(a) The Department of Medicine participates in the National Resident Matching Program (NRMP) and adheres to its procedural guidelines for accepting medical school graduates into the training program. Appointments to or dismissals from the program are made by the Program Director on recommendation of the Resident Evaluation and Promotion Committee.

Appendix A: "How to Count Vacation Days" for a full explanation. Please note that vacation leave is essential, per ABIM, and cannot be forfeited for any reason, including late start, extended illness, or parental leave.

(d) House officers may NOT ENGAGE IN EMPLOYMENT OUTSIDE OF THE HEALTH CENTER SYSTEM. Third year residents with a permanent license may work in the Emergency Department at this facility with the following restrictions.

(e) On successfully completing training, each house officer receives a certificate signed by the Program director and other appropriate individuals.

(f) MEDICAL RECORDS delinquency, if persistent, can result in probation and dismissal from the Program.

(a) They are responsible for supervising and directing the activities of the first year residents and medical students in the performance of their duties on the covered service.

(b) They are responsible for placing an appropriate supervising resident note on the chart of every patient admitted to their service. Together with the private physician, they are responsible for the care of the patients on their service. THEY ARE THE LEADERS OF THEIR TEAM. All first years’ and medical students’ notes must be reviewed and signed on a daily basis.

(c) They have primary responsibility for the educational activities of their floor team including, conducting organized teaching rounds in the morning, chart rounds in the afternoon, assuring attendance at scheduled rounds and conferences, and reviewing first year resident and student work-ups.

(d) Third year residents, because of their additional experience, are expected to play a more significant administrative and educational role. Patient care and teaching responsibilities increase with increasing experience.

(e) Total R2 or R3 service size when supervising a single R1 on primary general medicine rotations should be limited to 16 patients. In the Intensive Care Unit when supervising four R1s, total service size should not exceed 24 patients.

(f) Second and third year residents on the floor and elective rotations take call two to four days per month in the ICU covering the R1 ICU resident from 7:00 p.m. to 7:00 a.m. Monday through Friday evenings with signout beginning at 6:30 p.m.; Saturday and Sunday call starts at 1:30 p.m. and extends until 7:00 a.m. the following morning.

7:00 a.m. six days per week. The Night Call Team must attend morning report daily but will be excused at 8:30 a.m.

(a) First year residents are subject to supervision and direction by the second and third year supervising resident, and the private attending physician for each patient assigned to them.

(b) When notified of a patient admission, the first year resident is to visit the patient AS SOON AS POSSIBLE AND IS TO RECORD THE REQUIRED COMPLETE HISTORY AND PHYSICAL (including rectal and pelvic exams) EXAMINATION WITHIN 12 HOURS. If a rectal or pelvic exam are not performed at admission they should be recorded prior to discharge and if not performed a reason must be documented.

(c) First year residents are responsible for daily progress notes. Students can write daily progress notes, but they must be reviewed and signed on the day they are written.

(d) The first year resident is responsible for maintaining an active problem list establishing that those tests ordered are performed and recorded in the chart. The first year resident can consider drawing any STAT blood work that they order on their patients if the phlebotomy service delay is excessive.

(e) First year residents are responsible for writing all orders on the patients on his or her service, under the supervision of the supervising resident and the private attending physician. Orders that represent a major change in therapy or that might expose the patient to significant potential morbidity should be reviewed with the supervising resident and the private attending physician. Supervising residents may assist R1 residents in writing orders on their patients but should make every effort to have the R1 resident write all orders. The private attending physician is actively discouraged from writing any orders on patients on the teaching service except under emergency circumstances or as a courtesy to the housestaff. When it is necessary that the attending physician write any orders on a teaching service patient, the orders should be followed by an additional order asking the house officer to co-sign the order. Third year student history and physicals do not substitute for first year resident history and physicals in the chart.

(f) Total R1 service size on primary general medicine rotations should be limited to an average of 6 to 8 patients per R1 resident during the first two months of the year and should slowly increase as competence and efficiency of the resident increases as the year progresses but should not exceed 12 patients per R1 resident service.

