Residency Manual (08DEC2021)

_{Full Text Here for Reference: Tables and images not formatted. For tables, please see the full handbook.}

_{NMRTC CAMP PENDLETON}

_{Department of Family Medicine}

_{Resident Manual}

_{Revised and Edited – November 2021}

_{200 Mercy Circle}

_{P.O. Box 555191}

_{Camp Pendleton, CA 92055}

_{P: 760-725-4357}

_{F: 760-725-1101}

_{SECTION I: INTRODUCTION}

_{● RESIDENCY MISSION STATEMENT}

_{SECTION II: DEPARTMENTAL POLICIES}

_{● LEAVE, TAD AND OUT ROTATION COVERAGE}

_{● NSIPS Go-By}

_{● RESIDENT LEAVE/TAD/DUTY FORM}

_{● PREGNANCY/POSTPARTUM CONVALESCENT LEAVE}

_{● PRIMARY AND SECONDARY CAREGIVER LEAVE}

_{● PARENTAL FAMILY LEAVE/ OTHER TIME AWAY FROM TRAINING}

_{● NAVY POLICIES FOR LACTATING SERVICE MEMBERS}

_{● SUPERVISION OF RESIDENTS AT NAVAL HOSPITAL CAMP PENDLETON}

_{● MANAGEMENT OF CONTINUITY COUPLETS}

_{● RESIDENT WATCH RESPONSIBILITIES}

_{○ POLICY FOR A RESIDENT REQUESTING A CHANGE-OF-DUTY}

_{○ RESIDENT WORK HOURS}

_{○ IMPAIRED RESIDENTS}

_{SECTION III: CURRICULUM}

_{● Elective Rotation Examples (Staff POC as of 2021):}

_{SECTION IV: CONFERENCES AND LECTURES}

_{● RESEARCH IN RESIDENCY}

_{SECTION V: RESIDENT EVALUATIONS}

_{● QUARTERLY EVALUATIONS}

_{SECTION VI: PROCEDURE DOCUMENTATION}

_{● REQUIREMENTS FOR PROMOTION AND GRADUATION}

_{SECTION VII: QUALITY IMPROVEMENT}

_{The following document is periodically revised and reviewed to serve as a guide for residents entering the program, and to advise them of the standard policies and procedures of the Family Medicine residency. It is not all-encompassing, but is intended to serve as a framework for residents to understand the basics of how the department and program operate.}

_{Several documents recommended for all residents have been noted in this handbook, and are in the command Knowledge Management Portal on the NHCP Intranet webpage. These include:}

_{- ACGME Common Program Requirements}

_{- ACGME Family Medicine Program Requirements}

_{- ABFM Requirements for Program Certification}

_{- OPNAVINST 6000.1D}

_{- BUMED INSTRUCTION 1524.1C}

_{SECTION I: INTRODUCTION}

_{RESIDENCY MISSION STATEMENT}

_VISION:

_{Be the PREMIER and PREFERRED Family Medicine Residency Program for residents, faculty, and gaining commands.}

_MISSION:

_{Graduate the Navy’s BEST Family Physicians.}

_AIMS:

_{1. Provide residents with a world-class, full-scope Family Medicine learning experience that promotes clinical excellence.}

_{2. Sustain a culture of professionalism that promotes character and attitudes worthy of our warfighters and military family.}

_{3. Develop leaders who model excellence and resiliency, committed to accomplishing mission, inspiring their team, and caring for their patients.}

_VALUES:

_{Character, Competence, Kindness, Humility}

_{FAMILY MEDICINE AS A SPECIALTY}

_{The specialty of Family Medicine was officially recognized on February 8, 1969, when the American Board of Medical Specialties and the Council on Medical Education of the American Medical Association approved a primary certifying board in the specialty.}

_{To be certified as a specialist in Family Medicine, a family physician must pass an intensive examination given by the specialty's certifying board, the American Board of Family Medicine (ABFM). Completion of a three-year residency is required.}

_{The Family Physician must be recertified every ten years. To be recertified, the Family Physician must complete required Continuing Medical Education hours/credits in Family Medicine, comply with guidelines for professionalism, licensure, and personal conduct, as well as pass a one day exam or enroll in longitudinal assessment method.}

_{The discipline of Family Medicine is a specialty in BREADTH that is patient/family oriented rather than disease or system oriented and is CONTINUING and COMPREHENSIVE rather than episodic, providing comprehensive care to patients of all ages, focusing on the family unit.}

_{The Family Physician studies in six broad areas of medicine - Pediatrics, Surgery, Internal Medicine, Obstetrics and Gynecology, Psychology and Family Medicine - to learn how to give each patient continuing and comprehensive health care (regardless of age or sex) in the environment of his/her family and community.}

_{Equally important, this training teaches the physician to practice PREVENTIVE MEDICINE; he or she learns not only how to make the patient well, but how to keep the patient healthy.}

_{The Family Physician has been described as a cross between the "old time GP" and the Modern Medical Specialist, but whatever words are used to describe him/her, he/she is still the only doctor who specializes in the entire patient within the context of the family unit.}

_{SECTION II: DEPARTMENTAL POLICIES}

_{LEAVE, TAD AND OUT ROTATION COVERAGE}

_{Resident’s time away from the program falls into a number of categories:}

_{1. Leave and other non-educational time away,}

_{2. Educational TAD for meetings and other authorized training,}

_{3. Out-rotations during which you are away from your panel,}

_{4. Out-rotations during which you are not away from your panel.}

_{Leave and other non-educational time away}

_{The ABFM limits absences for leave and other non-educational time to 4 weeks per academic year with additional time granted if qualified as “Family Leave”.}

_{2021-2022 NHCP Residency Leave Policy is further specified by the following:}

_{1. Residents of all training levels will be REQUIRED to take 2 calendar weeks of leave (non-contiguous). This equates to 5 working days off at one time. No exceptions. Examples include:}

_{a. Saturday through next Sunday, 9 days total}

_{b. Thursday- Wednesday, 7 days total}

_{c. Wednesday-Tuesday, 7 days total}

_{d. Both count as 1 ACGME week of leave}

_{2. R1 and R2 are allowed 1 optional week of leave. Option to split this week into 2 halves, when added together equates to 5 working days off (3 weekdays used for first leave period and 2 weekdays off for second leave period). Examples include:}

_{a. Thurs-Sun (4 days total) + Wednesday through Sunday (5 days total)}

_{b. Full week as noted above in bullet 1.}

_{3. R3 allowed 2 extra optional weeks on top of the mandatory weeks. The full week vs split week rules apply as above.}

_{4. Leave is allowed on outpatient rotations only. A maximum of 5 days of weekday leave is allowed on 4 week rotations. For 2 week rotations, only a split week of leave can be taken (maximum of 3 days of weekday leave allowed).}

_{5. NSIPS approval required for:}

_{a. Local leave taken during a weekday}

_{b. Leave outside the liberty radius (>350 miles from NMRTC CP) both weekdays and weekends}

_{6. Leave not used one year does not carry over to the next (i.e. you are still constrained by the above limits even though you will be accumulating leave on the books for use later). Vacation periods cannot be consecutive (e.g. last week of GME-I year and first week of GME-II year). You cannot shorten your residency by foregoing vacation.}

_{Educational TAD for meetings and conferences}

_{Expect to limit absences for educational meetings and conferences to five (5) days per calendar year. This does not count toward the leave and non-educational time away limits. All residents are eligible for TAD to a conference or educational activity. TAD approval must be accepted by the PD or APD.}

_{Out rotations away from your panel}

_{Out rotations are those during which you have no FM clinic or watch responsibilities at Camp Pendleton. These remote site rotations are limited to no more than two (2) months in each academic year. GME-I will do ICU at NMCSD. GME-II will do NICU and Children’s Hospital rotations. GME-III will do Medicine at UCSD and may choose an elective away from the program. Adding a second full-out rotation during the GME-III year will be on a case-by-case basis and will be heavily influenced by the resident’s projections to achieve at least 1650 clinic appointments. This second full-out must be approved by the APD or PD. Residents cannot be away from the program for more than eight consecutive weeks for purposes of continuity with periods between interruptions in continuity being at least 4 weeks. You must have TAD orders and coverage for all these rotations.}

_{Out rotations not away from your panel}

_{During these rotations you return to NHCP for FM continuity clinic and call. These rotations do not count as time away from your panel, but do require coverage and TAD orders. GME-II will do Children’s ER. GME-III will do Palomar ER.}

_{Coverage rules}

_{Any time a resident goes away for any reason they must have a proxy/surrogate (a designated colleague who handles telephone calls, checks lab results, checks the mailbox, and covers routine OB/nursery admissions on your patients). This includes those times when out of the hospital and out of reach for more than 24 hours. As a general guideline:}

_{Interns may cover only interns}

_{GME-II and GME-III Residents can cover anyone}

_{Coverage should be from your own team}

_{Covers for a minimum of 2-weeks, if at all possible (utilize 2 people/2wks each)}

_{Advised to cover only one person at a time}

_{Residents/interns on the Adult Medicine Inpatient Team, Pediatrics Team, or on OB should not be covering}

_{The difference between an in-house rotation and an out-rotation can be pretty blurry when you're not totally away from the hospital. The following list should answer most questions; please see the APD if you still have questions.}

_ROTATION

_PROXY

_{FM CLINIC}

_{TAD ORDERS}

_WATCHES

_{PALOMAR ED}

_YES

_YES

_YES

_NO

_{CHILDREN’S ED}

_YES

_YES

_YES

_NO

_NICU

_YES

_NO

_YES

_NO

_{CHILDREN’S INPT}

_YES

_NO

_YES

_NO

_UCSD

_YES

_NO

_YES

_NO

_{ICU (NMCSD)}

_YES

_NO

_YES

_NO

_C4

_YES

_NO

_YES

_NO

_{OTHER ELECTIVE – NOT FULL OUT}

_{YES (ADVISED)}

_YES

_NO

_YES

_{The Watchbill Coordinator, GME coordinator, and APD keep track of time away based on the information put on request sheets, as well as the input into the on-line scheduling program; currently AMION. The only information readily available to the APD is the cover sheet and printed NSIPS form. If the actual leave period deviates from the request, notify the APD.}

_{Applying for leave or TAD}

_{Requests for leave or TAD should be submitted at least 60 days prior to the start of the rotation that includes your leave period.}

_{1. Leave must be requested for any non-academic time spent away from the hospital and shall include regular leave, emergency leave, convalescent leave and any time off not otherwise covered by liberty.}

_{2. TAD must be requested for academic and/or official military business that requires you to be away from the hospital. This includes attendance at meetings, seminars, medical licensure, out-rotations (as defined above), board exams, and house hunting.}

_{3. Requests are to be made on the following forms, all of which are available through the GME office:}

_{a. All absences greater than 24hrs along with TAD – RESIDENT COVER SHEET}

_{b. E-leave request/authorization – NSIPS FORM}

_{The forms are self-explanatory. Obtain all required signatures (team leader, department head or rotation coordinator for the specific rotation, and resident/intern who will be covering you) prior to submission of the forms to the APD, via the GME coordinator and watchbill residents. Before leaving on leave/TAD the leave authorization/TAD orders should be printed. It is recommended to always carry a copy of your orders with you when TAD and a copy of your NSIPs approval when on leave.}

_{NSIPS Go-By}

_{The Navy Standard Integrated Personnel System (NSIPS) is the Navy’s single, field-entry, electronic pay and personnel system for all USN/USNR Sailors. This web-enabled, Enterprise Resource Planning (ERP) system offers Sailors 24-hour access to their Electronic Service Record (ESR), training data, and career counseling records. NSIPS is available world-wide, both ashore and afloat. NSIPS is currently deployed on 150 ships and is available via the ship’s network using a disconnected operations infrastructure, synchronizing data with the ashore network when connectivity permits.}

