Residency Program Alert, June 2005

Residency Program Insider, June 1, 2005

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Residency Program Alert, June 2005


Orientation programs help ease residents' transition

The call to competency: Teaching essential skills

Teaching and monitoring procedural skills: Challenges for RPDs

A strong policy can help with disruptive residents

ACGME to accredit sleep medicine programs


Orientation programs help ease residents' transition

After four (or more) long, hard years of studying and honing their skills, medical students are ready to transition from being students to physicians. But for many new residents, this transition can be overwhelming. Although some are more prepared than others to enter residency, a comprehensive orientation program can start everyone off on the right foot.

Residency is a time of transition as much as it is a time of learning, and residents need to be acclimated to their new roles and to the expectations and resources at your facility.

"Sometimes residents just want to hit the ground running," says Starla Pathak, OB/GYN residency program coordinator at Tufts-New England Medical Center in Boston, "but there is a lot they need to do before they can get to that point."

Steps to success

Pathak, whose residency program orientation lasts for five days during the end of June, says that although resident orientations differ greatly among hospitals, all residents can benefit from being formally introduced to their new surrounding and responsibilities.

"We . . . take them step-by-step through what is expected of them and how they can succeed," she says.

For residents who have followed their educational path directly from high school to college to medical school, a residency program may be their first true job experience. For others, a residency program will present them with greater responsibility than they have ever held before. This can be a daunting prospect. Orientation programs serve not only as an introductory course in professionalism, but also as an opportunity to let residents know

  • what your hospital expects from them

  • how they will be evaluated

  • how they can contribute positively to patient care

    David Chelmow, MD, FACOG, director of the Tufts-New England Medical Center, explains that his organization's orientation program is divided into the following segments:

  • Social: Faculty buy lunch and mingle with the new residents.

  • Administrative: During this portion of the program, residents are oriented to the program's policies and procedures.

  • Transition: Between the social and administrative sections of the orientation, a half day is set aside to help with the transition from being a student to being a resident. Chelmow finds it helpful to discuss time management skills, competencies, and how to respond to patient emergencies with the residents. He even provides each class with a recommended reading list to help in their transition.

    "We make sure that residents can't go back and say 'I was never told that. I never received that,' " he says, adding that residents are required to sign a form stating that they have covered the orientation materials. "After that, it is up to them to review it."

    Great expectations

    At the University of Texas Southwestern Medical School in Dallas, James Valentine, MD, director of the surgery residency program, holds a 10-day orientation session during which residents must pass an advanced trauma life support class and an advanced cardiac life support course.

    Valentine also details the hospital's goals and objectives, which can be found on the program's Web site. He discusses with residents

  • performance expectations

  • performance evaluation tools

  • the importance of gaining competencies

  • professionalism, including appearance, behavior, and patient interactions

    In addition, the legal risk management team discusses legal pitfalls with residents.

    "The most important thing that should happen during orientation," he says, "is that residents learn what we expect from them. If that is not understood, then we are doing something wrong."

    Tip: Valentine suggests that program directors limit their program materials. If residents are inundated with too much information at once, it will be lost, he says.

    Resident recreation

    Although much of what is covered in a typical orientation session can be mundane (e.g., reviewing hospital policy), not all of it has to be a snore. Allowing residents to interact with each other and more experienced residents can help create a pleasant social atmosphere and shape your program's environment.

    At the Tufts-New England Medical Center, new residents are paired with older residents for a day and go through the rotation they will be covering. "I think more gets transmitted in that one day then in the preceding three days," says Chelmow.

    The social aspect of pairing residents create a friendlier environment and allows people to get together and shake hands before they are gowned and gloved performing a delivery together, he says.

    Taking the social aspect of orientation even further, Kathryn Andolsek, MD, MPH, associate director of graduate medical education at Duke University Medical School in Durham, NC, intersperses her program with a mix of recreational and "ice breaker" activities.

    "Orientation needs to be about orienting to role change," she says. "The transition from medical student to resident, as well as to your institution, program, and community must all be addressed."

    The most popular orientation recreation activity at Duke is a scavenger hunt in which residents must find practical things in the community, she says.

