Vascular Surgery Residency Program2008 - 2009

Section I: Vascular Surgery Residency Program Introduction

Program Requirements & Educational Training Program Overview

The goal of the Vascular Surgery Training Program at the Duke University Department of Surgery is to prepare the trainees to function as qualified practitioners of vascular surgery at a high level of competence expected of a board-certified specialist. The program provides educational resources for the development of proficiency in the diagnosis and treatment of diseases of the arterial, venous and lymphatic circulatory systems exclusive of those components intrinsic to the heart and intracranial vessels. In addition to developing the clinical skills listed above, the Vascular Surgery Residents (“VSRs”) will develop skills with respect to interpersonal and communications skills, professional behavior and delivery including ethical practice, and the systemic nature of health care in relation to Duke University Health System. VSRs will be provided adequate time and sufficient facilities for study and be assured of a rotation schedule that provides an equivalent opportunity for each. Service responsibilities will not detract from educational activities.

Section II: Vascular Admissions/Selection Criteria

Selection for a residency position in vascular surgery is based on a number of factors. Those factors include:

1. As an Independent Program, as described by the ACGME, vascular surgery education in the independent format for the Duke Vascular Surgery Residency, the incoming vascular surgery resident must:

a. Successfully complete a general surgery residency program accredited by the ACGME. During the general surgery residency, up to 1 year of credit toward a vascular surgery residency can be achieved as long as there is demonstration of 12 months of appropriate vascular surgery education. This would shorten the subsequent required vascular surgery residency education to 2 years instead of 3 years. In this format, the residents must complete, at minimum, the last two years of vascular surgery education at the same institution.

2. Eligible for Board Certification from the ABS at the start of Residency – July 1, respectively

3. Graduation from an ACGME Accredited Program in General Surgery, or a Subspecialty that would further your professional career with a Vascular Surgery Residency

4. Completion of all USMLE Requirements for Licensure5. Three Letters of Recommendation from ABS Board Certified Surgeons 6. Professional Statement of Goals and Career Objectives for the reason a candidate wants

to be a Vascular Surgery Resident at Duke7. Completed Application to the Program Director no later than February 15 annually8. Personal interview with Program Director and Faculty members upon completion of initial

review for admission – all materials must be up-to-date prior to interview for consideration or the residency will be denied (if graduating from a residency program, you must be eligible for ABS by the time you enter our Vascular Surgery Residency –

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verification must be in the Residency Office no later than 10 days prior to the first day of orientation).

Section III: Specific Vascular Policies and Schedules:

The Vascular Surgery Residency Work Environment and Supervisory Lines of Responsibility

The Duke University Residency in Vascular Surgery is designed to provide consistent and outstanding didactic, clinical and technical education to the Vascular Surgery Resident. Attaining these goals enables the Resident to effectively provide superior health care to patients.

In addition, the Duke Residency in Vascular Surgery prepares the Resident to independently manage the preoperative, operative, and postoperative care of patients with arterial, venous and lymphatic disease(s).

A. Resident Appointment, Reappointment, Promotion & Dismissal

All Employment Agreement letters are for one year. Contracts are prepared and signed by the Program Director, Resident and Designated Institutional Officer (DIO).

Completion of the program is based on several factors. Those factors include:

a Outcome assessment through various formatsb Operative case experiences in both open and endovascular

surgical arenasc Out-patient imagingd Accurately and timely log all surgical case operative experiences via the

ACGME case log entry system and ensuring that the minimum requirements are met before the end of the residency.

e Formal and informal evaluations from Program Director and faculty membersf Commitment and interest in scholarly activitiesg Commitment and interest in teaching of junior residents, medical students

and other health care providers

In addition, at any time during the Resident’s training, a written or verbal report to the Program Director of inappropriate behavior or actions by the Resident is received, it will be discussed with him/her. After investigation and evaluation of the allegations appropriate actions may be taken which may include, but are not limited to: advice, warnings, counseling, psychological support, change in rotations, or recommendation to the Institution that the Resident be given a leave of absence or be dismissed using the appropriate due process policies of Duke University Hospital.

Reappointment and/or graduation for individual Residents depends upon their ongoing clinical skills evaluation by each attending surgeon, evidence of ethical behavior, and professional characteristics of an individual capable of independent practice in vascular surgery.

If it is decided that the Resident should take a leave of absence or be dismissed, the Resident, the Chairman of the Department and the DIO will be notified in writing. Final decisions are subject to Duke University GME House Staff policies and shall always be in writing.

