Frequently Asked Questions: Surgical Critical Care, Pediatric Surgery, and Vascular Surgery Review Committee for Surgery ACGME

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1 Frequently Asked Questions: Surgical Critical Care, Pediatric Surgery, and Vascular Surgery Review Committee for Surgery ACGME Question Introduction What type of information is required by the Review Committee regarding the introduction of an integrated vascular surgery program when the Sponsoring Institution already has an independent vascular surgery program? Vascular Surgery Int.C.1. and Int.C.2.] Program Personnel and Resources Why are there required qualifications for new program directors? Surgical Critical Care II.A.2; Pediatric Surgery II.A.3; Vascular Surgery II.A.3.] What type of educational and administrative experience is required before appointment as a new program director? Surgical Critical Care II.A.2.a); Pediatric Surgery II.A.3.a); Vascular Surgery II.A.3.a)] Sponsoring Institutions that submit an application for an integrated vascular surgery program (0+5) where an independent vascular surgery program (5+2) is already present must indicate in the application whether it plans to run program formats simultaneously or if it plans to phase out the independent program format once the integrated program format has graduated its first cohort of residents. If the Sponsoring Institution decides to maintain an independent vascular surgery program after having previously indicated that it would close that program, the institution must make a request to the Review Committee. The request must include supporting documentation of the adequacy of case volume to support both programs simultaneously. In the past, young faculty members were frequently appointed as program directors with the expectation of learning on the job in a role that was often limited to custodian and contact person. Today, a surgical program is very complex, and the accreditation requirements are extensive, so it is important that individuals are already prepared to take on the role, are already respected, senior members of the faculty, and have reached a stage in their academic practices that enables them to truly devote the time and effort required to oversee a high quality program. In order to be prepared to function as a new program director, individuals must already have a comprehensive understanding of and ability in educational and evaluation methods, active experience in managing and administering a complex organization, and leadership and communication skills. Individuals who are appointed as new program directors should have served for at least five years as a GME faculty member with at least two years at the institution at which they are being appointed as program directors. Where applicable, individuals should have been promoted or be eligible for promotion to the rank of Associate Professor. Individuals should have already served as an associate program director for at least one year Accreditation Council for Graduate Medical Education (ACGME) Page 1 of 9

2 Why must a program director be boardcertified As a senior leader and role model, the program director is expected to be an expert in in the specialty/subspecialty of the the specific field of the program. Current board certification is the minimum benchmark program? of expertise. Surgical Critical Care II.A.2.b); Pediatric Surgery II.A.3.b); Vascular Surgery II.A.3.b)] Why must a program director have an active, unrestricted license to practice medicine in the state in which the program is located and unrestricted credentials at the primary clinical site? Surgical Critical Care II.A.2.c).(1)-(2); Pediatric Surgery II.A.3.c)-d); Vascular Surgery II.A.3.c)] Why must the program director have documented scholarly activity, and what types of scholarly activity are sufficient? Surgical Critical Care II.B.7.; Pediatric Surgery II.A.3.e); Vascular Surgery II.A.4.s)] As a senior role model and respected clinical leader, a program director must be recognized as an expert in the practice of surgery, must be fully cognizant of the requirements for licensure and credentialing, and should be actively engaged in the practice of surgery in the clinical site where the program is located. The program director sets the tone for the scholarly environment of the program. In order to be effective in this capacity, the program director must be recognized and respected by faculty members and residents as having demonstrated success in scholarship. It is highly recommended that the program director have documented scholarly activity in all three areas described in the Program Requirements. Because it is expected that both faculty members and residents are involved in research and publications, the program director should have evidence of peer-reviewed publication during the most recent five-year period. In addition, the program director should have contributed to the field of surgery by analyzing or reviewing clinical practice. It is highly desirable that a program director has actively participated in national or regional surgical meetings and served on committees of national or regional surgical organizations. Although there are other ways to demonstrate scholarship, the Review Committee recommends these guidelines for demonstration of scholarly activity by program directors Accreditation Council for Graduate Medical Education (ACGME) Page 2 of 9