    During the scavenger hunt, residents are divided into teams and asked to find items in a designated amount of time. Some items included specific forms or correct notations of drugs, while others were places they had to visit, such as where to find the local regulator book store, to where residents could take salsa dancing lessons, or where residents could register to vote. To prove they went to each location on the list, residents took pictures on disposable cameras given to them during the orientation. The scavenger hunt allows teams to interact while learning about their new surroundings.

    Note: Orientation for new residents is about more than filling out forms and delineating protocol. It is about helping your residents adjust to a new phase in their life. A successful program will help your residents grow and help your hospital develop competent, happy physicians.

    "Orientation programs for residents need to keep focus on helping make the transition from student to this new situation," says Andolsek. "Otherwise, it becomes simply an employee orientation, and that is not what the hospital should be trying to accomplish."

    New resident orientation

    Editor's note: Below is an excerpt of the orientation policy and procedure followed by the OB/GYN residency program at Tufts New England Medical Center in Boston.

    The orientation phase of training new residents begins on Match Day. Usually, your department will send a welcome letter to your list of matched students the day of or the day after Match Day (mid-March each year). If your chair or program director sends a welcome letter, include your name, telephone number, e-mail address, and fax number in that letter or in a letter of your own.

    In your correspondence to the incoming residents, briefly outline when you expect them to arrive in your department for an official orientation period (usually late June) and what forms and/or information is needed between March and June. Provide any housing information that is available; send names of all newly matched incoming residents to each so they can communicate with one another; send names and beeper numbers of your current residents so the incoming residents can contact them for questions; and finally, send the address, telephone, and fax numbers of your graduate medical education office or hospital administration office (depending on the governing body of your program).

    Determine whether you or your graduate school office, or hospital administration sends salary, fringe benefit, insurance, and visa information to incoming residents.

    Work with your program director to create an orientation schedule. It can be a day, several days, one week, or more depending on your needs. Between Match Day (mid-March) and Orientation (late June) you may want to send the incoming residents the following information:

  • Rotation schedule for the new academic year

  • Vacation/holiday schedule and/or request forms

  • Education conferences for June--in case they move to town early and want to attend

  • Resident research day/graduation activities invitations for current chief residents in case new residents are in town early

  • Special sessions in July (e.g., surgical/anatomy labs, U/S and laparoscopy courses)

  • Upper class residents' address, telephone and pager numbers, e-mail address

  • Request proper name spellings and/or name changes since Match Day for name tags, and sizes for lab coats


    Orientation day or week is a time to present basic administrative, clinic, hospital, billing, occupational health requirements, and other overall information to your new residents including the following:

  • Personal information--insurance, salary and automatic deposit, benefits, spouses' groups, mental health resources, library access, e-mail, IDs, parking permits, mailboxes, immunization records, and visa information.

  • Department and hospital resources--(include the locations) L&D, NICU, OR, ER, libraries, call rooms, cafeteria, medical records. Processes for medical records, vacation, and other primary care rotations. Information such as department locations and contact person for ER, geriatrics, internal medicine, surgery, family practice, and OSHA requirements. Communicate chain of command at each hospital or rotation.

  • Evaluation processes--discuss teaching and evaluation expectations; faculty evaluations of residents; resident evaluations of faculty, usually annually; resident evaluations of medical students; resident evaluations of the program, usually annually; evaluation of CME activities; and evaluation of special education sessions including the orientation program. Use evaluation feedback from orientation program to improve/revise for the following year.

    Sample graduate trainee adverse action process

    (Attachment to contract issued to graduate trainees)

    Applies to all residents and fellows (graduate trainees) engaged in clinical activities.

  • "Adverse action" includes any of the following actions by the hospital/training program: revocation of a right or a privilege; suspension of a right or privilege; censure; written reprimand; imposition of a fine; required performance of public service or of a course of education, counseling or monitoring arising out of the filing of a complaint or a formal charge reflecting on the graduate trainee's competence to practice medicine.

    The following actions are also included only if related to the graduate trainee's competence to practice medicine or to a complaint or allegation regarding any violation of law, regulation, or bylaw: restriction or nonrenewal of a right or a privilege, denial of a right or privilege, resignation, leave of absence, withdrawal of an application or termination or nonrenewal of a contract.