In the Intensive Care Unit, total service size should not exceed 4 to 5 patients per R1 resident.

(g) The first year resident is responsible for maintaining an active problem list establishing that those tests ordered are performed and recorded in the chart. He or she is responsible for establishing that PELVIC and RECTAL examinations are performed on all patients, where appropriate, before discharge. The first year resident can consider drawing any STAT blood work that they order on their patients if the phlebotomy service delay is excessive.

(i) First year residents are responsible for notifying their supervising resident and the private physician of ANY major change in the condition of the patients on their service. Upon the death of a patient, the first year resident MUST IMMEDIATELY NOTIFY THE SUPERVISING RESIDENT AND THE PHYSICIAN OF RECORD.

EFFORT TO OBTAIN AN AUTOPSY, with the assistance of a supervising resident.

(k) Patients can only be discharged by the first year resident on order of the physician of record. The supervising resident MUST be notified of all discharges.

(l) First year residents SHARE responsibility with the supervising residents for the supervision and teaching of the students assigned to them. All student notes must be reviewed, annotated as appropriate, and signed. Student History and Physicals are not a substitute for R1 History and Physicals as they are not a part of the permanent record.

(a) See Student Orientation Packet available in the Department of Internal Medicine.

(a) Attending physicians who admit their patients to any teaching service are responsible for the supervision and education of the residents assigned to their patients. All recommendations and changes in care should be effected through the R1 residents and the assigned supervising resident. Attending physicians should make every effort to avoid writing any orders on patients on the teaching service. Attending physicians who serve as subspecialty consultants for patients on the teaching service also have supervisory and teaching responsibility for the residents assigned to the patient on whom they are consulting. They should review their impressions and recommendations with the housestaff and should make every effort to allow the housestaff to write the orders implementing their recommendations. Attending physicians who serve as "teaching attendings" on any of the medical services have no responsibility for direct patient care or supervision of patients on the teaching service. Their major responsibility is the clinical education of residents on their service utilizing the patients on the service and, in addition, they should recognize their role as mentors and role models to the resident on the service.

(a) All supervising residents assigned to the general medicine floor function as the Triage Resident on their Long Call day.

(b) The Triage Resident works with admitting physician, the ED, and reservations in accepting and assigning patients to the covered service and evaluates proposed transfers from other areas of the hospital, prior to their being moved to covered medicine.

(c) The triage function is acquired by the supervising resident on Long Call and overnight Saturday call.

(d) Mistriaged patients from the ED are the accepting team’s responsibility for writing the H&P. Mistriaged patients from the R2/R3 team will be returned to him/her for the H&P (e.g., floor emergency).

(a) Official in-house duty hours for residents and students are determined according to the service to which they are assigned. For housestaff and students on floor service, the time of in-house duty is 6:00 a.m. to 4:30 p.m. Monday through Friday, except post overnight call when housestaff may leave between 12 noon and 1:00 p.m., and 7:00 a.m. to 12:00 noon on Saturday, Sunday and official hospital holidays.

Call schedules may change times on designated days. Scheduled work weeks will not exceed 80 hours/week, averaged over 4 weeks, on any rotation. Elective work weeks will generally average 40-50 hours/week. Duty responsibility is always patient care dependent and MAY REQUIRE ARRIVING EARLIER AND STAYING LATER but in no case will house officers be on duty for greater than 30 consecutive hours, be directly responsible for patient care for more than 24 consecutive hours, or be off for less than 10 hours, except as approved by the IM RRC..

Each resident will have one full day off per week on average.

(b) ALL RESIDENTS are expected to attend and participate in all scheduled teaching conferences. If attendance falls below 70%, then counseling will be provided and could lead to academic probation. If they are unable to attend, the office MUST BE NOTIFIED.