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Vacation, Leave of Absence and Academic Conference Policies**

VSRs will be allotted two (2) one week paid vacations, which must be scheduled at least one month in advance. In addition, VSRs are permitted to attend one meeting per academic year. All travel must occur in the U.S. VSRs are encouraged to be academically productive and will be granted additional meeting time for approved meetings where they have had an abstract accepted. VSRs should check with the Program Director prior to submitting abstracts to determine if the meeting is an approved meeting.

Maternity / Disability Leave: 6 weeks leave following an uncomplicated delivery (8 weeks following a Caesarean section). The Family and Medical Leave Act (FMLA) entitles a covered employee to take up to 84 days of unpaid leave in a 12-month period for the birth or adoption of a child, or the "serious health condition" of the employee or the employee's child, spouse, or parent.

Paternity Leave: 5 days of paid leave

Absences in excess of the ABS Requirements for Vascular Surgery must be made up by extension of the fellowship training.

**Fellows requesting any type of leave are required to notify the Program Director as early as possible to arrange for adequate coverage during your absence. These policies are subject to change without notice.

Overall Policies for Duke University Hospital and Medical Center (Please see the Duke University Hospital GME Policy Manual and Benefits Guide for Further Details)

All Duke University Hospital graduate medical trainees will receive compensation according to the Graduate Medical Education training level.

Additionally, Residents are required to comply with the Federal Drug Free Workplace Act – form more information please refer to this website at:

http://www.dol.gov/elaws/drugfree.htm.

Also outlined in the benefit guide is the Duke University Policy for House Staff Grievance and the Duke University Harassment Policy.

All trainees in the Vascular Surgery Residency are required to have a full an unrestricted North Carolina State Medical License and must be registered with the North Carolina Medical Board.

Duke University is committed to maintaining a bias-free environment for all members of the University community including freedom from harassment. Harassment is defined as the creation of a hostile or intimidating environment in which verbal or physical conduct because of its severity and/or persistence is likely to interfere significantly with an individual's work.

Sexual coercion consists of unwelcome sexual advances, request for sexual favors, or other verbal or physical conduct of sexual nature when submission of such conduct is made explicitly or implicitly a term or condition of an individual's employment or submission to or

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rejection of such conduct is used as a basis for employment decisions affecting an individual.

Such conduct has the purpose or substantially interfering with an individual's work performance or environment. The conduct alleged to constitute harassment under this policy should be evaluated from the perspective of a reasonable person similarly situated to the complainant and considering all the circumstances.

Supervision Policy

The goal of our educational program is to provide an environment that allows for the full development of skills as described above. This requires a balance between observation and performance both in the operating room, on the ward, and in the out patient setting. This balance is determined by the individual attending, Resident’s skills and patient preferences. It is expected that during this program a graduated process of supervised performance will occur.

A.  Definitions:

Attending Physician: A licensed independent practitioner who holds admitting and/or attending physician privileges consistent with the requirements delineated in the Bylaws, Rules and Regulations of the Medical Staff of Duke University Hospital or with the requirements delineated in the governing regulations of the assigned and approved off-site healthcare entity.

Trainee: A physician who participates in an approved graduate medical education (GME) program.  The term includes interns, residents, and fellows in GME programs approved by the Duke Institutional Committee on Graduate Medical Education.  (A medical student is never considered a graduate medical trainee.)

B. Attending Physician Responsibilities:

In hospitals participating in a professional graduate medical education program(s), the medical staff has a defined process for supervision of each participant in the program(s) in carrying out patient care responsibilities. Such supervision will be provided by an attending physician with appropriate clinical privileges, with the expectation that the graduate medical trainee will develop into a practitioner who has the knowledge, skills and experience and abilities to provide care to the patients with the disease states applicable to his/her training program.

The medical staff has overall responsibility for the quality of the professional services provided by individuals with clinical responsibilities.  In a hospital, the management of each patient's care (including patients under the care of participants in professional graduate medical education programs) is the responsibility of a member of the medical staff with appropriate clinical privileges.  Therefore, the medical staff assures that each participant in a professional graduate medical education program is supervised in his/her patient care responsibilities by a member of the medical staff who has been granted clinical privileges through the medical staff process.