    Adverse action may be taken for due cause, which shall include, but is not limited to, any of the following reasons:

  • professional incompetence, or conduct that might be inconsistent with or harmful to good patient care or safety, lower than the standards of the medical/professional staff, or disruptive to hospital operations

  • conduct which calls into question the integrity, ethics, or judgment of the graduate trainee, or which could prove detrimental to the hospital's patients, employees or operations

  • violation of the bylaws or policies and procedures of the professional/medical staff, the hospital, or [medical school]

  • misconduct in science

  • failure to perform duties

    Allegations of misconduct in science

    Any allegation of misconduct in science pertaining to a graduate trainee shall not be governed by the procedures described here, but shall be addressed and resolved pursuant to the process set forth in the bylaws of the medical/professional staff/applicable policies.

    Initiation of adverse action

    The adverse action process may be instituted by the relevant department chair/service chief. The department chair/service chief shall give written notice of the action or proposed action and the reason for it to the affected graduate trainee. The graduate trainee shall also be notified of his or her right to a hearing as described below, in the event the department chair/service chief recommends one or more of the following adverse actions: revocation or suspension of a right or privilege, or, if related to professional competence or a complaint or allegation regarding a law, regulation or bylaw, the restriction, reduction, or non-renewal of a right or privilege.

    In the event that the adverse action is one that does not entitle the graduate trainee to a hearing, the action of the department chair/service chief shall be the final decision of the hospital/training program in the matter.

    Hearing procedure

  • In the event that the proposed adverse action is one that entitles the graduate trainee to a hearing, the graduate trainee shall also be advised of his or her right to appear with counsel and to introduce witnesses or evidence, subject to the limitations set forth below. The graduate trainee shall have 30 days after such notice to request a hearing. Failure to do so shall constitute a waiver. In the event that the graduate trainee does not make a timely request for a hearing, the action of the department chair/service chief shall be the final decision of the hospital/training program in the matter.

  • If the graduate trainee requests a hearing, the director of graduate medical education shall appoint a hearing committee that shall consist of not less than three persons. One member shall be a graduate trainee. No person who has actively participated in the initiation of the adverse action or proposed action shall be appointed to the hearing committee.

  • The department chair/service chief whose adverse action or proposed action occasioned the hearing or his or her designee shall have the initial obligation to present evidence in support of the action or proposed action. Thereafter, the graduate trainee requesting the hearing shall have the burden of providing by clear and convincing evidence that the action or proposed action was arbitrary or capricious, or unsupported by substantial evidence.

  • The hearing need not be conducted strictly according to rules of law relating to the examination of witnesses or the presentation of evidence. The hearing committee shall consider such evidence as reasonable persons are accustomed to rely on in the conduct of serious affairs. The hearing committee may take notice of any general, technical, medical or scientific fact within the specialized knowledge of the committee and shall decide all other procedural matters not specified in this policy. The graduate trainee may not retry, and the hearing committee and the hospital/training program may rely on and accept as true any finding of fact contained in a final decision by the applicable licensing, certifying or regulatory authority, or by [medical school] in any investigation it conducts, provided the graduate trainee was a party to the proceeding in which the finding of fact was made.

  • The hearing committee shall issue a written report of its findings of fact and recommendations concerning what adverse action(s), if any, should be taken by the hospital. A copy shall be sent to the affected graduate trainee, the director of graduate medical education, the chief medical officer and the relevant department chair/service chief.

    Appellate review

    The graduate trainee or the department chair/service chief may request that the board of trustees conduct an appellate review of the matter, or the board may conduct a review on its own initiative. The board may provide for such review by a board committee appointed for the purpose. If neither the graduate trainee nor the department chair/service chief request appellate review, and the Board does not decide to conduct such review on its own initiative, the decision of the hearing committee shall be the final decision of the hospital/training program in the matter.

    The proceedings of the board of trustees or board appellate review committee shall be based on the record of the hearing, the hearing committee's report, and any written response that the affected graduate trainee and the relevant department chair/service chief wish to make. At the sole discretion of the board of trustees or board appellate review committee, it may also consider new or additional information. If it does so, it shall share this information with the affected graduate trainee, the department chair/service chief and the hearing committee and give them the opportunity to respond.