_{To access the electronic leave portal either visit the Command Intranet site and follow the various links, or click on or cut and paste the following URL into your web browser (it is CAC enabled):}

● _{https://nsipsprod.nmci.navy.mil/nsipsclo/jsp/index.jsp}

_{User resources are available, as well as a tutorial if you want some practice with using this service.}

_{Procedures for going on Leave/TAD}

_{1. Designate a surrogate to manage your patient panel while you are away using rules as above. Include in your turnover to your surrogate if you have any continuity OB patients that you anticipate may deliver while you are away.}

_{2. Complete leave/TAD form for GME office (below)}

_{3. Complete NSIPS request}

_{4. Communicate to your clinic team nurses the dates you will be gone and who will be your surrogate. Options for this include Outlook appointment, email, or direct communication with the nursing team. Each team has a list in their office of who is away and who is covering. Make sure you are on the list before you leave.}

_{5. Assign your surrogate as a proxy to your MHS Genesis account. This will allow your surrogate to access your Message Center and respond to all results and messages while you are away.}

_{6. Set an Outlook email away message for the dates that you will be gone that states who your surrogate is in your absence.}

_{RESIDENT LEAVE/TAD/DUTY FORM}

_{RESIDENT: ___________________________ TEAM: _________}

_{ABSENT FOR: LEAVE ___TAD___ ROTATION:_________________________}

• _{Rotation Coordinator approval of leave dates}

_{__________________________}

_{(Coordinator signs here or resident provides copy of e-mail stating permission)}

_{LEAVE DATES: ________-_________ # LEAVE ½ weeks taken this academic year ____}

• _{NSIPS Leave Request completed and Copy included with this form}

• _{All encounters in Genesis are complete (Verify encounters **1 YEAR** back)}

• _{Proxy/Panel will be covered by:}

_{__________________________}

_{(place the name(s) of designated surrogate(s) in the NSIPS remarks)}

• _{Team Nurse notified of dates and panel coverage RN initials:_____}

• _{Resident Scheduler Signature (Any of them will suffice)}

_{___________________}

_{LAST STEP (Resident leaves paperwork with GME Coordinator):}

• _{Training (GMT, Life Support, HIPPA, Provider Annual training, etc.) is up to date}

• _{Individual Medical Readiness (PHA, Birth Month Recall, HIV, Dental) is up to date}

_{GME Coordinator Signature (training verified)}

_{________________}

_{APD Signature}

_{________________ NSIPS Approved Date: _______}

_{*APD will sign request in NSIPS (you will get an APPROVAL email), and hard copies will be submitted to GME Coordinator for tracking purposes.}

_{Revised JUL2021}

_{PREGNANCY/POSTPARTUM CONVALESCENT LEAVE}

_{SECNAVINST 1000.10B (https://www.secnav.navy.mil/doni/Directives/01000%20Military%20Personnel%20Support/01-01%20General%20Military%20Personnel%20Records/1000.10B.pdf)}

_{1. This document of policy is drafted to provide uniformity and administrative guidance regarding the management of pregnant residents who either enter their residency in a state of pregnancy or who subsequently become pregnant during training. The overriding concern is the health of the resident and that of her unborn child. Also important are the assurances that the resident fulfill all education requirements and that patient care for her panel be uninterrupted by her absence.}

_{2. Reference (a) mandates that special consideration and duty restrictions be afforded all pregnant Naval and Marine Corps members during their entire pregnancy. These include:}

_{a. Shall be exempt from physical fitness testing and training}

_{b. Shall not stand at parade rest or attention for longer than 15 minutes}

_{c. Shall be exempt from all routine immunizations except influenza and tetanus-diphtheria unless clinically indicated}

_{d. Shall not be exposed to chemical or toxic agents}

_{3. Beginning at the 28th week of gestation, these restrictions go on to include:}

_{a. Should be assigned a work week that does not exceed 40 hours. These 40 hours can be distributed as the training schedule dictates over the work week. The hours are defined by presence at work and not by the type of work performed. Pregnancy does not remove a resident from watch-standing responsibilities; however, all the hours shall count as part of the 40-hour limitation. A resident may request a work waiver to extend her hours beyond 40 per week if she is physically capable and her physician concurs.}

_{b. Should be allowed to rest at least 20 minutes every four hours.}

_{4. The time requirements and stressors imposed by the rigorous clinical and administrative duties of residency training are in direct conflict with the directives set forth in reference (a). However, all Navy Family Medicine residency programs are required to strictly comply with reference (a), and we are obligated to insure that our pregnant residents do not work more than 40 hours per week beginning at their 28th week of pregnancy (unless granted a waiver by NMP).}

_{5. Whenever possible, training in late pregnancy will be shifted to less demanding rotations. The American Academy of Family Physicians has encouraged the use of home study electives to be used around the due date or during the convalescent period (these would need to include some FMC time).}

_{6. The watch standing frequency may be modified from 28 weeks gestation until return from convalescent leave depending on individual circumstances. The total watches for the year will be kept at the equivalent of her year group. These can be made up either early in the pregnancy or after the pregnancy/convalescent period.}

_{Convalescent/Maternity Leave (SECNAVINST 1000.10B)}

_{1. Is limited to a Covered Service Member birthparent after a qualifying birth event. In cases where a baby is stillborn, or the Covered Service Member suffers a miscarriage, convalescent leave, other than Maternity Convalescent Leave, may be granted.}

_{2. Is limited to six weeks of non-chargeable leave, unless additional Maternity Convalescent Leave is specifically recommended, in writing, by the medical provider of the Covered Service Member to address a diagnosed medical condition and is approved by the member’s CO. A birth parent may, with the concurrence of a medical provider, elect to receive a period of Maternity Convalescent Leave that is less than six weeks}

_{3. Must be taken immediately following childbirth, except that the leave will not commence until the first full day following the date a Covered Service Member is discharged or released from the hospital (or similar accredited facility) following childbirth, or the first full day after a planned home delivery under the care of a certified nurse midwife}

_{4. May be taken consecutively with either Primary or Secondary Caregiver Leave, but must be taken prior to any caregiver leave (for a maximum of 12 weeks in conjunction with Primary Caregiver Leave, or eight weeks in conjunction with Secondary Caregiver Leave). If additional Maternity Convalescent Leave is authorized and approved, the full period of the extended Maternity Convalescent Leave will be taken prior to any caregiver leave and, the amount of caregiver leave will be reduced one day for each day of additional Maternity Convalescent Leave taken (i.e., that portion of the period of Maternity Convalescent Leave that is in excess of six weeks). Primary or Secondary Caregiver Leave, if not taken in conjunction with Maternity Convalescent, must be taken within one year of a qualifying birth event or qualifying adoption.}

_{5. Cannot be divided into separate periods of leave. If a mother ends Maternity Convalescent Leave before the six week expiration, the remainder of the Maternity Convalescent Leave is forfeited}

_{6. May be taken consecutively with approved ordinary (i.e., chargeable) leave. If taken in conjunction with ordinary leave, may exceed the maximum limit of 6 weeks (or extension of con leave for medical purposes) if approved by the CO. If taken with caregiver leave and ordinary leave, the order in which the types of leave must be taken is as follows: Maternity Convalescent Leave, caregiver (Primary or Secondary) leave, ordinary leave.}

_{7. Must not be disapproved by a CO.}

_{8. May not be transferred to other Service Members to create any kind of shared benefit.}

_{9. Will be forfeited if unused at separation from active service.}

_{Primary and Secondary Caregiver Leave}

_{Primary Caregiver Leave}

_{1. Is limited to Covered Service Members who meet the definition of, and are designated as, “primary caregiver” in conjunction with qualifying birth events or qualifying adoptions}

_{2. Is limited to six weeks of non-chargeable leave and must be taken within one year of a qualifying birth event or qualifying adoption. A designated primary caregiver may elect to receive a period of Primary Caregiver Leave that is less than six weeks}

_{3. May be taken consecutively with Maternity Convalescent Leave and/or approved ordinary (chargeable) leave. However, Primary Caregiver Leave may not be taken consecutively with chargeable terminal leave and/or administrative absence for transition (commonly referred to as permissive temporary duty or PTDY). If taken consecutively with Maternity Convalescent Leave, Primary Caregiver Leave must be taken after Maternity Convalescent Leave. If not taken in conjunction with Maternity Convalescent Leave, it must be taken within one year of a qualifying birth event or qualifying adoption. If taken in conjunction with ordinary leave (other than terminal leave or PTDY), the Primary Caregiver Leave must be taken before the ordinary leave. If taken in conjunction with both Maternity Convalescent Leave and ordinary leave (other than terminal leave or PTDY), the order in which the types of leave must be taken is as follows: Maternity Convalescent Leave, Primary Caregiver Leave, ordinary leave}

_{4. Must be taken in only one increment.}

_{5. Is not authorized in cases of a qualifying birth event where the child is given up for adoption, and/or parental rights are terminated or surrendered.}

_{6. Eligibility, or the leave itself if started, terminates upon the death of the child. In such cases, Covered Service Members may transition to an emergency leave (chargeable) status in accordance with reference (b); SECNAVINST 1000.10B 16 Jan 2019 4 Enclosure (3).}

_{Secondary Caregiver Leave}

_{1. Is limited to Covered Service Members who meet the definition of, and are designated as, “secondary caregiver” in conjunction with qualifying birth events or qualifying adoptions.}

_{2. Is limited to 14 days of non-chargeable leave and must be taken within one year of a qualifying birth event or qualifying adoption. A designated secondary caregiver may elect to receive a period of Secondary Caregiver Leave that is less than 14 days.}

_{3. May be taken in conjunction with Maternity Convalescent Leave or approved ordinary (chargeable) leave. If taken in conjunction with Maternity Convalescent Leave, Secondary Caregiver Leave must be taken after Maternity Convalescent Leave. If not taken in conjunction with Maternity Convalescent Leave, it must be taken within one year of a qualifying birth event or qualifying adoption. If taken in conjunction with ordinary leave (other than terminal leave or PTDY), the Secondary Caregiver Leave must be taken before the ordinary leave. If taken in conjunction with both Maternity Convalescent Leave and ordinary leave (other than terminal leave or PTDY), the order in which the types of leave must be taken is as follows: Maternity Convalescent Leave, Secondary Caregiver Leave, ordinary leave.}

_{4. Must be taken in only one increment.}

_{5. Is not authorized in cases of a qualifying birth event where the child is given up for adoption, or parental rights are terminated or surrendered.}

_{6. Eligibility, or the leave itself if started, terminates upon the death of the child. But, in such cases, Covered Service Members may transition to an emergency leave}

_{Designation of Primary and Secondary Caregivers}

_{1. In the case of a qualifying birth event or qualifying adoption, the Covered Service Member will designate the child's primary caregiver.}

_{2. Only one primary and one secondary caregiver may be authorized for each qualifying birth event or qualifying adoption.}

_{3. In no case will a Covered Service Member be designated as both a primary and secondary caregiver and permitted to receive both Primary and Secondary Caregiver Leave for the same qualifying birth event or qualifying adoption.}

_{4. In the case of a dual military couple, one Covered Service Member will be designated as the primary caregiver and the other Covered Service Member as the secondary caregiver. Each will be granted the caregiver leave associated with those respective designations. Caregiver leave is not transferable between members of a dual military couple.}

_{5. In the case of a Covered Service Member who desires designation as a primary or secondary caregiver for a qualifying birth event of a child(ren) born outside of a marriage, the member’s parentage must first be established.}

_{6. Designations of primary and secondary caregivers will be made as early as practicable. Ideally, at least 60 days in advance of an anticipated due date or anticipated date of a qualifying adoption.}