The position of attending physician entails the dual roles of providing quality patient care and effective clinical teaching.  Although some of this teaching is conducted in the classroom setting, the majority of it is through direct contact, mentoring, and role modeling

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with trainees.  All patients seen by the trainee will have an assigned attending physician. The attending physician is expected to:

Exercise control over the care rendered to each patient under the care of a resident, either through direct personal care of the patient or through supervision of medical trainees and/or medical personnel.

Document the degree of participation according to existing hospital policies. Effectively role model safe, effective, efficient and compassionate patient care and

provide timely documentation to program directors required for trainee assessment and evaluation as mandated by the program’s Residency Review Committee  (RRC), where applicable.

Participate in the educational activities of the training programs, and as appropriate, participate in institutional orientation programs, educational programs, performance improvement teams, institutional and departmental educational committees.

Review and co-sign the history and physical within 24 hours, Review progress notes, and sign procedural and operative notes and discharge

summaries.

In general, the degree of attending involvement in patient care will be commensurate with the type of care that the patient is receiving and the level of training, education and experience of any medical trainee(s) involved in the patient’s care. 

The intensity of supervision required is not the same under all circumstances; it varies by specialty, level of training, the experience and competency of the individual trainee, and the acuity of the specific clinical situation.  An attending may provide less direct personal care of a patient seen for routine care when supervising a senior level trainee, and may provide more direct personal care of a patient receiving complex care when supervising a junior level trainee. An Attending physician may authorize the supervision of a junior trainee by a more senior level trainee based on the attending physician’s assessment of the senior level trainee’ experience and competence, unless limited by existing or future hospital policies, such as the use of lasers.

Medical care teams frequently are involved in the management of patients and many different physicians may act as the attending physician at different times during the course of a patient’s illness.  However, within the medical care team, the faculty attending physician must provide personal and identifiable service to the patient and/or appropriate medical direction of the trainee and when the trainee performs the service as part of the training program experience. 

The following are specific instances in which involvement of the attending physician is required

For Inpatient Care:

Review the patient’s history, the record of examinations and tests, and make appropriate reviews of the patient’s progress;

Examine the patient within 24 hours of admission, when there is a significant change in patient condition, or as required by good medical care;

Confirm or revise the diagnosis and determine major changes in the course of treatment to be followed;

Either perform the physician’s services required by the patient or supervise the treatment so as to assure that appropriate services are provided by trainees or others, and that the care meets a proper quality level;

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Be present and ready to perform any service that would be performed by an attending physician in a non-teaching setting.  For major surgical or other complex, high-risk medical procedures, the attending physician must be immediately available to assist the trainee who is under the attending physician’s direction;

Make decision(s) to authorize or deny elective and urgent admissions,  discharge from an inpatient status or release from observation or outpatient status

1. When an in-patient is to be transferred to another service, the attending physician or a designee of the referring service shall inform the patient of the change in service as soon as possible prior to the transfer.  The receiving service shall assign a new attending physician who shall accept responsibility for patient care. Confirmation of the transfer to another level of care or acceptance of patients in transfer is the responsibility of the attending physician.

2. An attending physician’s decision shall be required to authorize an in-patient’s discharge, or release from observation or outpatient status.

Issue all “No Code” or DNR orders.  “No Code” or DNR orders shall be issued only by an attending physician.  In extenuating circumstances the order may be issued by the attending physician verbally, by telephone, while the responsible registered nurse and trainee listen to and witness the verbal-telephone order; such verbal-telephone order shall be signed within twenty-four hours of issuance by the attending physician.

Assure a completed history and physical and a completed, appropriately signed, and witnessed consent form is placed in the patient’s record prior to the performance of an operative or invasive procedure involving substantial risk.

Assure appropriate documentation is made immediately in the medical record when a procedure is completed on a patient  

For Outpatient Care:

The extent and duration of the attending’s physical presence will be variable, depending upon the nature of the patient care situation, the type and complexity of the service. The responsibility or independence given to trainees depends on their knowledge, manual skills and experience as judged by the responsible attending physician. The attending physician supervisor must be designated and available to all sites of training in accordance with Accreditation Council for Graduate Medical Education (ACGME) institutional and program requirements and specific departmental policies.

C.  Graduate Medical Trainee Responsibilities:

Each graduate medical trainee physician must meet or may exceed the qualifications for appointment to Associate member of the Medical Staff of Duke Hospital, whether in an Accreditation Council for Graduate Medical Education (ACGME) or non-ACGME graduate medical education program.