    The board of trustees or board appellate review committee shall issue its decision in writing. A copy shall be sent to the affected graduate trainee, the director of graduate medical education, the chief medical officer and the relevant department chair/service chief(s). It shall be the final decision of the hospital in the matter.

    Summary adverse action

    The relevant department chair/service chief or hs or her designee with the concurrence of the chief medical officer, if available, may make an immediate summary suspension or take other immediate summary adverse action whenever such action is deemed necessary to maintain acceptable standards of care, safety, operation, integrity or ethics at the hospital/training program. The person effecting such adverse summary action shall send a written report of such action and the reason(s) thereof to the graduate trainee involved, the director of graduate medical education and the chief medical officer within three days of taking action. The graduate trainee may request review of this action within 30 days.

    Upon such request the director of graduate medical education shall appoint a committee to review the summary suspension or other action. Within 14 days of the graduate trainee's request, the committee shall decide whether the action appears to be substantiated by fact and is reasonable and should be continued in force, or whether it should be lifted. The committee shall send prompt written notice of its decision to the graduate trainee involved, the relevant department chair/service chief, the director of graduate medical education, and the chief medical officer.

    Source: Partners Healthcare, Boston. Reprinted with permission.




    The call to competency: Teaching essential skills

    Following the seminal 1999 Institute of Medicine (IOM) report To Err is Human, which showed that nearly 100,000 patients were killed per year in the United States due to avoidable medical error, the quality of patient care came under heightened scrutiny. The report called for raising medical safety standards across the board, including in medical education.

    The ACGME rose to this challenge by introducing its core competency standards that aim to ensure that residents are adequately trained to provide high quality patient care. But defining the competencies was just one part of the solution. The next step, which residency programs are charged with carrying out, is to teach those competencies.

    To help residency programs meet this challenge, Hershey S. Bell, MD, FAAFP, associate dean for faculty development and evaluation at the Lake Erie (PA) College of Osteopathic Medicine, discussed the ACGME's competencies and suggested improvements to the medical education system during the RPA audioconference, "Core Competencies Challenge: Next Steps in Complying and Promoting Quality Patient Care in Graduate Medical Education." (See the editor's note below for more information about this HCPro, Inc., audioconference.)

    Improving the system

    Quality patient care begins with a quality medical education, said Bell. If we don't improve our systems of teaching, we can not hope to truly improve our healthcare system. "In order to resolve the quality issues in American healthcare, we have to look at what we teach and how we teach it," he said. "Unless we reduce the variation in medicine, we run the risk of perpetuating the problem that the IOM brought to our attention."

    The ACGME has traditionally been more concerned with whether hospitals are capable of training residents to be competent than with the residents' competence, Bell said. After all, residency programs must be capable of providing the training necessary for residents to gain competence before a competent physician can be produced.

    To Bell, the competency movement is not about the "art" of medicine, but actual skills, knowledge, and attitudes that physicians must adopt before they have the privilege to display artistry.

    "There are basic fundamentals that all physicians should know before they start to practice," he said. "Every system produces exactly the outcome that it was designed to produce, and medical education is no different."

    Bell said physicians who cover for one another, display tribalism behavior and foster attitudes of superiority, both major blocks to peer review and to improving our system of care. He also argued that medical education fails to effectively address certain aspects of physician practice, such as the following:

  • Lifelong learning: "We teach that at the end of a course you are done, which is not consistent with the competencies."

  • Ambiguity: "We give tests that have one correct answer and drill residents during rounds for one specific piece of knowledge."

  • Collaboration: "Do our learners see us working together on behalf of patient care, or do they see us in isolation?"

    These shortcomings are not consistent with creating quality healthcare, and fully competent physicians must be able to effectively address these issues, Bell said.

    Teaching competency

    Bell pointed to the Association of American Medical Colleges' (AAMC) assertion that patient-centeredness must be hardwired into medical education--an idea that Bell contends is crucial when developing competency.