R1 admissions on General Medicine Floor or ICU rotations are limited to 5 new patient admissions (plus two intra-service transfers on Floors) per 24 hour period or 8 new admissions for any 48 hour period. In unusual circumstances, when the on-call team finds it necessary to exceed these limits, the supervising R2 or R3 resident may admit up to 3 additional new patients without the participation of the R1 resident (on teams with only one R1 resident.) [See service size limits 4(d)]

R2 or R3 admissions are limited to 8 new patients per 24 hr. period or 12 patients in any 48 hour period.[See Service Size Limits 3(e)]

(d) It is the responsibility of the resident to notify the Department of Medicine, as early as possible, in the event of an illness that will prevent him or her from carrying out his or her assigned responsibilities. Absence for illness greater than 2 days requires a treating physician's note.

(f) IN NO CASE WILL MEMBERS OF THE HOUSESTAFF CROSS COVER FOR ONE ANOTHER WITHOUT NOTIFICATION OF THE CHIEF RESIDENT. The only exceptions to this rule are routine cross coverage for clinic responsibilities or attendance at conferences.

(g) Whenever leaving or returning to the hospital (on duty hours), except for scheduled continuity clinics or electives, each member of the housestaff MUST notify the Medicine office and the telephone operators.

(h) Beepers MUST be carried whenever responsible for patient care. They must be maintained in good working condition at all times. Lost beepers, or broken beyond repair, will be the financial responsibility of the resident in question. The Medicine office and telephone operators MUST be notified if beeper is not working to receive a replacement.

(i) The Program Director may limit the number of house officers who leave the hospital at any one time.

(j) Patients on the covered medical service will not be transferred to an uncovered service without notification of the patients' private physicians.

(k) Subspecialty consultations should not be initiated without consent of the primary physician. Consultant's recommendations should be called to the attention of the primary physician and should be carried out only with the consent of the primary physician.

(l) All residents and students are expected to make rounds on their assigned patients AT LEAST TWICE DAILY and to record an appropriately complete progress note outlining the patient's course on a daily basis and to maintain an official problem list on each patient. All student notes must be reviewed, annotated and signed by a house officer.

(m) Professional attire is in order at all times. This "dress code" will definitely be enforced:

Floor Residents can only care for patients boarding in the ED if:

Intensive care unit residents can only see ICU patients in the emergency department if the following criteria are met:

Medical Floor –

(a) When treating a private patient, the house officers are expected to keep in close touch with the private physician.

(b) The house officer must notify the private physician of any significant changes in the patient's condition and should discuss major diagnostic and therapeutic plans before they are initiated.

(c) In emergency situations, the patient should be treated at the discretion of the responsible resident with the private physician being notified AS SOON AS POSSIBLE.

(d) Except in unusual circumstances, all orders on the covered service should be written by the house officer primarily responsible for the patient, in most cases, THE FIRST YEAR RESIDENT.

(e) Resident responsibility for patients outside of the teaching service is limited to emergency coverage only for hyper-acute unexpected problems that might arise when the attending physician is not available within the hospital. All subsequent management is the responsibility of the attending physician unless the residents accept the patient in transfer to the teaching service. (See Appendix D, SMHC Policy on Internal Medicine Housestaff Coverage of Uncovered Services, for specific examples)

(f) Admissions to the covered service are assigned by the TRIAGE RESIDENT or the "on-call" admitting resident.

(g) Phone calls to private physicians should be made by the housestaff. It is NOT appropriate for third year medical students to call the private physician unless the resident is on the line.

(a) The maintenance of accurate, TIMELY and complete medical records is a critical component of quality patient care and is an important responsibility of the housestaff.

Use of the H&P Template (see Appendix) is encouraged. Note ROS can be filled in as it is elicited but HPI should only be recorded after complete H&P exam is performed.

(c) An off-service/transfer note is to be written on the chart of any patient transferring to a new house officer. At a minimum, this should include summary of hospital course, current medications, outstanding tests or procedures, and current impression and PLANS. The receiving house officer is also responsible for a transfer/accept note with comprehensive summary and impression and plans.

(d) All orders must include date and time and a printed or stamped name under every signature.

(f) Orders must be rewritten when patients are transferred to or from the ICU or from an uncovered service to a covered service. These orders are the responsibility of the unit resident and must be countersigned by the floor resident.