_{PARENTAL FAMILY LEAVE/ OTHER TIME AWAY FROM TRAINING}

_{SECNAVINST 1000.10B (https://www.secnav.navy.mil/doni/Directives/01000%20Military%20Personnel%20Support/01-01%20General%20Military%20Personnel%20Records/1000.10B.pdf)}

_{ABFM Family leave Policy and Time Away from Training Guidelines for Board-Eligibility (}https://www.theabfm.org/sites/default/files/PDF/ABFM%20Family%20Leave%20Policy-5-21-2020.pdf₎

_{1. This document of policy is drafted in line with the most recent ABFM family leave update (2020, reference b). The purpose is to support residents as they add to their families and attend to major personal or family health events. ABFM sites circumstances in line with the federal Family and Medical Family Leave Act (FMLA), including:}

_{a. The birth and care of a newborn, adopted, or foster child, including both birth- and non-birth parents of a newborn.}

_{b. The care of a family member* with a serious health condition, including end of life care}

_{c. A resident’s own serious health condition requiring prolonged evaluation and treatment}

_{*Decisions about what constitutes family member and what constitutes serious health condition is best left to the Program Director and their institutional policies. ABFM intends to leave those decisions at the local level where they are best able to be individually made.}

_{2. This policy does not apply to other types of personal leave and/or interruptions from a residency (e.g., prolonged vacation/travel, unaccredited research experience, unaccredited clinical experience, military or government assignment outside the scope of the specialty, etc.). This policy likewise does not apply to periods of time for which a resident does not qualify for credit by reason of resident’s failure to meet academic, clinical, or professional performance standards.}

_{3. Approval is not required to be sought from ABFM if a resident takes Family Leave as outlined as long as the resident is on schedule to meet other training requirements. However, ABFM still requests that residencies report in RTM any Family Leave or other LOA, even when extension of training is not required, to allow for data tracking that supports ongoing evaluation of this policy change.}

_{4. Time Allowed for Family Leave}

_{a. Family Leave Within a Training Year: ABFM will allow up to (12) weeks away from the program in a given academic year without requiring an extension of training, as long as the Program Director and CCC agree that the resident is ready for advancement, and ultimately for autonomous practice. This includes up to (8) weeks total attributable to Family Leave, with any remaining time up to (4) weeks for Other Leave as allowed by the program.}

_{b. There is no longer a requirement to show 12 months in each PGY-year for the resident to be board-eligible; however, by virtue of the allowable time, a resident must have at least 40 weeks of formal training in the year in which they take Family Leave. This policy also supplants the previous 30 day limit per year for resident time away from the program.}

_{c. Total Time Away Across Training: A resident may take up to a maximum of 20 weeks of leave over the three years of residency without requiring an extension of training. Generally speaking, 9-12 weeks (3-4 weeks per year) of this leave will be from institutional allowances for time off for all residents; programs will continue to follow their own institutional or programmatic leave policies for this.}

_{d. If a resident’s leave exceeds either 12 weeks away from the program in a given year, and/or a maximum of 20 weeks total, (e.g. second pregnancy, extended or recurrent personal or family leave) extension of the resident’s training will be necessary to cover the duration of time that the individual was away from the program in excess of 20 weeks.}

_{e. Residency Directors must make appropriate curricular adjustments and notify ABFM of requested extensions through the RTM system, for approval by ABFM. Reports must include an explanation for the absence from training, the number of total days missed, and a plan for resuming training as basis for calculating a new graduation date. Residents must still achieve 1650 continuity visits by the end of residency and each year of residency must include a minimum of 40 weeks of continuity clinic.}

_{5. Additional Considerations}

_{a. ABFM will allow Family Leave to cross over two academic years. In this circumstance, the Program Director and sponsoring institution will be the ones to decide when the resident is advanced from one PGY-year to the next.}

_{b. Other Leave time may be utilized as part of approved Family Leave, or in addition to approved Family Leave. ABFM encourages programs to preserve a minimum of one week of Other Leave in any year in which a resident takes Family Leave. Consideration should be given to the importance of preserving some time away for resident well-being outside of a period of Family Leave.}

_{c. Residents are expected to take allotted time away from the program for Other Leave according to local institutional policies. Foregoing this time by banking it in order to shorten the required 36 months of residency or to retroactively “make up” for time lost due to sickness or other absence is not permitted.}

_{d. Time missed for educational conferences does not count toward the time away from training under the Family Leave time allowed in this policy.}

_{6. Certification Timeline in Instances of Extension of Residency Training}

_{a. When a resident’s training completion dates change, ABFM will provide opportunities to take their initial certification exam within the year, as described below:}

_{i. If they are anticipated to complete training between July 1st and October 31st, they may apply for and take the Certification Examination in April of their PGY-3 year, with permission from the program director through the RTM system.}

_{ii. If they are anticipated to complete their residency between November 1st and December 31st, they will be eligible to take the Certification Examination in November of their graduating year. Residents completing training between January 1 and April 30 of the following year may also apply for the November exam with permission from the program director through the RTM system.}

_{NAVY POLICIES FOR LACTATING SERVICE MEMBERS}

_{OPNAVINST 6000.1D}

_{1. COs must develop command policies to delineate support of breastfeeding Service members.}

_{2. COs must ensure the availability of a private, clean room for expressing breast milk. A separate toilet space is unacceptable for breast milk expression due to sanitary concerns. Commands must ensure breastfeeding Service members have ready access to running water for hand washing and pump equipment cleaning within the same room as the lactation room. Service members may store breast milk in an insulated container for up to 24 hours and refrigerated for up to 5 days. Breast milk should be contained and labeled to avoid contamination by other items located in the vicinity.}

_{3. TRICARE provides breast pumps and breast pump supplies at no cost for new mothers.}

_{POLICY FOR LACTATING RESIDENT}

_{1. A minimum of 30 minutes every 2.5 hours (resident dependent) shall be granted to express breast milk for any lactating resident.}

_{2. When lactating residents are in the clinic, 40 minutes per half day will be allocated to expressing breast milk. No patients will be booked during that time.}

_{3. During inpatient rotations, the rotation coordinator should be notified of the resident’s lactation requirements. Residents are responsible for notifying the inpatient team/attending of times they will be away for expressing breastmilk. Inpatient teams/attendings should make accommodations to the schedule (rounds, teaching, etc.) to time when the resident is not expressing breast milk whenever possible.}

_{4. An attempt should be made to accommodate resident’s preference of office space (i.e. smallest office possible with other female residents). Pumping is allowed in the resident’s office space and privacy should be respected when possible.}

_{5. Residents will be granted access to NHCP lactation room on the 3rd deck (MSW).}

_{6. Residents will be granted access to refrigeration in the lactation room, breakroom, or personal refrigerator (as long as it complies with NHCP appliance policies).}

_{SUPERVISION OF RESIDENTS AT NAVAL HOSPITAL CAMP PENDLETON}

_{Purpose - The purpose of this document is to establish guidelines and responsibilities regarding the supervision of resident physicians by members of the medical staff at Naval Hospital Camp Pendleton (NHCP).}

_{Supervision of Residents}

_{1. Inpatient Supervision:}

_{a) PGY-1 residents are unlicensed physicians and will require co-signature on all notes, H&Ps, and other documentation. On rotations with senior residents, all work including physical exams, notes, and decision making should be supervised by a senior resident. A senior resident should co-sign all notes, providing supervision and taking ownership of the patient care. For rotations without senior residents, staff must sign all notes and supervise all aspects of PGY-1 residents or other non-licensed trainee’s performance.}

_{b) PGY-1 residents must ensure timely and accurate communication to senior residents and staff assigned to supervise them.}

_{c) PGY-2/3 residents, and trainees of commensurate experience in other training programs, are expected to work more independently. All daily inpatient notes and H&Ps must be cosigned by staff.}

_{d) Staff must be readily available by phone for consultation at all times by trainees. If not present in the hospital, all staff must come in to the hospital at the trainee’s request to help manage patients.}

_{e) Staff are expected to organize rounds with the resident or trainee team at least daily. The primary purpose of these rounds is to ensure safe patient care, but they should also include relevant teaching and trainee feedback.}

_{f) Attending staff should review daily progress notes and co-sign notes daily or more often based on the patient’s condition. The attending staff is required to ensure accurate and thorough progress notes are completed in a timely manner.}

_{g) All discharges and transfers must be approved in advance by the attending provider.}

_{2. OB Inpatients:}

_{a) Patients admitted to L&D will be admitted to either the Family Medicine Inpatient Team or the Obstetrics and Gynecology (OB/GYN) service.}

_{b) The attending staff will write an admission note on an obstetric patient within twelve hours of that patient’s admission. Staff OB/GYN physician involvement will occur as soon as possible if the patient is considered high risk or complicated.}

_{c) Supervision of Trainees Caring for Obstetrical Patients. Trainees caring for obstetrical patients on the Labor Deck or on the wards are supervised by appropriately privileged attending staff (e.g., an Obstetrician, Nurse Midwife, Family Medicine staff physician with obstetrical privileges, etc.). An Obstetrician will be present, in the hospital, twenty-four hours a day, seven days a week for consultation and emergency intervention.}

_{d) An attending staff will be present in the hospital and immediately available for all deliveries}

_{e) All residents must be directly supervised by supervising staff for deliveries. All PGY-1 resident must be directly supervised by either a senior resident or staff for common obstetrical procedures. PGY-2 and PGY-3 residents may be indirectly supervised for common obstetrical procedures based on competency evaluation. A list of residents along with level of supervision required for selected procedures will be iteratively updated and posted, typically on the Command Intranet.}

_{f) An attending physician will make daily rounds on all obstetrical patients.}

_{3. OB Triage/Outpatients:}

_{a) On L&D, senior residents who have qualified as senior OB/ICU; (SOBI) may release patients after appropriate evaluation and treatment, and after consultation with supervising staff. Junior residents must discuss all patients with the SOBI or attending staff prior to releasing a patient.}

_{b) Attending staff will review and co-sign the charts of all L&D patients prior to relinquishing the duty to on-coming staff.}

_{4. Supervision of Residents in Outpatient Clinics:}

_{a) Residents in the Family Medicine Clinic: Each workday morning and afternoon, at least one staff Family Physician will be designated as the clinic preceptor. Additional preceptors may be assigned as determined by resident supervisory and educational needs. The preceptor(s) will oversee resident care of clinic patients and will remain immediately available, without other obligations, in the Family Medicine clinic throughout the period residents are seeing patients. It is the responsibility of this clinician to provide appropriate procedural and didactic instruction necessary to educate the residents and ensure high quality patient care.}

_{b) 100% of outpatient clinic encounter notes for all residents (PGY1, PGY2, and PGY3) must be cosigned by a staff physician.}

_{c) 100% of OB patients are precepted by all residents (PGY1, PGY2, and PGY3)}

_{d) 100% of patients who are sent to the Emergency Department from clinic are precepted}

_{e) Year Group Specific Requirements:}

_{(1) PGY1s: Precept 100% of outpatient encounters for the entire academic year.}

_{a) Supervising staff will additionally provide direct supervision by seeing each PGY1 patient for the first 3-6 months of training, as dictated by the Clinical Competency Committee and Program Director.}

_{(2) PGY2s: Precept minimum of 2 non-OB patients per half-day of clinic.}

_{(3) PGY3s: Precept minimum of 1 non-OB patient per half-day of clinic.}

_{f) When precepting a patient, the precepting must occur prior to the patient leaving the clinic.}

_{g) Residents in Other Clinics: Expect to precept 100% of patients and send 100% of notes for cosign to attending staff physicians unless directed otherwise by your attending staff physician.}

_{5. Supervision of Procedures:}

_{a) All residents are encouraged to perform procedures during inpatient and outpatient rotations.}

_{b) Attending staff are responsible for supervising procedures and for co-signature of all procedure notes completed.}

_{c) All residents must be directly supervised during procedures by credentialed staff until they are approved by the Program Director to perform the procedure under indirect supervision. Following approval, residents should be indirectly supervised with direct supervision immediately available.}

Management of Continuity Couplets

Continuity is a hallmark and primary objective of family medicine. Residents are expected to participate in the pre-natal care, delivery, and postpartum care of their panel of OB continuity patients throughout training.

