Policies

Reappointment and promotion training requires satisfactory rotation and cumulative evaluations by faculty indicating satisfactory progress in scholarship and professional growth. This includes demonstrated proficiency in:

• Incremental increase in clinical competence, including performing applicable procedures (ACGME case log is to be updated by the 5th day of each month)
• Appropriate increase in fund of knowledge; ability to teach others
• Clinical judgment
• Necessary technical skills
• Humanistic skills; communication with others, integrity
• Attendance, punctuality, availability, and enthusiasm
• Adherence to institutional standards of conduct, rules, and regulations, including program standards and hospital and clinic rules with respect to infection control policies, scheduling, charting, record-keeping, and delegation to medical staff
• Adherence to rules and regulations in effect at each health care entity to which assigned
• Satisfactory performance on ABSITE in-service examination

Residents are expected to meet all of the educational goals of the Duke General Surgery Residency Training Program each year of training.

See educational goals by program year (PDF).

The Duke Department of Surgery operates in compliance with the Institutional Committee for Graduate Medical Education (ICGME) policy on the passage of medical licensing examinations for entry to and continuance in graduate medical education programs sponsored by Duke University Hospital. Read the policy.

Each resident is required to take the ABSITE examination each year. Residents who score below the 50th percentile will engage in a remediation program proctored through a regulated reading program under the supervision of a designated surgery faculty member.  Two consecutive years below the 50th percentile will be considered below minimal programmatic standards.

Resident performance is evaluated after each month of clinical service. Evaluation criteria include the resident’s performance and comprehension of the patient core competencies, resident's ability as a technical surgeon, and the management of pre- and postoperative patient care issues.

Progress is monitored at the biannual faculty meeting, as well as by the resident’s mentor, the program director, and with the resident.

Aspects of professionalism that are monitored include:

• Conference attendance: Residents are expected to attend 80 percent of required conferences
• Record-keeping: Timely dictations of operative notes and patient discharge summaries
• Compliance with hospital policies: Maintenance of ACLS, BLS certification, HIPAA compliance, current medical licensure, yearly TB skin testing, etc.
• Personal record-keeping: Up-to-date maintenance of surgical case logs in the ACGME database and duty hours

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

Upon arrival at Duke, each resident will select an advisor in his or her field of specialty interest. The advisor will guide the residents through their training and, in particular, advise them with regard to their investigative laboratory choices.

Advisors meet with the resident following the program director's semi-annual review of each resident's evaluations and performance.

Residents are free to select a different advisor at any time, and this will be encouraged if career goals develop in a direction that the advisor is not able to direct.

Duke Surgery exposes residents only to levels of decision-making appropriate for their level of experience, and all residents function under the supervision of department faculty.

We adhere to the Duke University Hospital policies and procedures regarding resident supervision (PDF).

The Duke General Surgery Residency Training Program has adopted the DUH Institutional policy as its own.

Frequently Asked Questions About the Clinical and Educational Work Hours Policy (PDF)

Background

Providing graduate medical trainees (trainees) with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and trainee well-being.

Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on trainees to fulfill service obligations and that the clinical demands on trainees are achievable without compromise of patient safety during scheduled hours (i.e., avoidance of excessive work compression).  Didactic and clinical education must have priority in the allotment of trainees' time and energies.

Clinical and Educational Work Hour (formerly Duty Hour) assignments must recognize that program directors, faculty, and trainees collectively have responsibility for the safety and welfare of patients and adherence to this policy. The institution is committed to the promotion of an educational environment, support of the physical and emotional well-being of its graduate medical trainees, and the facilitation of high quality patient care.

Policy

As an accredited ACGME program, the Duke General Surgery Residency Training Program shall maintain compliance with ACGME requirements or ACGME's interpretation of such requirements; therefore, this policy will be superseded by any applicable revisions to ACGME institutional, common, or specialty-specific program requirements.

The Duke General Surgery Residency Training Program must maintain compliance with this policy and any additional specifications provided by the ACGME Review Committee in order to maintain sponsorship by DUHS.

This policy applies to all Duke General Surgery Residency trainees.

Clinical and Educational Work Hours

• Clinical and Educational Work (CEW) hours are defined as all clinical and academic activities related to the graduate medical education program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. CEW hours do not include reading and preparation time spent away from the work site.
• CEW hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
• Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks). At-home call cannot be assigned on these free days.  One day is defined as one continuous 24-hour period free from all clinical educational, and administrative activities, including at-home call.
• Residents must have adequate time for rest and personal well-being activities must be provided.  This should consist of a 10-hour time period (and must consist of an 8-hour period) provided between scheduled CEW periods.  All trainees must have 14 hours free of duty after 24 hours of in-house call.

On-Call Activities

The objective of on-call activities is to provide trainees with continuity of patient care experiences.

• Residents must be scheduled for in-house call no more frequently than every third night, averaged over a four-week period.
• Trainees must not be scheduled for more than six consecutive nights of night float. Night float must occur within the context of the 80-hour and one-day-off-in seven requirements.
• Continuous on-site duty, including in-house call, must not exceed 24 hours. Residents may be allowed to remain on-site for no longer than four additional hours for effective transitions of care and didactic learning. Trainees must not be assigned additional patient care responsibilities after 24 hours of continuous in-house duty.

At-home call

• At-home call must not be so frequent or taxing as to preclude rest and reasonable personal time for each trainee.
• The frequency of at-home call is not subject to the every third night limitation. Trainees taking at-home call must be provided with one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period. At-home call cannot be assigned on these days.
• When trainees are called into the hospital from home, the hours trainees spend in-house are counted toward the 80-hour limit.
• 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.

In-House Night Float

• Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.

Moonlighting and Temporary Special Medical Activity (TSMA)

• Because graduate medical education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the trainee to achieve the goals and objectives of the educational program. The PTD must monitor the effect of moonlighting and TSMA activities on CEW hour compliance, and trainee well-being.
•  All TSMA and moonlighting activity must be voluntary.
• Moonlighting and TSMA hours must be counted towards the 80 hour maximum hour limit.
• Trainees in the General Surgery Residency Training Program (PGY 1-5), exclusive of the Surgery Research Fellowship Program, are not permitted to moonlight.
• Other Special Situations: Eligibility for TSMA moonlighting is affected by visa and active military status. Trainees that are visa holders or active military should check with their PTD and if relevant, visa services and their military supervisor to determine eligibility.

Oversight

• The program must have written policies and procedures consistent with the Institutional, Common and Program Requirements for trainee CEW hours and the working environment. These policies must be distributed to the trainees and the faculty. Trainees are required to log CEW hours. Monitoring of CEW hours by the program directors is required with sufficient frequency to ensure an appropriate balance between education and service, but all program directors should review their trainees’ CEW and CEW violations at least monthly, detailing their reviews in MedHub.
• Institutional CEW hours are reviewed monthly by the DIO with the MedHub Administrator.
• Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care.
• Exceptions to CEW hours policy are not allowed.
• Violations of the CEW hour standards may result in program or institutional sanctions, such as withdrawal of program sponsorship or Corrective Actions for Associate Members of the Medical Staff.

Well-Being

Duke’s General Surgery Residency Program is committed to providing an optimal, adaptable training and clinical environment focused on the clinical, professional, and personal development of physicians at all levels.

We recognize that residents, fellows, and faculty experience high rates of burnout driven by factors that span numerous domains. Our program strives to take a multi-faceted approach to address these contributing factors.

Each person has an individualized concept of well-being. Our program provides opportunities and programs to enable each resident to flourish, and we strive to improve our resources and better support each other.

We have a layered support network, including program faculty, chief residents, advisors, and coaches to help you navigate life in and outside of the hospital.

Our Mission

To enable individual well-being and to encourage a culture of self-reflection and compassion in which residents can be thoughtful stewards of patient-centered medical decision-making, can develop tools for self-care, and can become leaders and advocates for themselves and others.

Our Vision

All residents are able to reflect on their experiences as physicians, to identify and cultivate aspects of work that are personally meaningful and provide a sense of belonging, and to develop their practice of self-improvement.

Resources for You

If you need immediate assistance for your mental or emotional health, you may always reach out to your program director, chief residents, or please call Personal Assistance Services at 919-416-1727, identify yourself as a GME trainee, and schedule an appointment. Personal Assistance Services (PAS) is a free, confidential counseling service, available to all employees and their immediate families. PAS has dedicated GME Prime Time appointments at 7a, 5p, 6p, and 7p reserved for GME trainees.

The Duke Surgery Department offers a variety of resources for mental health and well-being for its trainees.

Wellness Policy for Resident/Fellow and Faculty Member Well-Being

Report Mistreatment Concerns

You may confidentially report unprofessional behavior toward GME trainees or any form of mistreatment to the Duke Graduate Medical Education Office here.

What to do in Case of a Mental or Behavioral Health Emergency

For urgent mental or behavioral health needs outside of normal business hours (e.g., nights, holidays, or weekends), we recommend the following protocol:

• Contact the DUMC paging operator at 919-684-8111.
• Identify yourself as a GME trainee in need of urgent assistance. You can self-refer or refer a colleague in need of support.
• The paging operator will contact the psychiatry attending on call. The attending will reach out to speak with you, assess your situation, and determine a safe and appropriate course of action.
• The National Suicide Prevention Lifeline can be reached by dialing or texting 988. Alternatively, you can call 1-800-273 (TALK) 8255. Crisis Text line, Text HOME to 741741.

Fatigue and Stress

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

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

The Duke Office of GME has identified transportation options for residents post call who are too fatigued to drive home safely.

Duke University Hospital Graduate Medical Education Leave of Absence and Vacation Policy

Applicable to: All residents and fellows who are enrolled as trainees in any Duke Graduate Medical Education (GME) program, whether ACGME-accredited or internally sponsored.

Effective Date of Benefit: Day of hire, defined as the first day after institutional orientation. Trainees must complete all onboarding requirements, including attending live orientation, prior to receiving this or any other benefit. Trainees who are unable to comply with this requirement may defer their program start dates until they are able to meet this requirement.

Eligibility Considerations: As all GME residents and fellows are Duke University Hospital (DUH) employees, this policy will apply effective July 1, 2022, to any trainee hired prior to July 1, 2022 whose program does not already provide vacation and leave benefits consistent with this policy, and to all Duke trainees hired on or after July 1, 2022. Trainees who were recruited and hired prior to July 1, 2022, with an expectation of a more generous benefit provided by their department will maintain that benefit during their training (paid by the department), but all programs will be expected to advertise and comply with this policy for all recruitments effective July 1, 2022.

Exclusions: Each program is responsible for determining its own program-specific policies regarding outside professional conference attendance (funding and amount time allowed), and time away for job or fellowship interviews. In general, time away for conferences should be considered work, and should be limited to the days required to complete the agreed upon activity. Programs may define their own policies for payment of specialty board certification application fees on behalf of their trainees, and the provision of specialty-specific equipment required for trainees’ function in their specialty-specific roles (e.g., surgical loupes, lead aprons). Programs are responsible for communication of these policies to their trainees. All program and departmental policies must comply with the respective medical specialty board requirements regarding absences from training.

View the full Duke University Hospital Graduate Medical Leave of Absence and Vacation Policy here.

To provide an additional, nonexclusive system of communication, exchange of information, and confidential concerns of individual graduate medical trainees regarding their educational programs, the graduate medical trainee may contact their resident or faculty representative on the Institutional Committee for Graduate Medical Education, who have full access to the committee and any ad hoc committees necessary to explore and address the trainee’s concerns, complaints, or grievances not covered under the Corrective Action and Hearing Procedures for Associate Medical Staff of Duke University Hospital.

The names of the graduate medical trainee and faculty representatives will be made available to all graduate medical trainees on an annual basis. Any records regarding these issues will have protected status of peer review.

Listed below are expectations on the part of the faculty involvement in patient care. 

In addition to the general circumstances enumerated below, residents may at any time request direct faculty supervision is uncertainty exists or if felt to be required by the resident.

Clinic Encounters

• All patient encounters in the clinic are to be seen with direct supervision at the time of encounter.

Inpatient Consults

• All new consults are to be staffed with faculty after initial evaluation by the resident.
  • Patients with conditions potentially requiring urgent surgical procedures are to be seen with direct supervision in a timely manner consistent with the potential urgency level of the case (level 1-6, one immediate OR, two within two hours, three within six hours, etc).
  • Non-urgent matters may be managed with indirect supervision at the time of consultation (PG-2 - PG-5) or direct supervision (PG-1).
• Existing consults:
  • All existing consults with stable issues are to be staffed daily by the faculty member with indirect supervision (PG-2 and above) or direct supervision (PG-1).
  • Existing consults with urgent issues (potential need for surgery, change to ICU status, specific request by primary team) are to be evaluated with direct supervision daily or at the time of a significant change to urgent status.

Ward Patients

• Admissions
  • All new admissions are to be staffed upon admission with faculty and then evaluated with direct supervision:
    • Within 24 hours of admission for non-urgent conditions.
    • In a timely manner consistent with the potential urgency level of the operative case in urgent patients.
• Existing Patients
  • All patients are to be staffed with faculty with indirect supervision at the least on a daily basis.
  • Direct faculty supervision is required for the following:
    • Requirement of operative procedure
    • Change in clinical status requiring:
      • ICU admission or significant clinical deterioration (Rapid Response Team)
      • Changes in DNR status
      • Possibility of operative intervention

ICU Patients

• All existing patients are to be evaluated with direct faculty supervision on a daily basis.
• All existing patients with significant changes (deterioration) in status are to be evaluated directly by the faculty.
• All new transfers to the ICU are to be evaluated (physically examined) promptly by in-house faculty (DRH and Duke) or in a timely manner judged by ICU faculty staffing the matter via indirect supervision (Durham VA).

Expected Communication Practices

The following should be communicated to the attending by the house-staff for patients admitted to surgical services:

For all critical changes in a patient’s condition, the attending will be notified promptly (generally within 1 hour following evaluation).  These include:

• Admission to the hospital
• Transfer to the ICU
• Unplanned intubation or ventilator support
• Cardiac arrest
• Hemodynamic  instability (including arrhythmias)
• Code
• Development of significant neurological changes (suspected CVA/seizure/new onset paralysis)
• Development of major wound complications (dehiscence, evisceration)
• Medication or treatment errors requiring clinical intervention (invasive procedure(s), increased monitoring, new medications except Narcan)
• First blood transfusion without prior attending knowledge or instruction (before or after operation)
• Development of any clinical problem requiring an invasive procedure or operation for treatment

The following will be discussed with and approved by the attending before they occur:

• Discharge from the hospital or from the Emergency Department
• Transfer out of ICU

 The attending should also be contacted if:

• Any trainee feels that a situation is more complicated than he or she can manage
• Nursing or physician staff, or the patient requests that the attending surgeon be contacted

Please see our Benefits page for details about our travel policy.