(g) Daily progress notes should be dated and timed and include a summary of the patient's complaints, physical findings, relevant laboratory information and an impression and PLAN.

(h) Dictation of discharge summaries is the responsibility of the first year resident (see Appendix) to be used.

3. Medical Records Completion Policy

Gynecology* (1 week)

Ophthalmology (1 week)

(vacation – 1 week)

6 Block Ambulatory/Geriatrics 1 month

(vacation – 1 week)

8 Medical Consult 1 month

9 ICU 1 month

Patient Care:

R1 to R2: Mastering of basic H&P skills, sophisticated differential diagnosis, relatively independent development of differential diagnosis, independent basic diagnostic and therapeutic plan development, and demonstration of compassion and sensitivity to patient and family needs. Passage of the R1 Clinical Competency Exam (CEX) or its equivalent (e.g. "Mini" CEXs.)

R2 to R3: Demonstration of greater independence and sophistication in all patient care skills, requiring minimal attending level intervention (correction), more sophisticated patient interaction with consistent attention to health promotion strategies. Passage of the R2 CEX or equivalent.

R3 to Graduate: Demonstration of sophisticated, independent, confident patient care skills without necessity of attending physician intervention. Passage of the R3 CEX.

Medical Knowledge:

R1 to R2: Acquisition of basic clinical knowledge allowing development of a moderately sophisticated differential diagnosis, moderately sophisticated diagnostic and therapeutic plans, and effective, reliable medical student, R1, nurse, and patient education.

R2 to R3: Demonstration of a larger, more sophisticated, more reliable (accurate), more functional data base of clinical and pathophysiologic knowledge allowing more sophisticated patient care, more sophisticated and more formal educational contributions, and allowing for more effective personal growth. Passing score on the USMLE III examination.

R3 to Graduate: Demonstration of a mature, very sophisticated clinical knowledge base with a broader understanding of biomedical data, medical statistics, and human behavior allowing for very sophisticated patient care, teaching, and communication.

Practice-based Learning:

R1 to R2: A basic understanding of and commitment to critical self-assessment, critical assessment of clinical/scientific evidence, and a sense of how these activities are important to continuous improvement in patent care.

R2 to R3: Demonstration of ongoing, active use of point-of-care clinical and scientific educational resources to continuously examine and improve knowledge and patent care, active involvement in self-assessment and self-improvement activities, and the ability to role-model and teach these skills.

R3 to Graduate: Demonstration of both a sophisticated understanding and practice of practice-based learning and a commitment to this competency as a life-long learning activity.

Interpersonal and Communication Skills:

R1 to R2: Basic but effective ability to interact and collaborate with patients, families, trainees, peers, attending physicians, and other health professionals.

R2 to R3: Demonstration of more sophisticated and more independently effective interpersonal and communication skills.

R3 to Graduate: Demonstration of very effective interpersonal and communication skills, the ability to model and teach these skills, and the ability to effectively and independently manage conflicts.

Professionalism:

R1 to R2: Demonstration of professional reliability and trust-worthiness and consistently ethical and non-discriminatory behavior.

R2 to R3: Continued demonstration of professional reliability and trust-worthiness, and consistently ethical and non-discriminatory behavior.

R3 to Graduate: Continued demonstration of professional reliability and trust-worthiness, and consistently ethical and non-discriminatory behavior, plus the commitment, when the situation arises, to place a patient’s needs above their own.

Systems-based practice:

R1 to R2: A basic understanding of our health care system and an understanding of the multidisciplinary system resources that can be utilized to optimize the quality and cost-effectiveness of care.

R2 to R3: Demonstration of a functional understanding of the broader context and complexity of our health care system and the different types of payer systems, and the use of available resources including clinical pharmacists, case-management, social services and home care in optimizing the quality, and cost-effectiveness of their patient’s care.

R3 to Graduate: Demonstration of the incorporation of a systems-based approach into their clinical practice.

Leadership:

R1 to R2: Demonstration of interpersonal skills and interactions with members of the health-care team that is predictive of effective leadership.

R2 to R3: Demonstration of effective leadership as a supervising resident.