1. OB continuity providers are assigned by the Family Medicine (FM) OB LVN at the beginning of pregnancy. Please refer to the OB continuity excel spreadsheet maintained and periodically shared by the FM OB LVN to track continuity patients. Residents are responsible for any continuity patients assigned to them even if they have not routinely seen the patient during their pre-natal course. The continuity provider is also listed in Genesis under Obstetric Care View -> EDD Maintenance -> Comments. This should populate at the top of any OB note for the patient.

2. If a continuity provider is on leave or TAD at the time of delivery, their surroagate is expected to care for the couplet in the hospital. Residents should sign out any continuities they expect to deliver in their absence to their surrogate for situational awareness.

3. It is the SOBI/senior OB resident's responsibility to notify any FM provider (intern, resident, staff, or their designated surrogate physician), when his/her OB patient is admitted in labor. The continuity provider should be listed in Genesis as above, but one can also refer to the OB continuity excel spreadsheet.

4. If the resident and/or their surrogate is post-call or feels impaired for any reason, then they may elect to delegate care of the laboring patient to the on-call team. Similarly, if the SOBI/senior OB resident is unable to reach the primary physician or their surrogate, then the on-call team will provide care of the laboring patient.

5. Uncomplicated post-partum OB patients and newborns will be managed by their continuity provider or designated surrogate. This will include daily rounds and a daily progress notes. They will be supervised by the FM MIU attending. All OB and newborn notes need to be co-signed by an attending. The attending also needs to co-sign all OB and newborn discharge orders.

6. In the rare circumstance that an FM patient does not have a clear continuity provider (for example, resident recently graduated and the patient has not been reassigned) or both continuity provider and their surrogate are unreachable/unavailable, daily rounding for mom and baby will be delegated to the senior OB resident. The senior OB resident will staff with the FM MIU attending for FM couplets. This discussion should occur at morning OB board turnover when all parties (SOBI, senior OB resident, and FM MIU staff) are present to make sure there is a clear plan for the couplet care.

7. Outside of rounds, during the business day, it is understandable that a continuity provider may not be readily available for acute issues with their couplet due to their other clinical responsibilities. In this scenario, post-partum FM moms and newborns needing acute management of complications will be managed by the FM MIU attending in collaboration with available OB and pediatric residents on the ward in order to maximize resident training opportunities. After-hours, FM couplets needing acute management of complications should be managed by the MOOD/SLASH.

OB continuity rules:

1. Residents are required to complete a minimum of 10 continuity deliveries prior to graduation. Residents are expected to continue to make every effort to deliver and care for their continuity patients even after meeting the minimum 10 deliveries.

2. To count a delivery as a continuity delivery, a resident must have seen the patient at least once as an outpatient (this can include a triage visit). They must be present for either delivery or baby care. If enroute and patient delivers prior to arrival, but resident is able to perform the newborn physical exam and note within an hour of life, this effort still counts towards continuity. For patients who go to c-section, it also counts if you either assist with the c-section or provide baby care in the OR. The resident is also required to round on the couplet to the point of discharge or find coverage.

3. For any given delivery, only one resident may count it as a continuity delivery. A supervising resident may still count the delivery toward their total delivery numbers.

4. It is the resident’s or their surrogate’s responsibility to coordinate coverage and/or round themselves by 1200 each day.

5. All residents and staff will report their continuities to the MOOD daily for turnover to the night team

6. All continuities will be recorded in New Innovations with continuity number in comment block (e.g. “Continuity 7/10”)

7. Failure to adhere to these expectations will lead to loss of the continuity number. If a pattern of poor patient care is noted (failure to round on couplets, failure to show for deliveries, failure to provide a safe and timely turnover), then a resident should expect verbal and/or formal written counseling from the APD/PD.

_{RESIDENT WATCH RESPONSIBILITIES}

_{The hospital will be covered at night and weekends by four residents, assuming the roles of MOOD, SLASH, SOBI and JOB. The specific responsibilities are outlined below.}

_{1. Medical Officer of the Day (MOOD): On board medical advisor for the Officer of the Day, serves as medical backup for all problems in the hospital.}

_{a. Can be assumed by a GME-2 or 3}

_{b. Coordinates medical resources in times of overload and all admissions.}

_{c. Obtains history and physical exam for each admission.}

_{d. Fields all requests for transfers into NHCP, and makes decision to accept or deny (after phone consultation with staff on in-house call for respective service).}

_{e. Deciphers critical lab results received after-hours upon notification from the lab.}

_{f. Responsible for teaching and supervising interns.}

_{2. SLASH: Partners with the MOOD as the night team; usually an intern.}

_{a. Admission history, physical, and orders.}

_{b. Manages issues on the wards in partnership with the MOOD and/or staff.}

_{3. SOBI (Senior OB/ICU): Senior resident in-house; responsible primarily for Labor and Delivery, but also has cognizance of the Special Care Nursery and ICU, and should be available to assist the MOOD when needed.}

_{a. Supervises all deliveries.}

_{b. Authority to admit (must consult with staff at time of admission).}

_{c. Authority to discharge patients after evaluation (must review all JOB triage encounters) and approved by staff.}

_{d. Serves as consultant (with staff back up) for OB/GYN cases from the ER.}

_{e. First choice to assist with all OB/GYN surgical procedures occurring on watch.}

_{4. JOB (Junior OB watch): Works directly with the SOBI on Labor and Delivery.}

_{a. May be filled by all year groups.}

_{b. Should be first in line to perform all deliveries and other procedures.}

_{c. Responsible for all admissions (unless otherwise directed by SOBI).}

_{d. Responsible for cross-coverage as first call for OB post/antepartum patients.}

_{5. Turnover to the MOOD and SLASH occurs in the team workroom on MSW at 1700 and 0600.}

_{6. Pediatrics interns, Adult Medicine Service, and Surgery interns will check out with the MOOD and SLASH for each respective service. A “Sign-out” sheet for each service is maintained by the residents and must be utilized. Turnover should follow the I-PASS format.}

_{a. All FP couplets must be turned over to the MOOD for situational awareness either in person or by phone.}

_{7. The watch residents must be made aware of any concerning patients, particularly in the ICU, and those with pending lab/x-ray results, or cross cover work to be done.}

_{8. Labor and Delivery turnover daily at 0715 and 1800 on weekdays, and 0745 and 1800 on weekends. This includes off-going residents and staff covering L&D during current shift, and the SOBI, JOB and oncoming staff for the next shift. The OB ward team will ensure check out on MIU patients to the SOBI/JOB.}

_{TRANSITIONS OF CARE}

_{In 2006, the Joint Commission added transitions in patient care to its National Patient Safety Goals, referencing the need for "a standardized approach to hand-off communications, including an opportunity to ask and respond to questions." This goal is even more essential since limits on duty hours have also increased the use of "cross coverage," defined as residents outside of the primary care team providing care in the absence of the primary team. Despite the ACGME's requirement that programs ensure that residents are competent in the hand-over process, resident physicians believe transitions are not adequately addressed in education and practice. Many note that processes are haphazard, with no system of organized interaction.}

_{Handoffs should provide timely, accurate information about a patient's care plan, treatment, current condition and any recent or anticipated changes. Handoffs should: 1) be standardized and clearly defined; and 2) involve face-to-face exchange between the caregivers involved.}

_{Below is the current model that was adopted by our program in 2015. Being aware of this protocol and employing it systematically each and every time will allow us to remember the most important information to communicate during a handoff.}

_I-PASS

_I

_{Illness Severity}

_{● Stable, “watcher,” unstable}

_P

_{Patient Summary}

_{● Summary statement}

● _{Events leading up to admission}

● _{Hospital course}

● _{Ongoing assessment}

● _Plan

_A

_{Action List}

_{● To do list}

● _{Timeline and ownership}

_S

_{Situation awareness and contingency planning}

_{● Know what’s going on}

● _{Plan for what might happen}

_S

_{Synthesis by Receiver}

_{● Receiver summarizes what was heard}

● _{Asks questions}

● _{Restates key action/to do items}

_{SUPPLEMENTS FOR MOOD WATCH}

_{The job of the Officer of the Day (OOD) is outlined in NAVHOSPCAMPENINST 1601.1B. There are certain duties of the OOD of which the MOOD should be aware. The OOD is the after-hours extension of the CO of the hospital. The Instruction reads: “The OOD has authority over all personnel assigned to the command except the CO and XO, but the OOD must understand the nature of the business of treating the ill, and that clinical decisions have precedence over all decisions”. These clinical decisions are made by the MOOD. Specific duties of the OOD that affect the medical officers standing watch are:}

_{Conducts decedent affairs interviews}

_{Is notified for all VIP admissions (if unsure, notify OOD)}

_{Notifies the California State Medical Examiner any time a death by trauma, alcohol, or criminal activity that occurs in the hospital}

_{Oversees the “Code Blue” paging system checks that occur daily}

_{Handles all questions of patient eligibility for care}

_{Oversees obtaining blood products when not available in our lab}

_{Provides medical information to other requesting commands}

_{Assists with obtaining any urgently needed supplies/equipment}

_{Oversees the cleanup of hazardous spills}

_{Oversees and signs all disengagement paperwork ensuring that it is accurate}

_{Code Blue pagers are carried by MOOD, SLASH, NOD (nurse of the day), duty respiratory therapy technician (RT), anesthesia watch (may be an anesthesiologist or nurse anesthetist), and the ED staff physician.}

_{GUIDELINES FOR THE RESIDENT WATCHBILL}

_{1. Resident requests for leave and TAD must be reported to the watchbill coordinator via the academic year leave request forum at least two (2) months prior to the start date. Requests made after the watchbill is written will be denied unless the requesting resident can arrange coverage.}

_{2. Residents on the following rotations are not generally put on the watchbill, and those returning from a full-out rotation should not be put on call immediately upon returning:}

_{a. ICU}

_{b. NICU}

_{c. Palomar ER}

_{d. UCSD Hospital Inpatient Medicine}

_{e. Obstetrics}

_{f. Rady Children’s Hospital}

_{3. In general, interns and residents will have 1-2 weekend shifts per month, typically lasting 14-16 hours (except for the Sunday SOBI and MOOD).}

_{4. Listed below are the recommended residents to stand each type of watch:}

_{a. SOBI: Primarily a GME-3, except later in the year when a GME-2 has met rotational requirements, and is approved by both OB and FM departments. Required rotations include GME-2 OB, NICU and Children’s.}

_{b. JOB: Can be any resident.}

_{c. MOOD: Any qualified intern or resident who has completed and passed ICU, PGY-1 Adult Medicine, and pediatrics ward rotations.}

_{d. SLASH: Any resident, but typically held by an intern.}

_{5. Special requests should be limited to one per month. Any request of more than 48 hours off the watchbill requires a leave request. Without a leave request, any resident is eligible for pre-scheduled and emergency duty coverage.}

_{6. Residents are off the watchbill entirely for the following events:}

_{a. Holiday party in December}

_{b. Friday evening of the resident retreat during the Fall/Spring}

_{c. Hail and Farewell in June.}

_{7. Attempts will be made to schedule call so as not to interfere excessively with rotations.}

_{8. It is every resident’s responsibility to review the watchbill after it is published to identify any errors.}

