Graduate Medical Education
MSC11 6093
1 University of New Mexico
Albuquerque, NM 87131-5156

Phone: (505) 272-6225
Fax: (505) 272-5184

email

Graduate Medical Education

Resident Handbook

Moonlighting

Moonlighting activities, whether internal or external, must be consistent with sufficient time for rest and restoration to promote resident educational experience, well being, and patient safety. Program Directors will closely monitor moonlighting activities to ensure they do not interfere with the Houseofficer’s ability to achieve the goals and objectives of the educational program. Internal Moonlighting is considered to be moonlighting at all UNM HSC and VAMC facilities. For example, some departments will allow Houseofficers to take extra call or provide extra service in their department and compensate them for it (through special compensation forms) since it is not part of the educational program. These hours would count toward the 80 hour work week. External Moonlighting is moonlighting at any institution which is not a required rotation or funding source for UNM GME Programs. External Moonlighting cannot be done at the same institution which is funding the rotation. External Moonlighting may be done through, and paid for, by UNM Locum Tenens. These hours would not be counted toward the 80 hours work week. However, Program Directors are responsible for monitoring fatigue which might be a result of this moonlighting. If it is determined that it affect a resident’s performance moonlighting may be limited or eliminated.

Permission forms for moonlighting are available in the GME Office. This form must be signed by the Program Director and must be on file in the GME Office. If the Program Director deems moonlighting is having an adverse effect on the resident, permission may be withdrawn at any time. Program Directors will be responsible for monitoring Houseofficers for signs of fatigue which may be a result of activities outside of the training program. Individual departments may have specific policies defining and/or denying moonlighting privileges. External moonlighting cannot be done in the same institution in which one is training. Moonlighting privileges can not used for the formation of one’s own practice. Residents who hold J-1 visas are prohibited from moonlighting. No trainee can be required to moonlight.

Programs are bound by Residency Review Committee requirements for duty hours and educational content and environment. Because of the educational advantage and mission of the SOM and in compliance with that mission it is advised that the all off site moonlighting experiences be coordinated through the UNM Locum Tenens program. The program assists the resident in the process of licensing and credentialing. Professional liability is covered in the institutionally sponsored program. Compensation is paid through the UNM payroll system thus minimizing any unplanned tax liabilities. The trainee’s Program Director must sign each special compensation form prior to payment. The University and the Houseofficer agrees to abide by the Association of American Medical Colleges’ statement on moonlighting by residents (memorandum 74-21, July 1, 1974).

AAMC STATEMENT ON MOONLIGHTING BY HOUSEOFFICERS

Graduate medical education should be a full time educational experience. Houseofficers should not be diverted from their primary responsibilities to their own education and to the patients charged to their care by the training institution by engaging in extramural professional activities. Therefore, as a matter of general principle, the Association of American Medical Colleges believes that “moonlighting” by Houseofficers is inconsistent with the education objectives of Houseofficer’s training and is therefore a practice to be discouraged. For those institutions that permit moonlighting, great care should be taken to preserve the educational character of their graduate medical education programs. The following general guidelines are recommended as the means by which the primary training institutions should monitor and control this practice.

1. The hospital governing board or executive committee of the faculty having responsibility for medical standards in the educational setting, should administer the authority to approve or disapprove “moonlighting” in the individual case. This authority may be delegated to the service chief or other individual who controls the content and quality of each training program.
2. In evaluating the content and quality of the training program for each Houseofficer, consideration should be given to the following:
1. The capacity of the Houseofficer to fulfill his educational objectives while at the same time pursuing additional work opportunities for income;
2. The nature of the work opportunity, including its educational value;
3. The needs of the community; and
4. The financial need of the individual.
3. Moonlighting by incumbents of internship and residencies approved by the Accreditation Council on Graduate Medical Education, may be permitted only if those activities are reviewed and approved by the person(s) responsible for the individual’s graduate training program. Houseofficers should be informed of the substance of this provision prior to appointment.
4. The ACGME may take the necessary steps in its process of approval of graduate medical education programs to assure compliance with the above guidelines.

NON COMPETITION CLAUSE (RESTRICITVE CONVENANTS)

Houseofficers are not subject to the UNM HSC non competition clause.