Graduate medical trainees are expected to

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Participate in care at levels commensurate with their individual degree of advancement within the teaching program and competence, under the general supervision of appropriately privileged attending physicians

Perform their duties in accordance with the established practices, procedures and policies of the institution and those of its programs, clinical departments and other institutions to which the trainee is assigned.

Adhere to state licensure requirements, federal and state regulations, risk management and insurance requirements, and occupational health and safety requirements.

Fulfill all institutional requirements, such as attending the Graduate Medical Trainee Orientation, maintaining BLS/ACLS certification, completing required instructional exercises, as detailed in their annual Agreement of Appointment.

The Vascular Surgery Residents and General Surgery Chief Residents are never assigned to the same service nor do they have the same responsibility for the patients on his/her service.

The Vascular Surgery Resident is responsible for the preoperative management of the patients with the help of the junior residents assigned to the Vascular Service and nurse practitioners under the supervision of the attending surgeon. The VSR will have first seen the patient in the surgical outpatient experience/clinic, Emergency Room, attending surgeons’ office, or upon admission to the hospital. He/she is assigned to those operations where he/she can assume the most senior role commensurate with his/her experience and abilities. Preoperatively, a dialogue is established between the VSR involved and the responsible faculty member to determine the specifics of therapy and the options for management. No patient can be taken to the operating room for any surgical procedure without the faculty member present in the operating room. Anesthesia cannot be induced until the faculty member has related to the patient. The faculty member must remain physically within the operating room area throughout the entire procedure until the patient is transferred to the post-operative care unit. All attestation sheets are signed by the faculty member of record, as are the operative notes. Under the supervision of the attending surgeon, the VSR is responsible for the postoperative in-hospital management of the patient and when possible will see the patient during postoperative visits.

The faculty members of Vascular Surgery share the responsibility of “on call.” There is one faculty member responsible each day for consultation and emergencies at night and on the weekends. Faculty presence in the hospital can be requested by the VSR at any time, and faculty attendance is mandatory for any operative procedure.

Vascular Surgery Fellow and Attending On-Call Schedules are made monthly, are available at all times, and are provided to the following:

Page officeAnswering serviceEmergency roomAdmitting officeAll Vascular attending(s)All Vascular ResidentsAll Interventional radiologist attendings and residentsNurses on Vascular serviceVascular ClinicGeneral Surgery Residency Office

This policy is consistent with the Duke University Hospital GME Supervision Policy. Please refer to the GME House Staff Manual and Benefits Guide at:

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http://www.gme.duke.edu/hsmanual/GME%20Manual%206-3-2005.pdf

Grievance Policy for House Staff*

The purpose of the Grievance Policy is to provide an additional, nonexclusive system of communication, exchange of information, and confidential concerns of individual Graduate Medical Trainees regarding their educational programs.  Graduate Medical Trainees may contact their Fellow or faculty representative on the Institutional Committee for Graduate Medical Education, who has full access to the committee and any ad hoc committees necessary to explore and address Trainee’s concerns, complaints, or grievances not covered under the Corrective Action and Hearing Procedures for Associate Medical Staff of Duke University Hospital. Failure to resolve these issues at this level can be referred, in writing, to the Director of Graduate Medical Education (Designated Institutional Official) for further consideration and final resolution. 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.

ICGME Approval: August 12, 1998ECMS Approval: September 21, 1998

*The Grievance Policy is replicated verbatim from the 2008 GME Trainee Manual.

Impairment Policy

I. Background

Graduate Medical trainees are at risk for all the health problems seen in the general population and are expected to function at a superior level as trainees in medicine and as health care providers. The supervision of their care provision and evaluation of their learning is complicated by the fact that their supervisors and evaluators are health care providers.   Role confusion can occur which interferes with both clear evaluation of performance and appropriate health care intervention for the trainee.

The policy, procedure and training program below are designed to enhance the quality of the Duke Graduate Medical Education program by providing guidance for handling issues of impairment of performance.

II. Policy

The Duke Office of Graduate Medical Education will address all cases of impaired performance among trainees in order to assure the safety of trainees and the safety of patients and co-workers. Impairment may result from physical and mental/behavioral health problems.  Services to support confidential and constructive intervention to resolve impairments will be made available.

III. Procedure

Supervisors of trainees will utilize the impairment checklist to evaluate trainees as appropriate. Concerns arising out of the evaluation will be brought to the Graduate Medical Education Program Directors (Program Directors).