_{9. Emergencies occur throughout the year requiring last-minute changes and coverage of watches. A spirit of cooperation and teamwork is essential in helping to deal with these difficult times. Unless leave has been submitted, any resident is eligible to be scheduled duty in an emergency. Priority will go to residents with the least number of total duty days on an outpatient rotation.}

_{10. When possible, a make-up liberty day will be granted to anyone called upon for emergency duty. Logistics chief will notify the resident’s outpatient rotation coordinator of this request and rotation coordinator’s approval is required. Previously scheduled clinic will not be cancelled for make-up liberty day. Can be used within 7-10 days of emergency duty shift.}

_{11. All residents should understand that designing a resident watch schedule is arduous and difficult. If you have a concern, utilize your chain-of-command to address it.}

_{POLICY FOR A RESIDENT REQUESTING A CHANGE-OF-DUTY}

_{1. Residents may request that a watch change occur after the watchbill has been created.}

_{2. Once posted, duty can only be changed when a fellow resident has agreed to swap duty days.}

_{3. Residents should complete the change of duty request in the forum approved for the respective academic year.}

_{4. This form should be routed through the resident watch coordinator chain of command.}

_{5. Reasons for disapproval include:}

_{a. Results in post-call clinics that cannot be changed.}

_{b. Results in an unacceptable work hour load that may compromise patient and resident safety.}

_{c. Involves a resident covering duties they are not qualified to cover.}

_{d. Does potential harm to the residency or command.}

_{6. Once approved the watchbill coordinators will change the duty in Amion.}

_{7. Residents must also check the schedule of the day on the days of the affected changes to confirm the change is accurate, and if not notify all relevant departments of the change.}

_{8. Failure to comply with these regulations may result in loss of this privilege in the future.}

_{RESIDENT WORK HOURS}

_{1. Residents will not work more than 80 hours per week, averaged over 4 weeks.}

_{2. Residents will have one (1) day off every seven (7) days, averaged over 4 weeks.}

_{3. Residents will be limited to 24 hours of continuous duty. The specific language in the “Common Program Requirements” is as follows:}

_{a. “In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.}

_{b. Under those circumstances, the resident must:}

_{i. appropriately hand over the care of all other patients to the team responsible for their continuing care}

_{ii. document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.}

_{4. The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.”}

_{5. Post-call clinics will not be scheduled by the program.}

_{6. There must be a minimum of eight (8) hours between work periods.}

_{7. Residents are expected to work together as a team on inpatient rotations in order to help each other meet these work hour rules, particularly ensuring adequate numbers of days off. Weekend rounds should be done utilizing the least number of residents needed.}

_{8. Residents who feel the work hour rules are being violated should report problems to the Chief Residents as soon as possible.}

_{DAILY EXPECTATIONS}

_{1. On inpatient services, morning rounds are to be completed prior to 0730 or after 0800. Afternoon rounds should be completed prior to 1700.}

_{2. Residents have mandatory didactics every Monday-Friday AM 0730-0800 (except the first Monday of new rotations), and 1215-1500 each Thursday.}

_{3. The work hours of 0600-1800 are considered only a rough guideline. Residents may need to stay longer on some days in order to complete admissions, perform procedures or participate in great learning cases. When this occurs, effort should be made to release the residents from duty earlier than 1700 on days when workload permits and learning opportunities are not present.}

_{4. Residents on inpatient rotations may round on previous patients, but are not allowed to see new patients or attend OR cases during the post-call period.}

_{5. Residents are not allowed to attend non-FMC clinics when post-call.}

_{6. Residents may attend an OR case of a patient they admitted while on call as long as the surgery will not extend past the four-hour post call limit.}

_{RESIDENT FATIGUE}

_{1. Resident fatigue can become a detriment to both resident training and delivery of quality patient care. With that in mind, it is the FM department's policy to create patient care mechanisms that attempt to avoid excessive resident fatigue.}

_{2. Residents should spend one day out of seven, averaged over 4 weeks, outside the hospital.}

_{3. Residents should not be on call more frequently than every third night averaged over 4 weeks.}

_{4. Any resident delivering OB care to one of his/her patients the night before or after a watch should use common sense concerning fatigue. The resident should consider turning OB/L&D care over to the SOBI/JOB if it appears that a significant amount of sleep will be lost.}

_{5. Any time a Resident is too fatigued to perform his/her duties they should report to their supervisor to be relieved. In the daytime this supervisor is their FM Team Leader. At night, this supervisor is either the SOBI or MOOD.}

_{6. All residents are to be trained using Sleep, Alertness, and Fatigue Education in Residency (SAFER) on the risks of sleep deprivation and fatigue.}

_{IMPAIRED RESIDENTS}

_Purpose

_{The overall goal of the FM training program is to produce fully competent physicians, capable of providing high quality care to their patients. Impairment by drugs/alcohol or by psychological difficulties can hinder the professional development of our residents, and threaten the health and welfare of our patient population and the efficiency of our clinical and academic operations.}

_{It is essential that resident impairment be prevented or when present, be rapidly identified and dealt with in a manner which leads the resident away from impairment while protecting the welfare of our patients.}

_Prevention

_{1. The high stress environment of residency training can create a fertile environment for both drug abuse and psychological illness such as depression. All staff and residents must be active in preventing this stress from creating impairment.}

_{2. To help alleviate some of the physical stresses of residency training, a resident should spend at least one day out of seven, averaged over 4 weeks, away from the hospital.}

_{3. Residents should be encouraged to be physically fit, and be given adequate time to maintain a regular fitness program.}

_{4. Residents should be encouraged to socialize away from the training program. However, events that encourage abuse of alcohol are discouraged.}

_{5. The Navy maintains an active random urine screening program for surveillance for illegal drug use. This is part of a clear-cut zero tolerance of illegal drug use by all military members.}

_{6. Advisors must be vigilant for signs that the pressures of training are overwhelming the resident. Advisors will meet one on one with each resident at a minimum of every three months for quarterly evaluations, and should investigate problems that stress might be causing their residents. Advisors have many informal ways of helping to alleviate stress including assisting with clinical duties, and using liberty or leave when deemed appropriate. Advisors must also be vigilant for signs of illegal drug or excessive alcohol use.}

_{7. The residents must know that help is readily available when they need it, and that (with the exception of illegal drug use) it will be a high priority to maintain a resident's position in the training program, while ensuring both the health and welfare of the resident and that of our patients.}

_Intervention

_{1. The decision that a level of impairment has been reached which requires formal intervention will be made by the FM staff in consultation with the PD and APD.}

_{2. A plan for intervention will be formulated which may include the use of psychiatric and substance abuse professionals. The combined goals of returning the resident back to the training environment and protecting the welfare of our patients will be considered in all decisions regarding this intervention program.}

_{3. Because of the Navy's clear-cut zero tolerance for illegal drug use, a resident impaired by illegal drug use will be at risk for removal from both the training program and the Navy.}

_Procedures

_{Information sources from which a possibly impaired resident can be identified include (but are not limited to) the following:}

_{Performance evaluations from preceptors on clinical rotations}

_{Complaints from patients or staff}

_{Command and Departmental Quality Improvement Indicators}

_{Input from the Command Family Advocacy Program}

_{Any observed negative change in behavior, appearance, or level of clinical or academic performance}

_{JAGMAN reviews or malpractice claims}

_{Prosecution for military or civilian infractions (other than minor)}

_{Military or civilian referral for substance abuse counseling}

_{In each case, the resident will be formally counseled by the PD and/or the APD and given an opportunity to make appropriate explanation or defense. At the close of the interview, the PD/APD may recommend any one of several actions including:}

_{Formal observation}

_{Ongoing or temporary psychological counseling}

_{Alcohol rehabilitation referral}

_{Physical examination}

_{Command directed drug and alcohol testing}

_{Remedial academic training}

_{Removal from patient care and suspension pending additional investigation and treatment if indicated}

_{The results of this formal counseling session and all follow-up counseling shall be clearly elucidated in the resident’s training record, with the counseling notes signed by the resident.}

_{While every effort shall be made to retain temporarily impaired residents in training, the welfare of the training program and our patient population dictate that no impairment can be tolerated indefinitely without progress toward resolution. A period of three to six months will generally be considered the maximum reasonable interval before return to full function is required.}

_{Separations from resident training shall be subject to relevant NAVHOSP and BUMED instructions.}

_{SECTION III: CURRICULUM}

_{GME-I Curriculum}

_{The first year resident is concerned primarily with inpatient rotations, where the resident will gain in-depth knowledge and experience in all the major specialty areas. The resident spends 1-2 half-days per week in the FM Clinic with a panel of approximately 75 patients.}

_{The first year resident should receive one new OB patient every other month during the year.}

_{The resident will spend one 4-week block in the ICU at NMCSD. The resident may also complete C-4 in San Antonio, Texas, during the year, and it will be scheduled during one of the outpatient services months.}

_{A typical first year schedule includes:}

_{Adult Medicine Inpatient 8 weeks}

_{General Surgery Inpatient 4 weeks}

_{Obstetrics (L&D, MIU) 4 weeks}

_{Gynecology Clinic 4 weeks}

_{Pediatrics Inpatient 6 weeks}

_{Orthopedics 2 weeks}

_{Sports Medicine 2 weeks}

_{Emergency Room 4 weeks}

_{Ophthalmology 2 weeks}

_{Psychiatry 2 weeks}

_{ICU (NMCSD) 4 weeks}

_{Family Medicine Clinic 4 weeks}

_{Dermatology Clinic 4 weeks}

_{Night float (Medicine or OB) 2 weeks (1 week each during Pediatrics)}

_{GME-II Curriculum}

_{The resident at the second year level increases their FM Clinic time to two to four half-days, with an increasing number of patients on the panel, approximately 250, and responsibility. The remainder of the residents time is spent in various rotations and electives.}

_{The second year resident should receive one new OB patient every month.}

_{In addition, the second year resident increases supervisory responsibility working with the first year residents after-hours as MOOD, and during admissions on the wards and covering the various services. The second year resident may also cover the JOB watch.}

_{The resident also receives additional training in Neonatal ICU at NMCSD and inpatient pediatrics at Rady Children’s Hospital. The resident is expected to enter into an active teaching role for interns and to begin planning and presenting some of the didactic conferences.}

_{The typical second year schedule includes:}

_{Inpatient Pediatrics (Rady Children’s Hospital) 4 weeks}

_{NICU (NMCSD) 4 weeks}

_{Obstetrics 4 weeks}

_{Population Health 4 weeks}

_{Adult Medicine Inpatient / ICU 8 weeks}

_{Cardiology 4 weeks}

_{Geriatrics (Hospice included) 4 weeks}

_{Neurology 4 weeks}

_{Pediatrics Clinic 4 weeks}

_{ENT 2 weeks}

_{Scholarship 2 weeks}

_{Elective 4 weeks}

_{Pediatric ER (Rady Children’s Hospital) 4 weeks}

_{GME-III Curriculum}

_{A senior resident spends three to five half-days in the FM Clinic seeing a panel of approximately 375 patients. The remainder of the resident’s time is spent in subspecialty rotations.}

_{The resident has enhanced supervisory roles, while serving as the MOOD, SOBI, or intern-level watches. The resident’s responsibilities consist of teaching both first and second year residents in all areas of Family Medicine.}

_{In the clinic, the resident is directly responsible to their Staff Team Leader and will provide supervision for the junior residents when the staff physician is not available.}