NON RENEWAL OF CONTRACT

All Houseofficers shall be notified in writing no less than four (4) months prior to the end of their annual contract year if their contract is to be non renewed or if they will not be promoted to the next level of training. If primary reason(s) for the non renewal or non promotion occur(s) within the four (4) months prior to the end of the Agreement, or in the case of Housesofficers will contract for less than twelve (12) months, UNM will provide as much written notice of the intent not to renew or not to promote, prior to the end of the contract, as the circumstances will reasonable allow. Determination regarding a decision not to reappoint will be made by the Program Director in consultation with the Department Chair and the Associate Dean for Graduate Medical Education.

PHYSICIAN IMPAIRMENT
In the event a Houseofficer becomes impaired during the training program, including but not limited to alcohol, drug, or chemical dependency, the Houseofficer may exhaust accrued annual, sick, and available catastrophic leave for treatment with pay. No Houseofficer will be disciplined or terminated for seeking such treatment. No Houseofficer shall be discipline or terminated for admitting they are impaired, or seeking medical leave for such treatment. This disciplinary safe harbor does not extend to impairment or dependence discovered other than by self-disclosure, nor does it extend to discipline for conduct, behavior, actions, or omission while impaired or dependent. Investigation and disposition of a Houseofficer suspected of impairment, including, but not limited to alcohol, drug, or chemical dependence are outlines in the UNM Physician Impairment and Substance Abuse Policy.

PHYSICIAN IMPAIRMENT AND SUBSTANCE ABUSE POLICY

During the training period, if two persons identify signs of possible substance abuse and/or impairment in a Houseofficer (i.e., behavioral changes, alcohol on breath), the attending physician and the Department Chairman or Program Director will, upon notification of same, advise the Houseofficer of the situation and may arrange for testing. (In an emergency situation, the Houseofficer will be admitted to and tested at University Psychiatric Center.) Upon discharge from the UPC, the attending physician and the Department Chairman or Program Director will evaluate the Houseofficer and schedule follow-up testing.)

Positive Drug Tests

The Medical Officer of Record (MOR) will determine the validity of the drug or alcohol testing. Positive or false positive test results will result in the Houseofficer being removed from patient care responsibilities until the situation is resolved. A positive test will call for an interview for follow-up by CARS (UNM Counseling & Referral Services), Employee Health (MOR), GME, and by the Department Chairman and Program Director within 72 hours, and for signing of a contract wherein the Houseofficer agrees to mandatory random testing, review by a monitor, and retesting as appropriate. The Houseofficer will be placed on paid administrative leave during that time for up to 72 hours. The Houseofficer may be referred to MTP (Monitored Treatment Program) for further evaluation and assessment. If test results are negative the Department Chairman or Program Director will arrange follow-up as appropriate to determine an appropriate course of action.

Continuing Abuse:

If the monitor determines that the Houseofficer's abuse problem persists, the monitor and Department Chairman will decide whether to:

1. place the Houseofficer on sick leave;
2. place the Houseofficer on disability leave; or
3. to dismiss the Houseofficer from the training program; and
4. notify the state licensing board.

If the Houseofficer disagrees with the decision of the monitor and Chairman, the matter may be appealed to the Dean, the Dean's designate, or taken through the Grievance Procedure for resolution.

CODE OF PROFESSIONAL CONDUCT

Houseofficers are responsible for professional conduct in all activities as outlined in the University of New Mexico HSC policy on Professionalism for students, residents, and faculty. Houseofficers are responsible for serving as a role model for medical students, other Housestaff and understand that my behavior has a powerful means for educating others. I expect the highest professional standards of myself and my colleagues, and therefore commit to the following:

Altruism

(privacy of patient welfare)

1. I will maintain patient well-being as my main focus and primary responsibility.
2. I will remember that the patient welfare comes before the educational needs of residents or students.
3. I am committed to supporting excellence in the missions of preventive care and chronic care as well as acute medical care, disease prevention, health maintenance and palliative care.