R3 to Graduate: Demonstration of effective, independent leadership, and the ability to stimulate and support members of the team to provide optimal patient care using all available resources.

R1 to R2: Demonstration of a commitment to teach all members of the health-care team, patients and their families.

R2 to R3: Demonstration of effective role-modeling and effective teaching, both formal and informal.

R3 to Graduate: Demonstration of growth and sophistication in teaching skills and teaching effectiveness, and the development of a stimulating, intellectually-honest atmosphere of academic interaction among members of their team.

R1 to R2: Demonstration of basic ability to organize activities in such a way as to allow for effective patient care, fulfill professional obligations, pursue self-improvement activities, and fulfill personal obligations and needs.

R2 to R3: Demonstration of the ability to effectively manage their own time and also effectively manage their team activities.

R3 to Graduate: Demonstration of organizational and management skills that are will adequately support their future professional activities.

(a) For specific certification requirements, you should refer to the current Directory of Residency Training Programs manual published by the Accreditation Council for Graduate Medical Education.

competency examination (CEX) be given each academic year. This has taken the form of an observed history and physical exam supervised by a member of the faculty and administered to all first, second and third year residents on a yearly basis. Any resident receiving an unacceptable evaluation will be retested by a member of the Resident Evaluation and Promotion's Committee. Failure on retesting will require remediation and retesting. Promotion requires successful passage of the CEX as a component of the Patient Care competency.

procedures appropriate for an internist. At this institution, this documentation takes the form of a paperless Web-based electronic procedure data-base that is part of our MyEvaluations.com system, also used for all of our form-based clinical evaluations and work hours tracking. Credit is granted both for performing procedures and for primary supervision of procedures, once competency has been established.

First year residents performing procedures need an appropriately credentialed supervising resident or attending physician to electronically confirm the procedure. Residents credentialed to independently perform or supervise a procedure require an attending physician's electronic confirmation that the procedure was performed for inclusion in that resident’s electronic procedure log.

(d) The American Board of Internal Medicine requires that candidates for certification meet high standards of humanistic behavior in their professional lives. The essential human qualities required of candidates seeking ABIM certification are INTEGRITY, RESPECT and COMPASSION. It is a major responsibility of the resident training program to stress the importance of humanistic qualities in the

relationship between patient and physician and to assess these qualities in its residents.

16. GRIEVANCE PROCEDURE:

(a) The term "grievance" is defined as a dispute or controversy arising in the interpretation or application of this contract or any rule or regulation or policy or practice of the Health Center which pertains to the residency program.

(b) In the event that the House Officer has a grievance as defined herein above, he/she may within fourteen (14) days request a hearing before the Medical Advisory and Appeals Committee before which Committee he/she shall have the right to be heard within a reasonable time after application in writing for a hearing is made to that Committee addressed to its Chairman. For purposes of appeal, the Committee shall include a member of the faculty and a member of the housestaff chosen by the grievant.

(c) After the conclusion of the hearing the Chairman of the Medical Advisory and Appeals Committee shall report the findings and recommendations of the Committee to the President of the Health Center and to the House Officer involved.

(d) Within fourteen (14) days after receipt of the findings and recommendations of the Medical Advisory Committee, the President or the House Officer may appeal the decision of the Medical Advisory Committee to the Board of Directors of SSM Health Care St. Louis or a committee appointed by the Board of Directors as determined by the Board. The decision of the Board of Directors or their appointed committee shall be final.

17. SICK LEAVE, FAMILY LEAVE, LEAVES OF ABSCENCE:

(a) Please note that the ACGME and ABIM require that any significant time lost due to illness or pregnancy (exceeding four weeks over the thirty-six month training period) or personal leave requires extension of the residency training period to make up for the time lost. Vacation leave is essential, per ABIM, and cannot be forfeited to compensate for any reason.

(b) Short leaves for documented illness of 1 week or less can generally be accommodated by the Program. Illness of greater than 1 week duration or illness resulting in frequent absenteeism requires activation of short term or long term disability per our HR policy. There are NO specified or guaranteed number of "sick days" that can be accrued and used as vacation.