_{The third year resident shall receive one new OB patient every month.}

_{The typical third year schedule includes:}

_{UCSD, Inpatient Medicine 4 weeks}

_{Sports Medicine 4 weeks}

_{Adult Medicine Inpatient 4 weeks}

_{AMMO (AM Inpt admits, PM clinic) 4 weeks}

_{Palomar ER 4 weeks}

_{Obstetrics 4 weeks}

_{Urology 4 weeks}

_{Scholarship 4 weeks}

_{Elective 8 weeks}

_{Radiology 2 weeks}

_{Endocrine/Med Subspecialty 2 weeks}

_{Pediatric Clinic 4 weeks}

_{Family Practice Management 4 weeks}

_{Elective Rotation Examples (Staff POC as of 2021):}

_{POCUS (Fish/Hughes)}

_{Pulmonology (Hogan)}

_{Allergy/Immunology (Naimi)}

_{Pharmacology (Khosho)}

_{Infectious Diseases (Dr. Groff at NMCSD)}

_{Faculty Development at USUHS}

_{Full Scope OCONUS (Rota, Spain)}

_{Residents have also elected to get extra training in rotations that we already do…}

_Ophtho

_ENT

_Sports

_{Urology at NMCSD (for additional vasectomy training)}

_{SECTION IV: CONFERENCES AND LECTURES}

_{RESIDENT RESPONSIBILITIES FOR LECTURES}

_{Daily presentations are a hallmark of the education we receive throughout residency. The opportunity to give a presentation to your fellow residents is an excellent time to research and develop your knowledge of a subject area that will serve you well in your future practice and board examinations.}

_{Please take this time to review the literature and to produce a good quality, evidence based presentation. Below is a brief overview of the specific lectures that will be given throughout each academic year. To prevent covering topics numerous times throughout the year please discuss your topic with the designated lecture schedulers prior to preparing the presentation. Details on what these presentations entail can be found below the table.}

_Year

_{Required Lectures}

_Intern

_{Medicine Case Report x 2}

_{ICU Case}

_R2

_{OB Lecture}

_{Ambulatory Medicine}

_R3

_{Patient Safety}

_{Art of Medicine}

_{EBM Lecture}

_{Medicine Case:}

_{Typically this is a morning didactic presentation that reviews an interesting case from your medicine month. It should really focus on the overview, pathophysiology, diagnosis and treatment of the given condition. See extensive explanation below and use templates in the share drive.}

_{ICU Case (Interns):}

_{A morning report case presentation covering an interesting patient/topic you participated in at NMCSD. It will be done the month after your return, most likely the 2}^{nd or 3rd week of the following block. PLEASE pick a topic that you feel is applicable to family medicine.}

_{Art of Medicine (R3):}

_{This is a unique presentation in and of itself. It is very open-ended and can cover any topic you think your peers could benefit from. Previous topics covered were preventing burnout, ethical topics, music’s effects on mood, Japan’s culture/healthcare, how to navigate the sexual history, and even home security. This will be done during your third year research block.}

_{Extra Lectures:}

_{If there is a family medicine topic that you would like to review, learn more about and give a presentation on, then please volunteer! Residency is a time to work hard and improve your skills. The chance to review and give a presentation will also solidify your knowledge.}

_{ESSENTIAL CONFERENCES}

_{Didactic conferences and lectures are an integral part of the Family Medicine training curriculum. They are provided to enhance resident learning in addition to clinical experience gained on the various rotations and in the FM Clinic.}

_{Each Thursday afternoon lecture/topic is scheduled for 45 minutes to one hour with a total of approximately 150 hours per year. Each morning conference is scheduled for 30 minutes with a total of approximately 125 hours per year.}

_{A comprehensive 18-month didactic curriculum was designed and is maintained with involvement from teaching staff and residents. Most topics for lectures and workshops should come from this master list. It is readily available on the SHARE Drive.}

_{Conference attendance is mandatory. When a resident is involved in a clinical activity, which in the best interest of the patient cannot be delayed, they may be excused by notifying the chief resident, team leader, or PD/APD. The APD and Team Leaders will track conference attendance. Those residents who routinely miss conferences may have an adverse ranking on Quarterly evaluations and fitness reports.}

_{MORNING REPORT}

_{Morning report begins promptly at 0730 every morning with the exception of the first Monday of new rotations when no report is held. The morning begins with the ringing of the bell by either Chief Resident or Senior Medicine/OB with announcement of admissions and deliveries then followed by a pre-scheduled presentation. Each resident/intern receives a morning report/Thursday conference schedule via the plan of the week on the NHCP Residency webpage each week.}

_{THURSDAY CONFERENCES}

_{The program conducts a block of didactic time on Thursday afternoons from 1215-1500. NHCP Staff or other guest speakers may present various topics, procedural workshops or simulation training.}

_{INTERN MEDICINE CASE}

_{The following are recommendations when preparing a successful medicine case:}

_{1. An intern should always present the case from the front of the room in a concise manner with the goal being a brief and accurate presentation.}

_{2. The R-2/R-3 then leads a discussion of the differential diagnosis}

_{3. This is meant to be an opportunity to discuss the process of evaluating a patient, establishing differential diagnoses and discussing the work-up that leads to the diagnosis.}

_{4. Always have available all pertinent laboratory, radiology, and ancillary studies, and be prepared to discuss and interpret.}

_{The following is a sort of checklist/go-by to help with preparation of the report:}

_{1. Intern: presents the case}

_{2. The intern’s senior resident will control the flow of the case’s differential and will write on the white board in form of:}

_{a. Most Likely}

_{b. Differential}

_{c. Must Rule Out}

_{d. Zebras}

_{3. Focus of a MOOD case is always to generate a differential dx and utilize features of the H&P and labs/imaging to adjust that differential}

_{Start with a Chief complaint}

_{Move to the HPI with an abbreviated ROS}

_{Answer clarifying questions about the HPI}

_{PMH, PSH, Meds, Allergies, SH, FH, Vaccines, Etc.}

_{Stop and now form the differential}

_{a. Most Likely}

_{b. Differential}

_{c. Must Rule Out}

_{d. Zebras}

_{Onto the Exam}

_{o Start with vital signs and general appearance then move briefly through the full exam, focusing on pertinent positives and negatives that will help navigate the differential, and always ask for other exam findings people are interested in}

_{Back to the Differential}

_{o In 1-2 minutes see if based on your exam you give more or less precedence to a particular diagnosis, re-rank accordingly}

_{Onto labs and imaging}

_{o If something is useful (EKG or imaging) put up on the screen}

_{Back to the Differential Again}

_{Pull the case together, and the most likely diagnosis should be selected}

_{Intern then presents brief description of take home point with added and relevant social determinants of health point}

_{EVIDENCE BASED MEDICINE}

_{This involves the critical review of a scholarly article and then presenting it during a scheduled journal club.}

_{The objectives of the Information Mastery & Evidence Based Medicine (EBM) curriculum are:}

_{1. To encourage residents to be life-long independent, self-directed learners}

_{2. To promote the recognition of information needs that arise in daily practice}

_{3. To encourage critical thinking when presented with information}

_{4. To utilize EBM principles on a regular basis to answer questions generated}

_{To fulfill the objectives, there will be one conference dedicated to information mastery during each block of the academic year.}

_{To maximize educational benefit and promote discussion during these sessions, the presenting resident will provide a copy of the chosen article to all staff/residents prior to the scheduled presentation. All participants will be expected to have read the article prior to the meeting.}

_{GRAND ROUNDS}

_{Grand Rounds will take place quarterly and are open to the entire medical staff. Currently the sessions involve topics thought to meet the broader interest of many different providers. Grand Rounds will be announced ahead of time, most often via the command Intranet page. The event with take place in the Galley Conference room or the FM Conference room.}

_{BEHAVIORAL SCIENCE}

_{Each rotation, several conference slots are devoted to Behavioral Science/Art of Medicine presentations. Behavioral Science topics will usually be presented by FM Mental Health staff, and residents must present an Art of Medicine topic. On occasion, other NHCP specialty staff or other invited speakers may be involved. Topics to be covered include, but are not limited to:}

_{Diagnosis and management of psychiatric disorders in children and adults}

_{Emotional aspects of non-psychiatric disorders}

_{Psychopharmacology}

_{Alcoholism and other substance abuse}

_{Physician/patient relationship}

_{Patient interviewing skills}

_{Counseling skills}

_{Normal psychosocial growth and development in individuals and families}

_{Stages of stress in a family life cycle}

_{Sensitivity to gender, race, age, sexual orientation and cultural differences in patients}

_{Family violence and neglect including child, partner, and elder abuse (physical and sexual)}

_{Medical ethics, including patient autonomy, confidentiality, and quality of life issues}

_{Factors influencing patient compliance}

_{Resident and Physician issues}

_{PATIENT SAFETY LECTURE}

_{A once a month morning report given by an R-3 after their medicine month with the goals of this lecture/resident responsibilities as follows:}

_{1. Identifies case with adverse or unexpected outcome or medical error or near miss. Cases may be drawn from any part of the hospital.}

_{2. Review and analyze the case to identify the number and types of errors which occurred.}

_{3. Develop a 20 minute presentation with the following components.}

_{a. Brief overview of rationale for case}

_{b. Review of case with timeline of key events}

_{c. Identification of errors and what type of errors (ex: omission, communication etc.)}

_{d. Identification of system errors that occurred, allowing error to reach all the way to the patient.}

_{e. What was the failure e.g. “Swiss cheese model?”}

_{f. Ideas for system based improvements.}

_{4. Goal is for these to be forwarded to Quality Management department or identified as possible process improvement projects for the hospital.}

_{ANNUAL CONFERENCES IN EMERGENCY MEDICINE}

_{These lectures are presented on an annual basis typically during the first month of the academic year, and then periodically throughout the year. They are presented by a variety of speakers from departments throughout NHCP, with an occasional guest from elsewhere.}

_{GI Bleeding}

_{Head/Neck Trauma}

_{Septic Joint}

_{Ophthalmologic emergencies}

_{Orofacial trauma}

_{Dermatologic emergencies}

_{Acute abdomen}

_{Burn injuries}

_{Spinal trauma}

_{Heat stress injuries}

_{Electrical injuries}

_{Abdominal trauma}

_{Bites, stings and envenomations}

_Anaphylaxis

_{Chest trauma}

_{Triage and disaster management}

_{Orthopedic emergencies}

_{ENT emergencies}

_{Hypertensive emergencies}

_{Depressed newborn}

_{Acute respiratory failure}

_Shock

_{Psychiatric emergencies}

_{Metabolic emergencies}

_{Acute Scrotum}

_{Overdose and poisoning}

_{Urogenital trauma}

_{Multiple trauma}

_{Acute MI}

_{Status epilepticus}

_{RESEARCH IN RESIDENCY}

_{An important part of graduate medical education is developing as physician-researchers. As frontline primary care physicians, we are uniquely situated to recognize patterns in patient presentations and response to therapy. Through the various platforms of resident scholarly activity, our program aims to foster an environment of inquiry and establish the habit of contributing to the body of knowledge in our discipline. With that in mind, we strive to provide robust support for our residents as they pursue excellence in research.}

_{Research Coordinators}

_{Research Coordinators exist to help support and expand scholarly activity at Pendleton. Please utilize them as resources if you are considering writing up a case or implementing a PI project. As detailed below, we expect all residents to participate in scholarly projects during their time with us. Research is a team sport and we aim to mentor our interns and work collaboratively with them on projects.}

_{Expectations and Minimums}

_{All residents are expected to complete a minimum of eight research points worth of scholarly activity during residency. The chart below shows the current point values of various scholarly activities. To keep track of all of the scholarly projects going on at Pendleton, we have created an excel tracker. Please log any projects you have completed during residency. Continue to log your scholarly activity (even after reaching the eight point minimum) as this is used by the program to assess the program as a whole. Moreover, residents who complete 20 or more points of research during residency will be recognized by the program with a Certificate for Excellence in Research. These numbers will also be used by the program when awarding the Annual NMRTC CP Research Award.}