Accountability

(reliability and responsibility, commitment to professional responsibilities)

1. I will be aware of ethical, professional, and legal standards as they apply to my responsibilities.
2. I will reliably and promptly attend all required activities.
3. I will comply with all of my program requirements. If I feel at conflict with a particular policy, such as the duty hour's policy, I will work to make my opinion known and to affect change, but will continue to adhere to the policy until it is changed.
4. I shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient.
5. I will communicate accurate and timely patient information to other members of the patient care team. I will not leave the clinic or the hospital prior to completing all of my required duties or prior to ensuring continuous care of my patients.
6. I will recognize and report impairment of any type in my colleagues or myself.
7. I will demonstrate personal conduct that reflects positively on the medical profession, my residency program, and the institution.

Excellence

(commitment to self improvement, commitment to professional competency, commitment to improving quality of care, commitment to scientific knowledge)

1. I commit to life-long learning and acquiring new knowledge and skills.
2. I will assess my progress and identify areas for improvement and issues for continued learning.
3. I will seek assistance from colleagues or professionals for any problems that adversely affect my education, quality of patient care or service to society.
4. I will participate in scholarship that benefits the participants of the training program, as well as contributing to the medical knowledge base of the medical discipline and that improves my own fund of knowledge.
5. I will challenge care team members to maintain a practice consistent with current standards of care, and with both cost-efficient and appropriate use of medical resources.
6. I will recognize the boundaries of my competency and commit to practice within those boundaries. I will respect the limitations of those working under me and will not ask them to exceed the boundaries of their competence.

Duty

(commitment to improving access to care, commitment to just distribution of finite resources)

1. I will commit myself to learning and applying best medical practices. "Best medical practice" is a term used to refer to medical practice that equitably balances evidence-based guidelines, ethical concerns, ethical business practices, patient preferences, cultural concerns, and the cost-effective and appropriate use of medical resources.
2. I will use resources appropriately with patient care as the cornerstone of decision making while being mindful of how applications of scarce resources impact the system.
3. I will apply appropriate ethical standards to all academic and clinical activities, including the provision of end-of-life care and withdrawal of care.

Honesty/Integrity

(commitment to maintaining trust by managing conflicts of interest, commitment to maintaining appropriate relations with patients)

1. I will demonstrate truthfulness in academic and clinical activities, including examinations and my other representation of my work
2. I will be truthful in all interactions with patients, peers, and faculty regarding patient data or other information.
3. I will participate in ethical medical research, including abiding by all appropriate HHRC regulations.
4. I will recognize and manage conflicts of interest implicit in the role of residents as care providers, students, and teachers in a clinical care and education system.
5. I will be cognizant of potential conflicts of interest with pharmaceutical or other medical industry representatives, and remember that patient welfare is my primary focus.
6. I will be cognizant of potential conflicts between my personal values, economic forces, institutional policies, ethical practice, and patient preferences. I will work to ensure that in spite of these potential conflicts, patients have access to the best current medical care.
7. I will provide full and truthful disclose of information to patients and families in the process of obtaining informed consent.

Respect for others

(respect for patient autonomy)

1. I will demonstrate the highest standards of ethical, legal, and professional behavior in the academic and clinical setting.
2. I will respect patient autonomy and ensure the provision of culturally competent medical care.
3. I will demonstrate humility and will not abuse the power of my position.
4. I will interact with all members of the health care team in a manner that respects and acknowledges the unique contributions those team members make to the medical care and resultant wellness of patients.
5. I will be respectful in my interaction with supervisors, colleagues, staff, families, and students.
6. I will not discriminate in any situation based on race, ethnicity, age, gender, sexual orientation, disability, socio-economic status, ability to pay, or other identifiable social category.

Privacy and Confidentiality

1. I will maintain privacy and confidentiality in interactions with patients and families.
2. I will communicate with other caretakers only that information required for the provision of timely, accurate, and high quality clinical care.
3. I will maintain the confidentiality of the medical record and will comply with all HIPPA requirements for transmission and sharing of patient specific medical information.

PROFESSIONAL ATTIRE

Houseofficers are expected to dress and appear in a professional manner at all times when on duty. Houseofficers’ dress should present an appearance consistent with their daily activities which engenders a sense of confidence, trust, and meets customer and patient expectations. Attire must be in compliance with the dress code for the facility in which one is serving. Dress must comply with OSHA and other federal standards.

