks within a realistic
clinical setting and within a time interval sufficient for proper patient care.
IV. Intellectual-Conceptual (Integrative and Quantitative) Abilities:
The applicant or trainee must be able to measure, calculate, reason, analyze, integrate and
synthesize. In addition, the applicant or trainee must be able to comprehend three-dimensional
relationships and to understand the spatial relationships of structures. Problem solving, the critical
skill demanded of physicians, requires all of these intellectual abilities. The applicant or trainee
must be able to perform these problem-solving skills within a realistic clinical setting and within a
time interval sufficient for proper patient care.
GME Policy Manual | May 17, 2013 | Page 43
V. Behavioral and Social Attributes:
The applicant or trainee must possess the emotional health required for full utilization of his/her
intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities
attendant to the diagnosis and care of patients, the development of mature, sensitive, and
effective relationships with patients, their families, peers and other healthcare personnel. He/she
must also have the skills to effectively lead a healthcare team consisting of residents, fellows,
students, nurses and other healthcare personnel. The applicant or trainee must be able to tolerate
physically and mentally taxing workloads and to function effectively under stress. He/she must be
able to adapt to changing environments, to display flexibility, and to learn to function in the face of
uncertainties inherent in the clinical problems of patients. Compassion, integrity, concern for
others, interpersonal skills, interest and motivation are all personal qualities that will be assessed
during the admissions and educational processes.
GME Policy Manual | May 17, 2013 | Page 44
DISTRIBUTION AND REVIEW
I acknowledge that I have received the “Manual of Policies and Procedures for Graduate Medical
Programs, dated May 17, 2013 in printed or electronic format, and, as required, I will review it
within the next two weeks.
________________________________________________
Name (Printed)
________________________________________________
Signature
________________________________________________
Training Program
________________________________
Date
GME Policy Manual | May 17, 2013 | Page 45