_{http://bit.ly/NHCP_Research}

_{NHCP Research Point System Values}

_{February 2021}

_{Scholarly Activity}

_Value

_{Completion of an IRB approved research project or a published well-conducted process improvement project in a journal}

₁₀

_{Acceptance of a manuscript describing a case report, clinical review, curriculum, or research project in a peer reviewed medical journal1}

₈

_{Submission, acceptance and presentation of a podium lecture or case report at a regional, national, or international medical conference}

₇

_{Submission, acceptance and presentation of a poster at a regional, national or international medical conference for a case report, curriculum or original research}

₆

_{Acceptance for publication of an EMedRef , 5-Minute Clinical Consult, or similar electronic reference1}

₅

_{Submission without acceptance of a manuscript describing a case report, clinical review, curriculum, or research project in a peer reviewed medical journal}

₅

_{Acceptance for publication of a letter to the editor in a peer-reviewed journal1}

₃

_{Development of a novel curriculum within the NHCP Residency program}

₂

_{Publications for lay public such as NHCP Newsletter, newspaper, or magazine articles on medical topics}

₂

_{Submission without acceptance of a completed scholarly work, case report, pre-prepared lecture at a regional, national or international conference2}

₂

_{Placing in a juried research competition3}

₁

_{Presentation of a Grand Rounds/M&M conference/Tumor Board to the hospital staff}

₁

_{Completion of CITI /IRB training}

₁

^{1Publication must be accepted not just submitted}

^{2Topic submissions do not qualify for scholarly activity points}

^{3Placing 1st, 2nd, or 3rd. 1 point awarded in addition to scholarly points for the project. Includes case reports or original research}

_{***While this list attempts to be inclusive of most scholarly activities undertaken by residents, if a resident undertakes a project that he or she believes to be worthy of points they may submit it for review by the Scholarly Activity Coordinator in conjunction with Program Leadership.***}

_{Findings Ways to Present/Publish}

_{The best opportunity to showcase your research is at the annual USAFP meeting. This is also a great venue for those new to research to present to our community of military medicine FM physicians. Residents are encouraged to seek out other conferences that they may wish to submit their projects. If you are interested in preparing a manuscript for journal submission, our program has resources to facilitate this process. This includes choosing a format for your project, identifying suitable conferences or journals for your project, finding a mentor, editing/revisions, and financial assistance for traveling or submission fees. Whatever your goal may be, please seek out a research coordinator for assistance. Additionally, every fall the research coordinators and faculty will lead a Case Report Workshop.}

_{IRB Approval and Patient Permission}

_{Protecting our patients is important to us. As a residency, we always observe appropriate guidelines regarding IRB review. When in doubt, reach out to the research coordinators and faculty. If you see an interesting case, consider obtaining patient consent at that time if interested in completing a case report or photo quiz on that patient’s presentation. Helpful Link: https://www.usafp.org/research/research-tools/}

_{SECTION V: RESIDENT EVALUATIONS}

_{COMPETENCY-BASED OBJECTIVE EVALUATIONS}

_{The ACGME requires that residents meet competency in six critical areas as a measure of overall competence as a physician. The evaluation process in the residency will strive to provide objective measures of those six competencies.}

_{The competencies are:}

_{1. Patient Care}

_{2. Medical Knowledge}

_{3. Practice Based Learning and Improvement}

_{4. Interpersonal and Communication Skills}

_{5. Professionalism}

_{6. Systems Based Practice}

_{1. Patient Care:}

_{Residents are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life.}

_{Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures}

_{Make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preference}

_{Develop, negotiate and implement effective patient management plans and integration of patient care}

_{Perform competently the diagnostic and therapeutic procedures considered essential to the practice of family medicine}

_{2. Medical Knowledge:}

_{Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others.}

_{Apply an open-minded, analytical approach to acquiring new knowledge}

_{Access and critically evaluate current medical information and scientific evidence}

_{Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of family medicine}

_{Apply this knowledge to clinical problem-solving, clinical decision-making, and critical thinking}

_{3. Practice-Based Learning and Improvement:}

_{Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.}

_{Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care}

_{Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice}

_{Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care}

_{Use information technology or other available methodologies to access and manage information,}

_{Support patient care decisions and enhance both patient and physician education}

_{4. Interpersonal and Communication Skills:}

_{Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.}

_{Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.}

_{Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families}

_{Interact with consultants in a respectful, appropriate manner}

_{Maintain comprehensive, timely, and legible medical records}

_{5. Professionalism:}

_{Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.}

_{Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues}

_{Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues}

_{Adhere to principles of confidentiality, scientific/academic integrity, and informed consent}

_{Recognize and identify deficiencies in peer performance}

_{6. Systems-Based Practice:}

_{Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.}

_{Understand, access and utilize the resources, providers and systems necessary to provide optimal care}

_{Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient}

_{Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management}

_{Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care}

_{METHODS OF EVALUATION}

_{Each resident undergoes constant informal evaluation and periodic formal evaluation. The sum of all these data points determines the final evaluation and ranking. Several objective measures of evaluation are used in determining overall scores, but there is subjectivity as well that is an important part of the evaluation process. Listed below are the primary areas of evaluation used in our program.}

_{1. Rotation Evaluations: At the end of each rotation residents will be rated in the performance of the six general competencies.}

_{2. Quarterly Evaluations: Each quarter the FM staff plus the chief residents meet to discuss progress of all residents in meeting the six general competencies. A consensus is achieved by recalling observed performance during precepting, on the watch and from input of other hospital and clinic staff. A general review of Team leader evaluations and rotation evaluations is also done. Team Leaders will comment on your performance in the six general competencies through review of your medical records, co-managing some of your patients, personal and professional interactions and via feedback from other hospital and clinic staff. Input from 360 Degree evaluations is also utilized if available. Each quarter the resident will meet with their faculty advisor to review performance and make plans for improvement when needed.}

_{3. In-Training Exam: The score on the in-training exam is used to help in the overall evaluation, primarily in the assessment of medical knowledge.}

_{4. Fitness Reports: The Fitness Report is important for measuring military performance and is the key tool used in assessing future Navy promotion and retention. It also helps to evaluate Professionalism and Patient Care among the six competencies.}

_{5. 360 Degree Evaluations: Once a year clinic ancillary staff, hospital ancillary staff, your peers and patients will complete an evaluation tool to assess performance in some of the six general competencies. Your faculty advisor will include this information in the Quarterly evaluation.}

_{INTERPRETING YOUR EVALUATIONS}

_{The grading scale should reflect comparison to the average performance of a family medicine resident in the specific year of training. The grading should not specifically compare residents among the current group but rather should reflect comparison to the universe of family medicine residents.}

_{The expectation is that the majority of residents will be performing at the expected level of training for the majority of items evaluated. A small number may receive marks denoting either above or below expected level of training.}

_{The overall evaluation rating will be:}

_{1. Not Competent: Recommend repeat rotation or other additional training}

_{2. Competent: At Expected Level of Training}

_{3. Competent: Exceeds Expected Level of Training.}

_{Residents who receive a “Not Competent” evaluation will be placed on academic probation pending recommendation of the Graduate Medical Education Committee (GMEC) and the Program Director for Family Medicine. Please see BUMEDINST 1524.1C, NHCP Graduate Medical Education Policy – Trainee Due Process and Grievance Procedures Policy and NAVHOSPINST 1520.1D for details on probation and due process (information on where to access these documents can be found on the last page of this manual.) These Residents may need to repeat that rotation. This may result in an extension of training.}

_{RESIDENT EVALUATION OF THE CLINICAL SERVICES}

_{Residents should evaluate the clinical service they have recently completed. The evaluation should cover the following areas:}

_{1. Attitude of staff toward teaching}

_{2. Adequacy of teaching material}

_{3. Teaching Rounds}

_{4. Work Load}

_{5. Attitude toward Family Medicine}

_{General comments about each rotation are encouraged, specifically concerning ideas that could improve the educational experience.}

_{The APD and the Program Director review comments and evaluations scores for Family Medicine. Comments are forwarded to the services as well while protecting resident anonymity.}

_{QUARTERLY EVALUATIONS}

_{Four times each year (October, January, March, June) each resident will receive feedback on their performance by the department in a Quarterly Evaluation with their assigned advisor..}

_{This meeting is used to give the resident a chance for review of their performance in all areas. The entire training jacket is reviewed with special attention given to the rotation evaluations for the preceding quarter. Outpatient clinic performance is also evaluated and summarized by the team leader.}

_{Attendance at required conferences and morning report will be reviewed, and the resident interests shared with and fostered by their advisor.}

_{The resident is given time to discuss their feelings about their training, and a chance to address problems which may have occurred.}

_{Procedure documentation by the resident is reviewed to ensure adequate quantity and range of experience.}

_{Progress toward the minimum of 1,650 outpatient FMC encounters (1,500 for residents who did not do an FM internship in the Navy) is reviewed, and plans made to address any anticipated shortfall (if indicated).}

_{Documentation of all QE’s will be maintained in the resident's training record.}

_{Suggested topics for the Quarterly Evaluation session can include:}

_{Rotation evaluations}

_{FMC chart reviews}

_{Inpatient chart audits}

_{Conference attendance}

_{Clinic problems}

_{FMC encounter numbers}

_{Procedure Numbers}

_Awards

_{Special activities}

_{Problems - complaints - suggestions}

_{Family and personal problems}

_{Military Issues/PFA performance}

_{SECTION VI: PROCEDURE DOCUMENTATION}

_{NEW INNOVATIONS ONLINE WEB PORTAL}

_{Residents are responsible for documenting procedures throughout their residency. New Innovations is the web-based system for this purpose. Residents should document ALL PROCEDURES, particularly those that will have direct bearing on credentialing at the end of residency.}

_{You should be listing staff for all procedures, particularly those which require supplemental privileges, but you may find that many staff members are not listed in the directory. For documenting purposes the staff member/attending for that procedure should be documented in the comments section.}

_{Additionally the use of the QR recording system is to be used by all residents for the evaluation of procedures that in turn will eventually be allowed for indirect supervision. Anytime you perform a procedure under direct supervision an attending can scan your QR code and complete an evaluation for you for that specific procedure. This data is used to track and sign off residents for the following procedures:}

_{First Trimester Ultrasound (includes both abdominal and vaginal) - 10}

_{Vasectomy - 20}

_{Colposcopy - 25}

_{IUD Insertion - Paragard / Mirena (must have a minimum of two of each) - 5}

_{Nexplanon Insertion / Extraction - 5}

_{Endometrial Biopsy - 5}

_{Joint Injection - 5}

_{In order to be signed off for indirect supervision a resident must have met the minimum number of procedures WITH a rating of “appropriate for indirect supervision” by at least two independent preceptors.}

_{ALL procedures must be recorded in a sustainable and audible format. This is up to the resident’s discretion how they will complete this (New Innovations, Excel, notebook).}

_{RECOMMENDED MINIMUM PROCEDURES}

_{The following procedures are to be logged in the New Innovations on-line system.}

_{The following is a list of all CORE and NON-CORE privileges for Family Physicians. Next to each procedure is a target number. To obtain the privilege you should complete the required number and be able to prove competency. In some cases a resident may be able to prove competency with a lower number. A resident may also achieve the required number, but not yet reach competency and so would not be awarded the privilege.}

_{Following this list are supervision requirements for various procedures. The first list is for common outpatient procedures. The second list is for inpatient procedures.}

_{The following pages provide examples of criteria to determine competency to perform select procedures.}

_{Supervision Rules for Procedures in the FM Clinic}

_{All residents must have direct supervision for procedures until they have met criteria for indirect supervision as detailed below:}