PROMOTION, REAPPOINTMENT AND CERTIFICATION

In the event that academic deficiency is noted, the Houseofficer will be informed. Written recommendations will be made identifying measures to be taken in order to correct the deficiency. A time frame will be given within which correction is to be made. If there is question regarding promotion to the next level of training, the Houseofficer will be notified in writing at least four (4) months prior to the contract end date. Written receipt will be required from the trainee. For reappointment to the next higher level of training, each Houseofficer must complete a new contractual agreement (UNM SOM GME Agreement) and have been recommended by their department for promotion to the next level of training. Determination regarding a decision not to reappoint will be made by the Program Director in consultation with the Department Chair and the Associate Dean for Graduate Medical Education. To receive a certificate of successful completion of a program, a trainee must satisfactorily complete programmatic, administrative, patient care and educational requirements and competency expectations. An appropriate certification shall be issued within one month of each Houseofficers' satisfactory completion of his or her training program or part thereof.

HOUSEOFFICER RESPONSIBILITIES

Responsibilities of Houseofficers at the University of New Mexico are detailed in the UNM School of Medicine Graduate Medical Education Agreement. They include, but are not limited to: patient services, education activities and seminars, teaching and supervision of other Houseofficers and medical students, orientation, committee participation, providing documentation of good physical health, CPR certification, places and hours of duty, standards of performance, and compliance with rules and policies of training sites. All Houseofficers shall conduct themselves in a manner that justifies the confidence placed in them by the citizens of the State of New Mexico and shall at all times maintain the integrity and ethics in accordance with the high responsibilities of public service. Any changes in the rotation request require a three month prior notice and the permission of all affected parties. Individual programs will have additional specific responsibilities which are to be written and given to Houseofficers at the start of their training. Houseofficers should be familiar with UNM HSC medical staff policies and procedures which are online at www.hsc.unm.edu/som/clinaffr Each Houseofficer will be provided with a copy of their RRC (Residency Review Committee) Program Requirements by their Department and are provided with goals and objectives for their residency and rotation. The information is available for RRC program requirements are online at www.acgme.org

SUPERVISION — HSC POLICY

Careful supervision and observation are required to determine the physician or dentist in training’s (trainee’s) abilities to perform technical and interpretive procedures and to manage patients. Supervision of trainees should be designed to provide gradually increased responsibility and maturation into the role of a judgmentally sound, technically skilled, and independently functioning credentialed professional.

It is the policy of the Medical Staff of the University of New Mexico Health Sciences Center to provide guidance to attending UNMHSC Medical Staff members to insure that the patient care provided by trainees physicians under their supervision is appropriate and of the highest quality and safety. Supervision of trainees in a clinical training program requires balancing multiple different institutional missions and goals while at the same time ensuring the progressive acquisition of skills necessary for independent practice at the completion of graduate medical education. Included among these goals are adherence to sound ACGME (Accreditation Council for Graduate Medical Education), and individual RRC (Residency Review Committee) and CDA (Council on Dental Accreditation) educational principles and guidelines for graduated clinical responsibility, adherence to regulatory guidelines as set forth by, but not limited to CMS (Center for Medicare and Medicaid Services) and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) (and others), commitment to ensuring patient safety and providing the highest quality care to our patients, and meeting the risk management and financial goals of the institution. Policy Cross References

Medical Staff Rules and Regulations, JCAHO Medical Staff Standard, MS 6.9, ACGME Accreditation Standards.

Purpose

The purpose of this policy is to specify the mechanisms by which trainee physicians and dentists are supervised by members of the University of New Mexico Health Sciences Center (UNMHSC) Medical Staff, and to establish guidelines for medical staff member supervision of trainees for all inpatient and outpatient care. This policy establishes the minimal requirements for trainee supervision at the teaching hospitals of The University of New Mexico Health Sciences Center (UNMHSC). A UNMHSC teaching hospital or individual training program may have additional requirements for trainee supervision as they pertain to that specific hospital or training program.