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Performance and/or behavioral concerns will be addressed with the trainee. Trainees will be encouraged to utilize the Personal Assistance Service (Employee Assistance) or Dean of Medical Education Counseling on a voluntary basis.    PAS is a free and confidential resource available to house staff and immediate family members. PAS provides assessment, short-term counseling and referral.  Clear expectations for improvement will be established in writing and evaluation will occur periodically.

Impairment concerns will be reviewed with Duke Employee Occupational Health (EOH) and/or the NC Physicians Health Program (NCPHP). With the concurrence of EOH and/or NCPHP the trainee will be referred by Program Director for mandatory evaluation and removed from patient care responsibilities.

EOH and/or NCPHP will evaluate the trainee and make recommendations for return to work to the Program Director and the Office of Graduate Medical Education.

Any trainee removed from any aspect of their training program for any reason must be returned to work through EOH and the Office of Graduate Medical Education must be notified.

IV.    Guidelines

Most trainees are eager, productive learners and colleagues; however, some experience difficulties in learning and/or performance and may demonstrate behaviors that are inappropriate.

How these issues are addressed can have a substantial effect on a trainee's career and Duke's mission as an educational institution. The following suggestions can enhance successful resolution:

Consult with PAS.  PAS is also a consultative resource for supervisors of trainees regarding how concern might be addressed.

Do not ignore, "push under the rug", or dismiss as a "bad day" inappropriate behavior. Address issues promptly to improve the outcome.

Document behaviors and incidents that create concern. Request co-observation with a colleague when possible.

Do not try to diagnose, do not argue. Rather, discuss concerns i.e. specific behavioral terms and expectations for improvement.

Offer and encourage trainee to use available resources.

Establish clear, written expectations for improvement and an evaluation plan.     

V. Manifestations of Impairment

Dramatic decrease in performance Persistent or repetitive absenteeism/lateness

Mood swings

Interactional difficulties

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Patient/colleague complaints

Disruptive behaviors

Medications missing from work area

Disappearances from work

Disordered thought

Alcohol on breath, other stigmata of drug use

Diminished physical appearance

VI.    Resources

Personal Assistance Service

2200 West Main Street, Ste 700

Durham NC 27705

919-416-1PAS (416-1727)

Personal Assistance Service (PAS) is the faculty/staff assistance program of Duke University. The staff of licensed professionals offers assessment, short-term counseling, and referrals to help resolve a broad range of personal, work, and family problems. There are no charges for any service provided by the PAS staff.

Employee Occupational Health Services

2200 West Main Street, Ste 600A

Durham NC 27705

(919)684-3136/286-6000

Employee Occupational Health (EOH) provides evaluation of health issues that involve the safety of the work force and the safety of patients, visitors, and products of Duke University. EOH services faculty and staff.

The North Carolina Physicians Health Program

The North Carolina Physicians Health Program (NCPHP) was established in 1988 by a collaborative effort of the North Carolina Medical Society and the North Carolina Medical Board to help impaired physicians. The NCPHP is set up to identify troubled physicians, get them the appropriate treatment and return them to the productive practice of medicine' Impairment can be caused by alcoholism/chemical dependency, psychiatric disorders, disruptive behavior, professional sexual misconduct and severe stress. Anyone who feels that they themselves or a colleague possibly has an impairment problem can seek assistance anonymously and confidentially by calling the NCPHP at 1- 800-783-6792.

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B. Rotation Schedule(s) and Information

VASCULAR SURGERY RESIDENCY ROTATION STRUCTURE

YEAR 1

6 months 3 months 3 monthsDuke university Research ir

YEAR 2

3 months 1 month 2 months 6 monthsIR Vascular non-

invas labelective (hem, card, ir, research or imaging)

DUKE UNIVERSITY

Duke University Vascular Service Rotation: The first six months of the year is spent on the busy clinical service at Duke North where the VSR actively participates in the management of a wide spectrum of major vascular cases. The vascular service consists of the VSR, a fourth year/SAR2 (clinical) resident, a second year/JAR and an intern, with the VSR in charge of the service. This insures that each senior resident can participate in both in-patient and out-patient activities.

During the Duke University Vascular Service Rotation, the VSR will be exposed to the full spectrum of in-patient vascular disease and their operative and non-operative management including cerebrovascular disease, aortic and other aneurysms, peripheral arterial occlusive disease, venous thromboembolism and visceral ischemic syndromes. Involvement, participation and proficiency in the care of the vascular patient with these disorders will progress from demonstration to mastery during the course of the residency.