3 Must all core faculty members in both independent and integrated programs be certified in vascular surgery by the American Board of Surgery (ABS)? Vascular Surgery II.B.2. and II.B.6.] Resident Appointments Will osteopathic residents who graduate from ACGME-accredited vascular surgery programs be eligible for ABS certification? [Program Requirement: Vascular Surgery III.A.] In independent vascular surgery programs, in addition to the program director, there must be, for each approved residency position, at least one full-time faculty member who is certified in vascular surgery by the ABS or possesses qualifications judged to be acceptable by the Review Committee. In integrated vascular surgery programs, in addition to the program director, there must be, for each approved residency position in the 36 months of concentrated vascular surgery experience, at least one full-time faculty member who is certified in vascular surgery by the ABS or possesses qualifications judged to be acceptable by the Review Committee. Example: a program with one approved resident per year would be required to have at least three full-time faculty members in addition to the program director who are certified in vascular surgery by the American Board of Surgery. Core (non-vascular) faculty members must be American Board of Medical Specialties (ABMS)-certified within their own fields or possess qualifications judged to be acceptable by the Review Committee. Residents who complete vascular surgery training in an integrated (0+5) program are subject to the same conditions as defined for general surgery. These residents will be required to complete at a minimum the last three years of residency training (PGY-3, -4, and -5) in an ACGME-accredited integrated vascular surgery residency program. The academic year in which a program obtains ACGME accreditation will count as one full year toward the three-year requirement, if satisfactorily completed by the resident. To be eligible for certification in vascular surgery by the ABS through the independent (5+2) pathway, osteopathic surgical residents must have successfully completed training in an ACGME-accredited surgery residency program, according to the criteria outlined above, prior to completing an ACGME-accredited vascular surgery fellowship. The vascular surgery fellowship must be accredited by the ACGME for the entire duration of training. All other ABS requirements for certification in vascular surgery in effect at the time of application must also be fulfilled Accreditation Council for Graduate Medical Education (ACGME) Page 3 of 9

4 Will osteopathic residents who graduate from ACGME-accredited surgery subspecialty fellowships be eligible for American Board of Surgery (ABS) certification? Surgical Critical Care III.A; Pediatric Surgery III.A.] Will residents in osteopathic general surgery training programs that become accredited by the ACGME on or after July 1, 2015 be eligible for appointment to a pediatric surgery program? Pediatric Surgery III.A.] Contact Review Committee Executive Director Donna Lamb with questions (dlamb@acgme.org; ). The ABS requires that graduates of training programs in surgical critical care, pediatric surgery, hand surgery, and complex general surgical oncology first be certified in general surgery by the ABS to be eligible for certification in these subspecialties. Thus residents in osteopathic surgical training programs that become accredited by the ACGME will be required to achieve ABS certification in general surgery prior to pursuing certification in these subspecialties. The ABS Policy for Entry of Osteopathic Trainees into ABS Certification Process can be found on the ABS website: Contact Review Committee Executive Director Donna Lamb with questions (dlamb@acgme.org; ). Effective July 1, 2016, individuals who have successfully completed a residency in general surgery accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada (RCPSC) may be eligible to enter pediatric surgery programs. This is a change from the prior requirement, which stated that applicants must be either admissible to or certified by the ABS or the RCPSC. The change was made to ensure uniformity of language across the general surgery disciplines, and is not intended to affect an individual institution s or program director s policy and/or process pertaining to resident recruitment. This change also does not define or imply eligibility of an individual to sit for the ABS examinations. To determine that all candidate residents are eligible for appointment in an ACGMEaccredited pediatric surgery program, and that residents have full disclosure of their eligibility to sit for the ABS examinations, program directors must: Ensure that candidates have completed an ACGME-accredited surgery residency program. For residents in osteopathic general surgery programs, the resident s program of record must have achieved an ACGME-accreditation status of Initial Accreditation prior to his/her completion of the program. For example, if an osteopathic general surgery program achieves Initial Accreditation in January, all program residents graduating in June will be considered to have completed an ACGME-accredited surgery residency 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 4 of 9

5 program. o Program directors are advised that the statuses of Pre-Accreditation, Pre- Accreditation Continued, and Initial Accreditation-Contingent are not synonymous with ACGME accreditation (i.e., neither Initial Accreditation nor Continued Accreditation). o Program directors are advised to carefully assess the status of all candidates programs at the time of recruitment in order to determine eligibility for appointment to an accredited position. o Program accreditation status is available publically on the ACGME website ( Ensure that each candidate has written documentation at the time of appointment identifying the type of position to which he/she is appointed (categorical or preliminary), accreditation of the position to which he/she is appointed (accredited or other learner ), and eligibility status to take the ABS examination. o Program directors are advised to maintain documentation of this notice in each fellow s file. o Osteopathic residents eligibility for the ABS examination may be located on the ABS website: Educational Program How can a program show that fellows have had supervised training enabling them to demonstrate competence in the management of cardiac assist devices? [Program Requirement: Surgical Critical Care IV.A.2.a.(2).(a).(i)] Contact Review Committee Executive Director Donna Lamb with questions (dlamb@acgme.org; ). The Review Committee recognizes that fellows may be able to achieve competency in the management of cardiac assist devices through direct, hands-on experience with cardiac assist devices, or through didactic instruction on the appropriate indications for use, the principles of insertion, troubleshooting, and adjustment of these devices. Each program will be expected to document how this competency is achieved by its fellows Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 9