GENERAL PROCEDURE

The UNMHSC Medical Staff member is responsible for all aspects of the care provided by trainee physicians and dentists to individual patients in both the inpatient and outpatient settings. It is expected that the medical staff member will maintain active personal involvement in the care of each patient under his/her direct or consultative care, and will document according to policy.

Section I. Procedures
Trainees will be supervised by credentialed and privileged clinical faculty who are licensed independent practitioners on the UNMHSC Medical Staff. The medical staff member must be privileged for the specialty care and diagnostic and therapeutic procedures that they are supervising. In this setting, the supervising medical staff member is ultimately responsible for the care of the patient.At least annually, each UNMHSC Residency and Fellowship Program Director will review the guidelines and listing of trainee clinical activities and make changes as needed.
Program Directors of ACGME-accredited programs will submit their updated listing of clinical activities to the Office of the Associate Dean for Graduate Medical Education (GME), and to the UNMHSC Office of Clinical Affairs for review. Program Directors of non-ACGME programs will submit their updated listing of clinical activities to the appropriate department chairperson or departmental committee for approval and then submit the approved guidelines to the Associate Dean for Graduate Medical Education and to the UNMHSC Office of Clinical Affairs for review.
The Program Director will ensure that all supervision guidelines are distributed to and followed by trainees and the Medical Staff supervising the trainees. Compliance with the UNMHSC Medical Staff Supervision of Physicians and Dentists in Training Policy will be monitored by the Program Directors.

Section II. Supervision of Trainees in the Inpatient Setting
All lines of authority for inpatient care delivered by inpatient ward or ICU teams will be directed to a credentialed and privileged medical staff member. The medical staff member has the primary responsibility for the medical diagnosis and treatment of the patient.

Section III. Supervision of Trainees on Inpatient Consult Teams
All inpatient consultations performed by trainees will be documented in writing, with the name of the responsible medical staff member/consultant recorded. The responsible medical staff member/consultant must be notified verbally by the trainee doing the consult at the time of the consult. The consulting medical staff member is responsible for all the recommendations made by the consultant team.

Section IV. Supervision of Trainees in Outpatient Clinics
All outpatient visits provided by trainees will be conducted under the supervision of a medical staff member who is physically present in the clinic. This medical staff member will interview and examine the patient at the discretion of the medical staff member, at the trainee's request, or at the patient's request. The medical staff member has full responsibility for care provided, whether or not he/she chooses to verify personally the interview or examination.

Section V. Supervision of Trainees in the Emergency Department
The responsibility for supervision of trainees providing care in the Emergency Department (ED) to patients who are not admitted to the hospital will be identical to that outlined for outpatient supervision above.
The responsibility for supervision of trainees who are called in consultation on patients in the ED will be identical to that outlined in section III above. Consulting medical staff members should be notified at the time of the ED consultation. Contact of a trainee for the sole purpose of arranging a follow-up visit does not require the notification of the medical staff member.

Section VI. Supervision of Trainees Performing Operative and Procedural
Suite Procedures
Operative, therapeutic and diagnostic procedures involving appreciable risk of morbidity or mortality performed by trainees require active Medical Staff member/ involvement. This includes involvement in the pre-procedural evaluation, decision-making, and planning processes, as well as the actual performance of such procedures.
This involvement will be documented in the medical record. Appropriate personal supervision based on the trainee's level of training and experience will be provided during performance of the procedure. At a minimum, this requires Medical Staff member/ availability within the operative/ procedural suite or Health Sciences Center complex (if immediately available within 5 minutes) during non-key portions of the procedure, and physical presence at the patient's bedside in the operating room or procedural suite during key portions of the procedure. The level of supervision provided by the Medical Staff member/ will be documented in the procedural note.