    "For many years we had a teacher- or physician-centered system, where the star of the show was the great professor with all the knowledge," he says. "We learned from that and developed learner-centered methods . . . But I don't think that is the be-all, end-all, method either. The [residents'] focus really has to be on the patient from the day they enter medical school to the day they leave fellowship. It's all about patient care--that's the hardwiring."

    Educators need to be aware of the messages they send, he said. And sending the message that residents' duties are all about patients the responsibility of the residency programs. "We need to be the role models of competence for residents," he added.

    To help deliver this message, Bell suggested that residency programs keep in mind the Dreyfus model, which is based on the idea that people move through the predictable phases of development--novice, advanced beginner, competent, and expert.

    Based on this model, medical students start as novices and develop into advanced beginners once they obtain skills. Residents must then become competent--the level at which they use their skills for the sole benefit of the patient. Continuing medical education then develops physicians into experts. However, Bell warned that competence is the minimum standard of professional behavior and is not acceptable as an end result. Residency programs need to help residents to transition from doing things to pass a test to doing them because someone's life is on the line--on behalf of patient care.

    Educators and accreditation, licensing, and certification organizations should ensure that students and working professionals develop and maintain proficiency in the following five patient care-focused core areas:

  • Delivering patient-centered care

  • Working as part of interdisciplinary teams

  • Practicing evidence-based medicine

  • Focusing on quality improvement

  • Using information technology

    To effectively teach the above competencies, Bell suggested using a type of formative education known as the FED model, which is as follows:

  • Feedback: "Teaching competency is about being on [residents'] sides," Bell said. "You need to have a 'we can get through this together' attitude. It's not about evaluation but feedback."

  • Encouragement: Residency programs need to have a way of educating--not punishing--when they see lapses in professionalism, he says. An environment of safety and sharing is essential in developing competency. If residents feel safe to challenge things and talk freely about their shortcomings, teachers can adjust the way they teach to be on residents' side of creating patient success.

  • Direction: In an environment where disclosure is rewarded rather than punished, teachers can give better direction about how to improve to achieve competency.

    Competency-based education should be concerned with the success of learners, Bell said. Teaching is giving feedback, and by creating an open environment dedicated to patient care, competency can be achieved by almost anyone.

    Editor's note: For more information about this audioconference, go to or call customer service at 800/650-6787.




    Teaching and monitoring procedural skills: Challenges for RPDs

    In 1988, an intern who had begun her internship at Yale-New Haven (CT) hospital just weeks earlier was asked to insert an arterial line into a patient. She accidentally stuck herself with a needle she was holding at the time of the procedure and, a short time later, contracted HIV. She won a subsequent lawsuit, claiming that she was made to perform a procedure she was not properly trained to do.

    The case has prompted many residency programs to question how residents' procedural skills training is monitored. After all, providing residents with the skills necessary to perform the procedures required of them is the foundation of any residency program. But how are procedures tracked and experience levels gauged? What effects might inequities in technology across residency programs have on training and safety for both residents and patients?

    According to Eric Holmboe, MD, vice president for evaluation research at the American Board of Internal Medicine (ABIM), residency programs are reexamining these issues in light of new technology and services that may limit residents' opportunities to gain the experience they need. "The question is, if we're preparing a resident for practice, what exactly do they need and how do we help them get it?"

    Basic procedural requirements

    Although each specialty maintains certain procedural requirements for residents, there are similarities across practices, Holmboe says. "There is a list of the procedures required for residents in internal medicine programs listed on the ABIM Web site. To begin, [residents] have to be judged competent by their program director in interpreting electrocardiograms, and they have to perform advanced cardiac life support." He lists the following additional procedural requirements for internal medicine residents:

  • Abdominal paracentesis

  • Arterial puncture

  • Arthrocentesis

  • Central venous line placement

  • Lumbar puncture

  • Nasogastric intubation

  • Pap smear and endocervical culture

  • Thoracentesis

    "I suspect that family practice residents would include some of these but would expand [the list], because they also care for kids. For those physicians who also go on to receive subspecialty training, there are additional procedural requirements. For example, in pulmonology, residents learn bronchoscopy," he says.

    Tracking methods vary

    Although the systems used to teach and monitor procedural competence and certification also differ among programs, Holmboe says the ABIM mandates that residents have procedures signed off by their program director. "They are supposed to perform a minimum of three to five director-supervised, successful procedures in each area." However, he adds, "If they attempt a procedure and aren't successful, it theoretically shouldn't count."

    The ABIM also has a tracking system whereby residents fill out a log as they perform the procedures necessary for certification and then must have the RPD or another faculty member sign off on it, Holmboe says. Although the practice of having residents record procedures that are later validated by directors or other faculty is not uncommon, the ABIM has developed a unique Web system for tracking such data.

    The ABIM's "fast-track system" collects a summative evaluation on each resident every year. Once the resident completes the year, the program director goes into the system and rates him or her on a nine-point scale for each of six competencies. The directors also rate residents on their overall moral and ethical behavior and then give them an overall rating on competence. If a resident receives an unsatisfactory rating for the year, it does not count toward certification," Holmboe explains.

    Judging competence and readiness

    Most RPDs would agree that determining a resident's readiness can be a difficult call, and situations like the one at Yale highlight the gaps in standardized protocol for making judgments in training. Holmboe, who trained at Yale but was not there when the incident occurred, says the event had a profound effect on Yale-New Haven Hospital in terms of how it prepares residents with regard to supervision and safety. In addition, it spurred the creation of a rule that Yale residents cannot be asked to do such procedures post-call.

    "Accidents occur when people are tired--post-call. I had an intern in the ICU in the same situation, and he was post-call. I told him not to do an arterial puncture. He was tired and clearly his reflexes were [affected]. He went ahead and did it, and he stuck himself. Nothing happened; the patient did not have any conditions, but he learned a tough lesson," Holmboe says.

    "I think there has been greater attention to safety both for the operator and for the patient regarding procedures. As far a precautions go--fatigue and when you're allowed to do procedures--most residency programs to my knowledge do not allow house staff to do potentially invasive or dangerous procedures post-call, and that's the right answer. They shouldn't be doing them," he says.

    In addition, because of the nature of existing rating systems for certification, it comes down to a judgment call by RPDs or faculty about whether a resident is competent, Holmboe says. "Part of the challenge is that the resources and methods used to teach vary widely from program to program. Some programs are beginning to use simulators for initial work with trainees. Mannequins can be used for central line placement, for example, where residents can learn landmarks," he says. Although the use of such tools is not widespread, it is becoming more common.

    RPDs face new issues in procedural training

    Holmboe describes several additional issues that he believes concern RPDs about procedural training and certification of residents:

  • Fewer opportunities for learning. "The opportunities for residents to perform procedures is becoming a big problem [because] as hospitals have developed new interventional services--particularly in interventional radiology--a number of procedures can now be done more quickly and efficiently by a trained interventional radiologist. [Hospitals] have actually created services that do these procedures, leaving fewer opportunities for the house staff," he says.

    For example, one Boston hospital uses a procedure service, whereby an experienced attending who has done a great deal of certain procedures works with the house staff 24 hours a day, he notes. Although such systems may be efficient, Holmboe says they further limit the number of opportunities for residents to learn.

    "We know . . . that the number of these procedures being done by practicing interns has dropped dramatically in the past 20 years," he says.

  • Effects of technology. Another issue is technology, he says. "We know it's safer to do some procedures under ultrasound guidance, [but] most of the internal medical residents don't know how to do ultrasound," he says. In addition, new devices, such as the percutaneous intravenous catheter line, which makes it unnecessary to put a direct stick into the subclavian or internal jugular artery, results in fewer opportunities for residents to learn certain procedures.

    "From a patient safety perspective, there is also growing evidence that residents ought to be learning some things on simulators or virtual reality [programs] . . . However, that technology can be expensive, it's not widely available, and that creates challenges for some residency programs," he adds.

  • Financial constraints. Size and location of residency programs also may tie to financial and educational constraints with procedural training, according to Holmboe. "There are certainly issues around affording simulators, mannequins, and other technology to teach residents before they touch a live patient." Smaller programs may not be able to afford the technology."

  • Teaching methods vary widely. The lack of standardized teaching methods also concerns RPDs. Holmboe notes the need to reexamine what skills are truly pertinent to residents. "Which of the procedures are truly core? Should every resident be learning all these procedures and doing these minimum numbers? Again, from a patient safety perspective, does that make sense?" he says.

    Although such questions are being asked at hospitals around the country, Holmboe says little has changed. "My impression, having been in several different programs over the past 10 years, is that there has been a lot more attention to the issues of performance of procedures--but I don't think the requirements as far as numbers for minimal competence have really changed all that much," he says.




    A strong policy can help with disruptive residents

    Residency programs are training grounds for some of the most dedicated and capable professionals in the United States. Residents are usually eager participants in developing competency, improving skills, and learning the ropes of the hospital setting.

    However, all too often residency programs are faced with a resident who exhibits disruptive behavior that threatens the program's learning environment. Having an effective policy in place and knowing how to deal with disruptive behavior in your residency program can help eliminate a problem before it grows.

    According to standard E-9.045 of the American Medical Association's (AMA) Code of Ethics, "Personal conduct, whether verbal or physical, that affects or potentially may affect patient care negatively, constitutes disruptive behavior. This includes, but is not limited to, conduct that interferes with one's ability to work with other members of the healthcare team."

    Develop a policy

    Disruptive behavior can take many forms, from repeatedly clashing with peers and patients, to failing to gain competency in areas necessary to deliver high quality patient care. To effectively handle disruptive situations, the ACGME requires residency programs to implement clear policies and procedures.

    According to the ACGME's institutional requirements, GMECs are responsible for monitoring and advising all aspects of residency education. The GMEC is also responsible for ensuring that each residency program establishes formal criteria and processes for the selection, evaluation, promotion, and dismissal of residents.

    Similarly, the AMA calls on medical staffs to create a policy to address disruptive residents. It suggests that such a policy should

  • describe the types of behavior that will prompt intervention

  • provide a channel for reporting and recording disruptive behavior

  • establish a process to review or verify reports

  • establish a process to notify reported physicians

  • include the means of monitoring post-intervention improvement

  • provide clear guidelines for the protection of confidentiality

  • ensure that individuals who report disruptive behavior are protected

    The AMA also requires that residents accused of disruptive behavior are allowed to defend their actions. Its requirements state that residency programs must provide residents with fair and reasonable written institutional policies about and procedures for grievance and due process. These policies and procedures must address

  • academic or other disciplinary actions taken against residents that could result in dismissal, nonrenewal of a resident's agreement or other actions that could significantly threaten a resident's intended career development

  • adjudication of resident complaints and grievances related to the work environment or issues related to the program or faculty

    Put policy into action

    Simply doling out punishment is not a constructive form of rehabilitation. Disruptive residents need to be told what they are doing wrong so they can correct the behavior. Suspension of responsibilities or privileges should be a last resort, according to the AMA.

    "Some students need more help than others," says Charles Ferguson, MD, surgical residency director at Massachusetts General Hospital in Boston. Ferguson says he meets with residents to get their view of the issue and to discuss how their actions are perceived by others. "If it become a recurrent problem and is disruptive to the point of causing a major issue in the program, I would follow our adverse action policy." (See below to review the policy).

    Ferguson stresses that his main goal is to help the resident resolve his or her disruptive issues, even going as far as providing professional psychological help if necessary.

    James Valentine, MD, RPD at Southwestern Medical School in Dallas, agrees that institutions dealing with disruptive residents should focus on rehabilitation, not punishment.

    "Disruptive residents generally receive a letter of warning, followed by a period of probation, usually six months, in which we work with them to . . . rectify their problem. If the problem persisted, we would consider dismissing them or not renewing their contract, but we have rarely had to do this," he says. "In most cases, we have been able to get residents off of probation by making them see how their actions are perceived through informal counseling or mentoring."

    Keep track of the process

    Documentation is crucial to ensuring that your disruptive resident policy remains transparent and litigation-free. All steps in dealing with a disruptive resident-- from the initial complaint, to the final action--should be recorded in his or her file. The resident in question should also be notified of each step recorded.

    "It should not be a subtle process," says David Chelmow, MD, FACOG, OB/GYN residency director at Tufts Affiliated Hospitals in Boston. "To ultimately terminate somebody, you need to have an extremely clear paper trail. If it looks like things are getting to that point, we enlist our hospital attorneys and risk management group to help with mediation and to make sure that our paperwork is in order. Documentation is critical."

    Tip: Chelmow suggests that programs make their disruptive action policies known and readily available to residents. His policy is given to residents at the start of their program as part of their officer handbook and then posted on the Web.




    ACGME to accredit sleep medicine programs

    On July 1, the ACGME will accept applications from sleep medicine fellowship programs seeking accreditation. Although the first batch of approvals will occur at a later date, the ACGME states that "programs accredited in the initial phase will have an accreditation effective date of July 1, 2005."

    This step follows the ACGME's 2003 approval of the American Academy of Sleep Medicine's (AASM) one-year fellowship training programs in sleep medicine and the accreditor's June 2004 approval of program requirements for such fellowships.

    In addition, the American Board of Sleep Medicine (ABSM) has applied for recognition from the American Board of Medical Specialties (ABMS). If approved, it would enable the ABMS to offer a multidisciplinary examination in sleep medicine and require applicants to complete an ACGME-accredited training program.

    Because ACGME has not finalized the application for accreditation, however, both the AASM and the ABSM stress that the establishment of a new ABMS exam is not yet certain and that eligibility requirements and grandfathering allowances have not been finalized. However, the two organizations anticipate that fellows currently in a sleep-training program would be grandfathered in, qualifying them to sit for a new ABMS examination.

    A significant step for the specialty

    "ACGME recognition and the establishment of a certification exam by ABMS represent an enormous advancement for our field," said AASM President Michael J. Sateia, MD.

    According to Sateia, "the AASM will be presenting a program for training directors at the Associated Professional Sleep Societies meeting in Denver in June that is designed to introduce them to the ACGME program requirements and to provide practical advice about the process for accreditation."

    A lengthy road to approval

    Sateia says it took almost five years from the time the groundwork was laid until the ACGME granted final approval of the sleep medicine program requirements. Although the AASM initiated the accreditation process and took the lead in preparing the application and supporting materials required by the ACGME, the association received invaluable support from the ACGME along the way.

    He recounts that the AASM took the following steps on its way to accreditation:

  • Application preparation and review period

  • Approval of the application

  • Drafting and preparation of program requirements

  • A formal review and response period for the requirements

  • Finalization of the program requirements by the ACGME

  • Appointment of a sleep medicine subcommittee

  • Preparation and distribution of the program information forms

  • Launch of the application process

    Note: Representatives from a number of specialty societies participated in various aspects of the process and provided general support of the accreditation efforts. "The AASM also enjoyed support in establishment of the certification examination in sleep medicine from the sponsoring specialty boards of internal medicine, pediatrics, otolaryngology, psychiatry, and neurology. Many people have labored long and hard to bring this about . . . We look forward to a very bright future for our specialty," Sateia says.

    AASM will suspend accreditation of fellowships

    Notably, the AASM will begin phasing out its accreditation process as a result of the ACGME's pending accreditation of sleep medicine programs. "The AASM is hopeful that the 53 existing AASM-accredited fellowship training programs will become ACGME-accredited fellowship training programs within the first two years." He also expresses hope that as many as 75-80 programs will be ACGME-accredited within three to five years.

    Note: There are currently 53 AASM-accredited sleep medicine fellowship programs in the United States. A complete list of AASM-accredited programs is listed at

    Sateia notes that, to qualify for application to the ACGME for accreditation, a facility must

  • be part of an academic program

  • maintain an accredited sleep center

  • have established, ACGME-accredited training programs in the sponsoring specialty

  • have board-certified academicians who are responsible for the supervision of trainees

    The requirements also delineate the specific aspects of didactic and clinical education required of sleep medicine fellows. In addition, as with all ACGME-accredited programs, numerous standard requirements also must be met.

    Initial phase of applications

    According to the ACGME, programs that want to be considered in the initial phase of sleep medicine applications must submit their forms to the its office no later than June 30 for accreditation effective July 1. Applications for sleep medicine fellowship programs, as well as the complete listing of program requirements, are available on the ACGME's Web site,

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