_{First Trimester Ultrasound (includes both abdominal and vaginal)}

_Vasectomy

_Colposcopy

_{IUD Insertion - Paragard / Mirena}

_{Nexplanon Insertion / Extraction}

_{Endometrial Biopsy}

_{Joint Injection}

_{Supervision Rules for outpatient procdures under Indirect Supervision (tracked by QR):}

_{All residents must have direct supervision on the following procedures until criteria for indirect supervision is met and finalized by the final two ratings done by the attending via QR code grading noting “able to perform independently”.}

_{First Trimester Ultrasound}

_{Completion of 10 supervised procedures. Then, Evaluation forms indicating trusted to perform procedure with indirect supervision from 2 different staff.}

_{IUD Insertion}

_{Completion of 5 supervised procedures. Resident should have at least 2 Mirena and 2 Paragard procedures before allowed for indirect supervision. Then, Evaluation form indicating trusted to perform procedure with indirect supervision from 2 different staff.}

_{Nexplanon Insertion / Extraction}

_{Completion of initial certification course.}

_{Completion of 5 supervised procedures. Then, Evaluation form indicating trusted to perform procedure with indirect supervision from 2 different staff.}

_{Endometrial Biopsy}

_{Completion of 5 supervised procedures. Then, Evaluation form indicating trusted to perform procedure with indirect supervision from 2 different staff.}

_{**Resident can be signed off after 2 procedures if resident is able to perform IUD placement with indirect supervision.}

_{Joint Injection}

_{Completion of 5 supervised procedures. Then, Evaluation form indicating trusted to perform procedure with indirect supervision from 2 different staff.}

_Colposcopy

_{Completion of 25 colposcopic exams. Then, Evaluation form indicating trusted to perform procedure with indirect supervision by two different staff.}

_Vasectomy

_{Completion of 20 vasectomies. Then, Evaluation form indicating trusted to perform procedure with indirect supervision by two different staff.}

_{Supervision Rules for Inpatient Medicine and Pediatrics}

_{All residents must be directly supervised until the following criteria are met. Once criteria are met, then residents may perform the procedure under indirect supervision.}

_Circumcision

_{Completion of 5 procedures under direct supervision of pediatric attending. Then a rating of trusted to perform under indirect supervision from one credentialed staff.}

_{Incision and Drainage of Abscess}

_{Completion of 3 procedures under direct supervision. Then a rating of trusted to perform under indirect supervision from one credentialed staff.}

_{Lumbar Puncture Adult}

_{Completion of 5 procedures under direct supervision. Then a rating of trusted to perform under indirect supervision from one credentialed staff.}

_{Lumbar Puncture Newborn}

_{Completion of 5 procedures under direct supervision. Then a rating of trusted to perform under indirect supervision from one credentialed staff.}

_{Peds in attendance for a Delivery}

_{Direct supervision from a qualified resident or credentialed staff. May be indirectly supervised once MOOD qualified.}

_{Perform an ICU admission with staff}

_{Must be MOOD qualified in order to discuss these types of admissions over the phone.}

_{Procedures Always Requiring Direct Supervision}

_{Thoracentesis}

_Paracentesis

_{Endotracheal Intubation}

_{Arthrocentesis}

_{Insertion of Central Lines}

_{Insertion of Arterial Lines}

_{Chest Tube Placement}

_{REQUIREMENTS FOR COMPETENCY IN COLPOSCOPY}

_{1. Completion of a basic departmental colposcopy course (generally eight hours). This course is part of the longitudinal curriculum in colposcopy and is offered annually by the residency.}

_{2. The American Academy of Family Physicians and American Society of Colposcopy and Cervical Pathology (ASCCP) also offer basic courses that would fulfill this requirement.}

_{3. Completion of at >25 colposcopy exams; 10 must include ECC and/or cervical biopsies.}

_{4. Successful completion of the Colposcopy Competency Form by 2 different Staff. The staff must rate the resident as trusted to perform independently.}

_{5. Final approval for credentialing rests with the PD.}

_{REQUIREMENTS FOR COMPETENCY IN VASECTOMY}

_{1. Completion of a basic Vasectomy lecture series (generally 2 hour course). This course is part of the longitudinal curriculum in vasectomies and is offered regularly by the residency.}

_{2. Demonstration of clinical and procedural competence in performing the following elements of a vasectomy:}

_{a. Pre-operative counseling}

_{b. Informed consent}

_{c. Identification and isolation of the vas deferens}

_{d. Performance of at least 3 methods of sterilization: excision, ligation, lumen cauterization, and/or encasement of an end into fascial tissue}

_{e. Post-operative counseling}

_{f. Recognition and management of complications}

_{3. Completion of at least 20 vasectomies.}

_{4. Competency is achieved when after completing 20 vasectomies the resident has at least 2 staff complete the Vasectomy Competency Form. The resident must be graded as trusted to perform vasectomy independently.}

_{5. Final credentialing is subject to approval of PD.}

_{REQUIREMENTS FOR PROMOTION}

_{R-1 Requirements for Promotion}

_{1. R-1 training year consists of 13, four-week service rotations. (A description of each rotation, including goals and objectives, is contained in the Family Practice residency files and the training manual).}

_{2. Family Medicine interns must successfully complete 12 months of training (all 13 prescribed GME-I rotations) prior to graduation from internship and/or advancement to the GME-2 level. Residents transferring in must have 12 creditable months of training. This is accomplished through a combination of their American Board of Family Medicine (ABFM) advanced credits and resitern rotations.}

_{3. Family Medicine interns must take and pass Step 3 of Medical Board exams.}

_{4. All interns must be certified by the CCC as competent to stand Medical Officer of the Day watches.}

_{5. All Interns must be approved by the Family Medicine CCC for either graduation or promotion at the final Milestone Meeting of the year (Usually held in May or June).}

_{R-2 Requirements for Promotion}

_{1. R-2 training year consists of 13, four-week service rotations. (A description of each rotation, including goals and objectives, is contained in the Family Practice residency files and the training manual).}

_{2. Family Medicine R-2’s must successfully complete 12 months of training (all 13 prescribed GME-2 rotations) prior to advancement to the GME-3 level.}

_{3. All R-2’s must be approved by the Family Medicine CCC for either advancement to R-3 at the final Milestone Meeting of the year (Usually held in May or June).}

_{4. All R-2’s must be certified as competent by the CCC for Senior OB duty.}

_{R-3 Requirements for Graduation}

_{1. R-3 training year consists of 13, four-week service rotations. (A description of each rotation, including goals and objectives, is contained in the Family Practice residency files and the training manual).}

_{2. Family Medicine R-3’s must successfully complete 12 months of training (all 13 prescribed GME-2 rotations) prior to graduation.}

_{3. All R-3’s must be approved by the Family Medicine CCC for graduation at the final Milestone Meeting of the year (Usually held in May or June).}

_{4. All R-3’s must be competent to be privileged in Family Medicine Core privileges plus Obstetric privileges.}

_{5. All R-3’s must have completed at least 1650 outpatient visits in the Family Medicine clinic. This includes a minimum of 165 visits for patients under the age of 10 and 165 visits for patients over the age of 60.}

_{6. All R-3’s must have completed at least 80 vaginal deliveries with caveat that presence in delivery room either delivering or assisting in delivery counts towards final delivery number, which is to be documented in New Innovations. All R-3’s should have completed at least 10 continuity deliveries as detailed in section II under management of continuity couplets.}

_{7. All R-3’s must have completed at least 750 encounters dedicated to the care of}

_{8. adult medicine inpatients.}

_{9. All R-3’s must complete a Performance Improvement Project.}

_{10. All R-3’s must complete Scholarly Activity to points level of 8 or more as referenced in section IV: Research in Residency}

_{SECTION VII: QUALITY IMPROVEMENT}

_{RESIDENT INVOLVEMENT IN HOSPITAL COMMITTEES}

_{Each GME-II and GME-III should consider taking part in at least one hospital committee, as participation and input is a regular part of most staff positions. NHCP functions with the following committees from which residents may choose and become a part of at the beginning of each academic year.}

_{Comprehensive Unit-based Safety Program (CUSP)}

_{Patient Safety (2)}

_{Team STEPPS}

_Ethics

_{Perinatal Advisory Board}

_P&T

_{GMEC (Mandatory for Chiefs)}

_{Quality Improvement (2)}

_Others

_{CUSTOMER RELATIONS PROGRAM}

_{Patients dissatisfied with the care they receive in Family Medicine have clear-cut routes to deliver their grievance.}

_{The Family Medicine Department has a Patient Contact Representative so that initially complaints can be handled on a departmental level. On receiving a complaint, the Department Representative gathers the information and delivers the complaint to the team leader of the Resident involved.}

_{Complaints that come from outside the Department (Command Patient Contact) are first routed through the APD and then onto the appropriate team leader.}

_{The team leader will handle the complaint. The team leader may choose to speak directly with patient or may choose to involve the resident in this process too. The resident should be notified of the complaint and appropriate counseling or teaching should occur. The vast majority of times the complaint specifics can be worked out by simply improving communication between the parties.}

_{It will be departmental policy to avoid switching patients from one Resident Physician to another except in cases where this is the only logical solution.}

_{CREDENTIALS PROGRAM}

_{Navy directives require that certain aspects of the credentialing process involve residents in training. Although no Resident Physicians have credentials to practice independently, data is gathered during their residency that is used to assist in making credentialing decisions at the end of their training.}

_{A Clinical Activity File (the Resident’s training folder) is maintained in which any adverse data relating to occurrence screening, risk management, or other QI screening is maintained. At the end of a resident’s training, the data is reviewed by the PD along with the resident monthly evaluations, Quarterly Evaluations, and procedure data to help the PD to formulate opinions relating to competence and credentialing.}

_{Residents have the ability to review information in their Clinical Activity File at any time, and review is mandatory at three scheduled Quarterly Evaluations each year. Adverse information in the record may be challenged by the resident using systems set up in standard Navy directives.}

_{OBSTETRICS PATIENTS}

_{Any patient requesting OB care (including FM patients) will have an initial appointment with the OB registration nurse. Pregnancy tests can be done in the FM Clinic if pregnancy has not been confirmed by urine HCG at NHCP.}

_{Patients will be assigned to either the FMC or OB/GYN for their care. Patients choosing FM will typically remain with their assigned provider.}

_{FM accepts 30-40 OB patients per month from OB registration. They are assigned in the following way.}

_{R-1/Staff: 6/year or ~ 1 new OB every other month.}

_{R-2/R-3: 12/year or ~ 1 new OB month}

_{SECTION VIII : ROTATION INFORMATION FOR RESIDENTS}

_{The program maintains a full set of competency- and year-group specific Goals and Objectives (G&O) for each clinical rotation. These are readily available on the command SHARE Drive, in the Knowledge Management Portal. The G&O should be reviewed prior to the start of each rotation so the resident is clear on expectations and required elements to satisfactorily complete the rotation. Additionally the information is found on the NHCP Family Medicine Resident website.}

_{SECTION IX: ADMINISTRATIVE GUIDELINES}

_{The items in the following table can be viewed online on the Department page in the Knowledge Management Portal from the Command Intranet page.}

_{Management of Unsatisfactory Professional Performance of Graduate Medical and Dental Education Trainees.}

_{NAVHOSPCAMPENINST 1520.1D}

_{Requirements for Successful Completion of Naval Hospital Camp Pendleton Family Practice Internship and Residency.}

_{NAVHOSPCAMPENINST 1520.1D}

_{Policies and Procedure for the Administration of GME Programs}

_{Instruction 1524.1B}

_{There are also various resources that can be found on the worldwide web:}

_{1. Requirements for Certification by the American Board of Family Medicine}

_{https://www.theabfm.org/cert/index.aspx}

_{2. Program Requirement for Family Medicine}

_{http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf}

_{3. Common Program Requirement for Residency Training}

_{http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf}