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Policies

The following policies apply to all general surgery residents at Duke. For further information regarding residency program policies, please refer to the policies and procedures listed on the Office of Graduate Medical Education website.

General Surgery Resident Reappointments and Promotion Criteria

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.

ABSITE Scores

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 Evaluations

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

Faculty Evaluations

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.

Advisor Policy

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.

Supervision Policy

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).

Duty Hours

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

Frequently Asked Questions About the Duty Hour 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. Didactic and clinical education must have priority in the allotment of trainees' time and energies.

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.

Duty Hours

  • Duty 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. Duty hours do not include reading and preparation time spent away from the duty site.
  • Clinical and educational work hours must be limited to no more than 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.  Residents should have eight hours off between scheduled clinical work and education periods.
  • Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
  • In rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain or return to the clinical site in the following circumstances:
    • to continue to provide care to a single severely ill or unstable patient;
    • humanistic attention to the needs of a patient or family; or,
    • to attend unique educational events.

On-Call Activities

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

In-house call

  • Residents must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period).
  • Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.
    • Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education.

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

  • 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.
  • Internal and external moonlighting 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.

Oversight

  • The program must have written policies and procedures consistent with the Institutional, Common and Program Requirements for trainee duty hours and the working environment. These policies must be distributed to the trainees and the faculty. Trainees are required to log duty hours. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
  • 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.
  • Surveillance of duty hours will be the continuing responsibility of the Resident Environment Section of the Institutional Committee for Graduate Medical Education (ICGME) who will report to the full ICGME at least biannually.
  • Violations of the duty hour standards may result in institutional sanctions, such as withdrawal of program sponsorship or Corrective Actions for Associate Members of the Medical Staff.

Duty Hours Exception

Some RRCs may grant exceptions for up to 10 percent of the 80-hour limit, to individual programs based on a sound educational rationale. However, prior permission of the ICGME is required. 

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.

Leave

A period of six weeks with pay is provided for uncomplicated maternity leave, and family medical leave.

Applicants for general surgery certification must acquire no fewer than 48 weeks of full-time experience in each residency year. This is required regardless of the amount of operative experience obtained. No more than four weeks of time off is allowed per year; the sole exception is approved medical leave.

For documented medical problems or maternity leave, the ABS will accept 46 weeks of training in one of the first three years of residency and 46 weeks of training in one of the last two years, for a total of 142 weeks in the first three years and 94 weeks in the last two years. Unused vacation or leave time cannot be applied to reduce the amount of full-time experience required per year without prior written permission from the ABS. Such requests may only be made by the program director.

Maternity Leave

Maternity leave is adjustable based on the individual’s clinical condition and could include one to two weeks pre-delivery followed by three to seven weeks post-delivery for recovery.

If the pre-delivery medical condition becomes inconducive to performing standard activities, leave could be adjusted to accommodate these needs based on the individual’s obstetrician recommendations.

In accordance with the policies of the American Board of Surgery, extended leave resulting in fewer than required number of weeks in full-time experience would necessitate additional time beyond the initial anticipated graduation date.

Paternity Leave

Paternity leave would use the designated vacation time already provided by the department on a yearly basis. Any additional leave for medical or personal/family reasons would be considered on an individual basis in accordance with the FMLA policies of the department for medical and/or family situations.

Financial remuneration would not necessarily be guaranteed and remedial time would be mandated. 

Family Leave

Family leave is based on the individual’s situation. Four weeks, using the vacation time already provided, will be provided with pay at the program director’s discretion. Any further time away will mandate remedial time, and financial remuneration would not necessarily be guaranteed.

As soon as the resident has knowledge of a need for professional, parental, disability, or sick leave, an immediate meeting with the program director is mandatory. In all cases, scheduling adjustments will need to be made far in advance to plan for leave time and resident coverage during the individual’s absence.

Medical clearance from the resident’s physician will be required for the individual to resume clinical duties.

Unscheduled Time Away

If a resident requires an unscheduled weekday 24-hour period away from their duty, this must be requested in-writing and approved by the program director far in advance to plan for leave time and resident coverage during the individual’s absence. Three or more unexcused absences from scheduled training will result in automatic suspension.

Grievance

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.

Protocol Defining the Requirement for Faculty Involvement

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

Travel Policy

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