The program provides an educational environment that allows the VSR to develop competencies in patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems based practice. They are expected to be compassionate in patient and family relationships, accurate in the interpretation of tests, knowledgeable in the choice of treatment, skillful in performing interventions (both open and endovascular), cooperative with ancillary services, organized in the overall management and in control during emergencies. They must possess pertinent biomedical knowledge; understand new and evolving clinical knowledge as well as the epidemiology of the various disease processes. An understanding of the statistical methodologies of clinical trials is expected as well. Communication skills are developed during the presentation of clinical information in the conference setting.

Interventional Radiology Rotation: During the final two months, the goals of the Interventional Radiology rotation are 1) to understand the principles of diagnostic percutaneous interventions, 2) to understand the principles of radiation safety, 3) to become familiar with the various types of radiological contrast agents, 4) to achieve competence in percutaneous arterial access via retrograde femoral, antegrade femoral, contralateral “up and over” femoral and antegrade brachial approaches, 5) to achieve competence in venous access via femoral, subclavian, bracilic, popliteal and jugular veins, 6) to develop competence in balloon angioplasty of iliac, renal and superficial femoral artery stenoses, 7) to understand and employ arterial and venous stents in appropriate clinical circumstances, and 8) to develop expertise in evaluating patients for endovascular aortic grafting. These

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skills will be complementary to those developed in the previous three rotations, and will be learned from the interventionalists’ perspective.

Diagnostic Imaging

Vascular Non-invasive Laboratory Training: A critical part of the vascular surgeon’s practice is the vascular non-invasive laboratory. The trainee will:

Acquire knowledge of ultrasound physics as it applies to current established techniques of vascular diagnosis. The trainee will become familiar with all major forms of instrumentation associated with routine noninvasive vascular diagnosis, including continuous-wave and pulsed Doppler, and Color-flow duplex ultrasound scan technology.

Learn to perform, supervise, and interpret the results of noninvasive testing modalities performed for major non-cardiac vascular disorders.

Learn the applications of noninvasive vascular testing in the development of practice guidelines, surveillance, outcome assessment, and clinical research in vascular disorders.

Learn the administrative skills necessary to serve as a medical director of a noninvasive vascular laboratory.

It is expected that each would qualify to take the RVT examination although RVT certification is not required.

MRA/CTA: VSRs will receive education in the special diagnostic techniques for the management of vascular disease (angiography, MRA, CTA, CT, MRI and MRA) throughout the course of their residency. This will be accomplished through formal rotations, conferences and formal settings. While rotating on IR, VSRs will receive formal training from radiologists in angiography, CTA, CT, MRA and MR. During Friday concerns, additional didactic learning will take place through the regular participation of radiologists in this conference.

General Principles: The VSRs are expected to create a portfolio of clinical information regarding the variety of patients seen including demographic information and relevant images pre and post treatment whenever possible. Our environment emphasizes respect and sensitivity for patient demographics as well as responsiveness and responsibility to their needs. VSRs are expected to understand the cost implications of care and concepts of resource allocation. VSRs are instructed on the variety of economic systems that effect the delivery of care as well as the CPT coding system that determines compliance and reimbursement. VSRs are expected to analyze their outcomes in a systematic way and provide a one summary report within 8 months of starting that confirms their understanding of Systems-Based Practice and Practice-Based Learning and Improvement in Vascular Surgery. Access to on-line medical information is provided.

Our program emphasizes one-to-one relationships between faculty and VSRs. There is a daily assessment of cognitive knowledge and patient care skills. There is constant feedback from Nurse Leaders on our clinical floor and our nurse practitioner. Our weekly Friday conferences allow for an evaluation and testing of cognitive knowledge and communication skills through didactic lecture, oral examination, and supporting documentation. Our daily working rounds allow for evaluation of patient care and family interaction.

Adverse outcomes of all patients are discussed and documented at Quality Assurance meetings. Additionally, a Death and Complications (M & M) conference is required weekly of all faculty and house staff/fellows in General Surgery (including the Vascular Surgery faculty and residents). This conference is an integrated approach to practice-based learning and improvement as well as patient care and medical knowledge.

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In addition to the Death and Complications conferences, the faculty and key nursing personnel are asked to objectively report their impressions of the VSRs’ progress on an extensive evaluation form quarterly. The faculty has an opportunity to discuss these evaluations at quarterly meetings. The program director meets with the VSRs to discuss the faculty evaluations quarterly and on an ad hoc basis when deficiencies or problems are noted.

VSRs are expected to take the qualifying and certifying examination of the Board of Vascular Surgery of the American Board of Surgery within 12 – 18 months following the successful completion of the Duke VSR program.

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 moonlighting (Temporary Special Medical Activity) must be counted toward the 80-hour weekly limit on duty hours and may be only approved on a case-by-case basis by the Program Director. Requests for TSMA activity must include documentation of duty hours.

Record Keeping

Attendance Records

VSRs are required to attend and sign in legibly at all Grand Rounds, Conferences and Journal Clubs. Attendance of 75% of Grand Rounds, Conferences and Journal Clubs will be considered as part of the promotion/graduation process.

Operative Case Logs

Annual Operative Case Logs must be submitted on-line via the ACGME. Annually, each VSR must submit cumulative reports the Program Coordinator. The Program Director will carefully monitor this data on a quarterly basis. If a VSR falls behind or fails to meet the minimum RRC requirements, the Program Director will identify appropriate cases to perform in order to bring the number of surgical cases in-line.

Failure to maintain the operative log on a monthly basis may result in suspension of clinical privileges until the log is updated.

Duty Hour Policy

All VSRs must maintain a log of their daily duty hours. Each week, the VSR will enter their duty hour data via e*Value. At the end of each week, the Program Director and Coordinator will review the data submitted. A monthly calculation will be tabulated and tracked to ensure ACGME compliance as follows:

1. Duty hours are defined as all clinical and academic activities related to the residency program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

2. Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities.

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3. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a four week period, inclusive of call. One day is defined as 1 continuous 24-hour period free from all clinical, educational, and administrative duties. Each VSR is must take their arranged day off.

4. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.

Any VSR who fails to comply with the ACGME rules place the program at risk. Failure to adhere to program requirements may include administrative leave or a corrective action plan. If a VSR fails to adhere to the corrective action plan, as a last resort, termination from the program will be considered.

Each VSR will be assessed each work day by supervising faculty regarding their previous night work hours, alertness and well being after night of taking call at home. If the VSR shows signs of lack of alertness or well being, the VSR will be sent home early the next day. If a resident has failed to obtain at least four (4) hours of sleep, the VSR will be required to leave no later than 12:00 p.m. (noon) that day. VSRs and faculty are required to review a one hour video annually on alertness and well-being and duty hour assessment.

Safety Training and HIPAA

Safety Training includes ACLS, BCLS, HIPAA, etc., and must be updated on-line annually. Reminders will be sent via email by the GME Office. You are required to maintain compliance at all times. Failure to comply includes Hospital mandated administrative leave and temporary loss of training privileges. This can result in a negative listing with the Physician Central Data Computer.

Evaluations

As a Vascular Surgery Resident, you will be required to participate in the Division’s evaluation requirements.

1. Rotation Evaluation/Form – to provide the Program with continual feedback on the value/educational merit of each rotation.

2. Faculty Evaluation/Form – to provide the faculty with valuable feedback concerning:

a. Teaching abilitiesb. Commitment to the Educational Programc. Research/Scholarly Activityd. Clinical Acumen/Knowledge

3. Resident Evaluation Form – per rotation – to provide the Resident with appropriate feedback concerning his/her abilities related to the six General Competencies which includes:

a. Medical Knowledgeb. Patient Carec. Interpersonal & Communication Skillsd. Professionalisme. Practice-Based Learning & Improvement

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f. Systems-Based Practice 4. Semi-Annual Evaluation Form – to provide the Resident with a semi-annual review

for promotion/graduation purposes.

5. Anonymous Program Evaluation – to provide the program with feedback related to continual improvement for. If deficiencies are found, the Residency Education Group will prepare an explicit plan of action which will be approved by the faculty and documented in the minutes of the meeting.

6. 360 Degree Evaluation – Midpoint during the year, a 360 Degree Evaluation will be distributed to vascular surgery faculty, peers, medical students, nursing staff and patients. The results of the evaluation will be anonymously tabulated and discussed by the Program Director and vascular surgery resident.