Section VII. Supervision of Trainees Performing Procedures in Locations Other Than OR or PS
Each Program Director will identify those procedures commonly performed in locations other than Operating or Procedural Suites by trainees in that program. This listing will be submitted to the Office of the Associate Dean for GME, and the UNMH Office of Clinical Affairs as stated in Section I of this policy. Procedures common to many training programs would include, but are not limited to, the following:

Endotracheal intubation
Cardioversion/defibrillation
Chest tube insertion
Lumbar puncture
Centeses
Incision and drainage
Wound debridement
Peritoneal lavage
Arterial line insertion
Central venous access
Moderate sedation
Adult medical resuscitation
Pediatric medical resuscitation
Vaginal delivery
Laceration repair
Skin biopsies
Sigmoidoscopy

Each Program Director will regularly review each trainee's experience and training in such procedures as part of that trainee's performance evaluation, and will determine whether that trainee is required to perform each procedure with "direct, physical supervision", immediate medical staff availability or by general supervision by a responsible attending. "Direct, physical supervision" may be performed by credentialed clinical faculty who are licensed independent practitioners on the medical staff of the UNMHSC teaching hospital, or by other trainees who have been approved to perform such procedures with general supervision by an attending.
The procedure specific listing of "minimum level of clinical faculty supervision" for each trainee will be documented and updated at least annually by each GME Program Director, and will be submitted by the GME Program Director to the Office of Clinical Affairs, which will maintain this documentation in a manner that facilitates timely access by other clinicians, consistent with JCAHO guidelines.

Section VIII. Specialty-Specific Additions or Exceptions to This Policy
Any additions or exceptions to the requirements of this Medical Staff Policy that a department/division or specialty may require should be submitted in writing to the Associate Dean for Clinical Affairs and to the Associate Dean for Graduate Medical Education for their review and approval.
In an emergency situation, a trainee may provide immediate care including the performance of invasive procedures (assisted by available Health Sciences Center staff) necessary to preserve life or prevent serious impairment for any patient under the trainee physician's care. The appropriate medical staff member will be contacted and apprised of the situation as soon as is practical and possible, and the discussion will be documented in the medical record.

GRADUATED LEVELS OF SUPERVISION

Houseofficers must be supervised by teaching staff in a way that assumes progressively increased responsibilities throughout the course of training according to their level of education, ability and experience. Each program must have a policy which outlines the type and level of supervision for each level of training in a program which is consistent with the RRC requirements for the particular program. A copy of each department's policy on graduated levels of supervision must be included in their program manual and a copy must be on file in the Office of Graduate Medical Education.

PORT SERVICE/ORGANIZATIONAL AFFILIATION

Houseofficers are represented by the GME Resident Council. The Resident Council is a peer selected organization. The Committee meets the first Tuesday of each month with representatives from all programs. The Resident Council elects membership to participate in the GMEC and the MEC. Houseofficers interested in joining this or other committees should contact the Office of GME.

WORK ENVIRONMENT

The Graduate Medical Education program is educational and is not designed to replace, nor will it result in the replacement of, employees of the training sites nor will it impair existing contract for services. Houseofficers will not take the place of training sites' regular personnel in providing health care services to patients and will not provide full and complete technical and or professional direction of patient care but will participate in such care with the medical staff of each training site.
Locked and monitored call rooms equipped with "panic buttons" are provided at the University Hospital and VAMC. Security is on site at all Health Science Center facilities and the Veteran's Administration Medical Center. Houseofficers are encouraged to call hospital security for escort from facility to facility and to the parking facilities. The University strives to have the work environment be compatible with and conducive to the educational mission of the GME training program. Houseofficers are to be able to be free of harassment while training. The work environment is drug and smoke free. Equipment is available to meet federal compliance standards including OSHA.
Accommodations will be made under the Americans with Disabilities Act. Issues around work environment may be raised without fear of intimidation or retaliation. Concerns should be reported to the Program Director, Resident Council, OEO, or the GME Office. The GME Office has an open door policy and may try to advise or mediate on behalf of the Houseofficers.
This handbook documents current policies as of 1 July 2007. Changes and additions are subject to unionization changes and not clarified at the time of this publication will be posted on the GME web site at http://hsc.unm.edu/som/GME/Residents.shtml

COMMITTEE OF INTERNS AND RESIDENTS

Residents at the University of New Mexico HSC are covered under a collective bargaining agreement. Houseofficers are eligible for membership in the Committee of Interns and Residents.For more information please contact your local union representative or 800 CIR-8877 or www.cirseiu.org