(c) Family Leave for Pregnancy or Illness or to care for a spouse or child as a primary caregiver is allowed per the Family Medical Leave Act of 1993. Up to 4 weeks of paid and up to 8 additional weeks of unpaid Maternal Leave is allowed. One week of paid and up to 3 weeks of unpaid Paternal Leave is allowed, unless the father must care for his wife as a primary caregiver, in which up to 4 weeks of paid and 8 weeks of unpaid Family Leave is allowed. As stated above, any time on Leave that exceeds one month during the 36 months of residency training must be made up to qualify for ABIM certification.

(d) Personal leaves of absence without pay for reasons other than illness or pregnancy are granted by the Program Director based on individual circumstances.

See Appendix B: SSM St. Mary’s Health Center Practitioners and Providers Aid Policy.

1. Impaired Physician: An impaired Practitioner or Provider is one whose behavior has been affected by alcohol, chemicals, mental illness, or any other illness which interferes with the Practitioner or Provider’s individual health, economics or ability to function competently. This behavior is often characterized by compulsion, loss of control and, in cases involving Drugs or Chemicals, continued use of Drugs and Chemicals despite adverse consequences. A Practitioner or Provider may be impaired in his/her ability to perform professional responsibilities, function responsibly in financial matters, or behave in a sexually responsible manner (i.e., sexual inappropriateness with patients, sexual addiction or sexual harassment).

3. Drug or Chemical Related Misconduct: Drug or Chemical Related Misconduct includes, but is not limited to, possession and/or illegal distribution of Drugs or Chemicals on either the SSM St. Mary’s Health Center campus or the SSM Cardinal Glennon Children’s Hospital campus; use of the Drugs or Chemicals on either campus; use of Drugs or Chemicals off-campus that adversely affects the Practitioner or Provider’s performance, his/her own safety or others’ safety at work, or negatively reflects on the reputation in the community of SSM St. Mary’s Health Center, SSM Cardinal Glennon Children’s Hospital, or any SSM Health Care-affiliated organization.

4. Missouri Physician’s Health Program (MPH Program): The MPH Program is the Missouri impaired physicians’ program, sponsored by the Missouri State Medical Association. (See, Appendix A-MPH Brochure).

5. Intervention: An intervention is an organized confrontation between a group of concerned, trained individuals and a potentially impaired Practitioner or Provider for the purpose of motivating that Practitioner or Provider to accept evaluation and treatment for his/her impairment. The intervention will include the Committee Chairperson, the campus-specific Medical Staff President or his/her designee, a representative of the MPH Program for physicians or other appropriate professional treatment provider, and depending on the circumstances, a spouse, practice partner, office staff, close friend, etc.

6. Evaluation: An evaluation is an assessment of the impaired Practitioner or Provider by a professional treatment provider and/or treatment center outside of SSM St. Mary’s Health Center or SSM Cardinal Glennon Children’s Hospital.

7. Treatment: Treatment is the process whereby the Practitioner or Provider is assisted to recognize and change behavior patterns contributing to the impairment. Treatment may range from individual psychotherapy to inpatient hospitalization.

8. Monitoring: Monitoring of an impaired Practitioner or Provider will be done by the MPH Program or other appropriate professional treatment provider. Regular reports as to the Practitioner or Provider’s compliance and progress in recovery will be communicated to the campus-specific Medical Staff President and the campus-specific Hospital President or their respective designees, and the Committee.

9. Advocacy/Care and Treatment Agreement: Each Practitioner and Provider who is subject to an intervention and who is deemed to require evaluation and treatment will be required to enter into an appropriate Care and Treatment Agreement with the Hospital consistent with SSM Health Care policy. In addition, physicians participating in the MPH Program shall also

-medications, fluids

-x-ray review

-anxiety, delirium/confusion

-falls, lacerations

-non-life-threatening chest pain, SOB, desaturation, and decline in mental status.

On the Uncovered Service, responding to calls about these clinical scenarios remains the responsibility of the attending physician.