7. Speaker/Objectives Evaluation Form – to provide the Resident or speaker with feedback concerning his/her didactic delivery related to:

a. Medical Knowledgeb. Professionalismc. Interpersonal & Communication Skillsd. Practice-Based Learning & Improvement

8. Program Director Evaluation Form – to provide feedback to the Program Director concerning:

a. Teaching abilitiesb. Clinical acumen/knowledgec. Commitment to the educational programd. Research/Scholarly Activitiese. Over-all Management/Supervision of the Program

9. Final Evaluation - The program director must provide a final evaluation for each VSR who completes the program. This evaluation must include a review of the VSR’s performance during the final period of education, and should verify that the VSR has demonstrated sufficient professional ability to practice competently and independently. The final evaluation must be part of the VSR’s permanent record maintained by the institution.

Section V: Department of Surgery Vascular Surgery Residency Specific Curriculum:

(The following information was adapted to the Vascular Fellowship from the Association of Program Directors in Surgery Curriculum, 4th Edition, 2002, ASE publication.)

DUKE VASCULAR SURGERY RESIDENCY CURRICULUM

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Basic Science Curriculum

Embryology of the Vascular System Molecular Biology Physiology and Pathophysiology of Blood Vessels Hemodynamics and Atherosclerosis Peptide Growth Factors Endothelial Cells Vascular Smooth Muscle Cells Macrophages Platelets Response of the Arterial Wall to Injury and Intimal Hyperplasia Atherosclerosis: Theories of Etiology and Pathogenesis Histopathologic Features of Nonarteriosclerotic Diseases of the Aorta and Arteries Regulation of Vasometer Tone and Vasospasm Venous System of the Lower Extremities: Physiology and Pathophysiology Structure and Function of the Lympatic System Diabetic Vascular Disease Plasma Lipoproteins and Vascular Disease Cigarette Smoking and Vascular Disease Coagulation and Disorders of the Hemostasis Blood Rheology and the Microcirculation Drugs in Vascular Disease Scientific Basis for Balloon Embolectomy Basic Principles Underlying the Function of Endovascular Devices Vascular Grafts Statistics for the Vascular Surgeon Aneurysmal Disease of the Abdominal Aorta Cerebral Blood Flor Basic Science of Renovascular Hypertension Basic Mechanisms in Mesenteric Ischemia Hemodynamic Basis of Portal Hypertension Anatomy and Physiology of Normal Erection Skeletal Muscle Ischemia and Reperfusion: Mechanisms of Injury and Intervention Spinal Cord Ischemia Associated with High Aortic Clamping: Methods of Protection Arteriovenous Hemodialysis Access Arterial and Vascular Graft Infection Neuropathic and Biomedical Etiology of Foot Ulceration in Diabetics

Clinical Curriculum

Diagnosis and Management of Aneurysmal Disease Diagnosis and Management of Extremity Arterial Occlusive Disease Diagnosis and Management of Renal Artery Occlusive Disease Diagnosis and Management of Visceral Ischemia Diagnosis and Management of Carotid Artery Occlusive Disease Diagnosis and Management of Innominate, Subclavian and Vertebrobasilar Arterial

Disease Diagnosis and Management of Thoracic Outlet Syndrome Diagnosis and Management of Acute Arteral Occlusion Diagnosis and Management of Diabetic Foot Problems

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Diagnosis and Management of Complications of Vascular Therapy Diagnosis and Management of Vascular Trauma Diagnosis and Management of Venous Thromboembolic Disease Diagnosis and Management of Chronic Venous Insufficiency Diagnosis and Management of Lymphedemia Indications and Techniques for Extremity Amputation Techniques for the Diagnosis of Peripheral Vascular Disease Use of Endovascular Therapy in the Management of Peripheral Vascular Disease Risk Stratification in Patients with Peripheral Vascular Disease Diagnosis and Management of Coagulation Disorders in Patients with Peripheral

Vascular Disease Diagnosis and Management of Miscellaneous Vasculogenic Problems Diagnosis and Management of Non-Atherosclerotic Vascular Diseases Diagnosis and Management of Arterial Venous Malformations Indications for and Techniques of Vascular Access Indications for and Results of Sympathectomy in Patients with Peripheral Vascular

Disease Diagnosis and Management of Portal Hypertension

Outcomes

By the end of this Vascular Surgery Residency, the trainee will be able to: Demonstrate knowledge of the anatomy, physiology and pathophysiology of the vascular

system, including congenital and acquired diseases. Demonstrate the ability to surgically manage the preoperative, operative, and

postoperative care of patients with arterial, venous, and lymphatic disease(s). Practice independently and competently as a Vascular Surgeon.

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