6 Resident/Fellow Duty Hours in the Learning and Working Environment Who may supervise residents and fellows Appropriately-credentialed and privileged attending physicians in the surgical clinical in the clinical environment? environment include appropriately-credentialed ABMS member board-certified surgeons (e.g., thoracic surgeries would be supervised by thoracic surgeons, etc.). In [Program Requirement: VI.D.1.] the critical care clinical environment, procedures must be supervised by appropriatelycredentialed ABMS member board-certified critical care physicians (e.g., anesthesia critical care physicians, critical care medicine physicians, critical care pediatric physicians, etc.). Who may provide direct supervision to PGY-1 residents? [Program Requirement: Vascular Surgery VI.D.5.a).(1)] What is indirect supervision with direct supervision immediately available? Surgical Critical Care, Pediatric Surgery, Vascular Surgery VI.D.3.b).(1)] What are examples of defined tasks for which PGY-1 residents may be supervised indirectly and examples of defined tasks for which PGY-1 residents should have direct supervision until competency is demonstrated? [Program Requirement: Vascular Surgery VI.D.5.a).(1).(a)] Each program is responsible for having clear policies for supervision. Direct supervision (physically present) may be provided by individuals who have been credentialed by the program to do a particular procedure or manage a particular clinical scenario and include more senior residents (PGY-2 residents and above who have met the competency requirements for the particular task at hand), fellows, and attending surgeons. Attending physicians such as anesthesia physicians, emergency department physicians, and hospitalists who are appropriately credentialed and with whom the program has a clearly defined relationship outlined in the supervision policy may directly supervise PGY-1 residents. For certain tasks, supervision may be provided "indirectly" (supervising physician not physically present) by phone/text/ discussion. When needed (as outlined by the programs supervision policy) or requested by the resident, the supervising physician must be physically present at the start of non-emergent tasks. For emergency situations, direct supervision should be available within 15 minutes. Indirect supervision is allowed for: 1. Patient Management Competencies a) evaluation and management of a patient admitted to hospital, including initial history and physical examination, formulation of a plan of therapy, and necessary orders for therapy and tests b) pre-operative evaluation and management, including history and physical examination, formulation of a plan of therapy, and specification of necessary tests c) evaluation and management of post-operative patients, including the conduct of monitoring, and orders for medications, testing, and other treatments d) transfer of patients between hospital units or hospitals 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 6 of 9

7 e) discharge of patients from the hospital f) interpretation of laboratory results 2. Procedural Competencies a) performance of basic venous access procedures, including establishing intravenous access b) placement and removal of nasogastric tubes and Foley catheters c) arterial puncture for blood gases Direct supervision is required until competency is demonstrated for: 1. Patient Management Competencies a) initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (ATLS required) b) evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartmant syndromes c) evaluation and management of critcially-ill patients, either immediately postoperatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments d) management of patients in cardiac or respiratory arrest (ACLS required) 2. Procedural Competencies a) carry-out of advanced vascular access procedures, including central venous catheterization, temporary dialysis access, and arterial cannulation b) repair of surgical incisions of the skin and soft tissues c) repair of skin and soft tissue lacerations d) excision of lesions of the skin and subcutaneous tissues e) tube thoracostomy f) paracentesis g) endotracheal intubation h) bedside debridement 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 7 of 9

8 What skills should members of the caregiver team have and how should these be ensured across the team? [Program Requirement: Surgical Critical Care, Pediatric Surgery, Vascular Surgery VI.E.3.] Are there any circumstances under which residents may stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty? Surgical Critical Care VI.G.5.a).(1); Pediatric Surgery and Vascular Surgery VI.G.5.c).(1)] All members of the caregiver team should be provided instruction in: 1. recognition of and sensitivity to the experience and competency of other team members; 2. time management; 3. prioritization of tasks as the dynamics of a patient s needs change; 4. recognizing when an individual becomes overburdened with duties that cannot be accomplished within an allotted time period; 5. communication, so that if all required tasks cannot be accomplished in a timely fashion, appropriate methods are established to hand off the remaining task(s) to another team member at the end of a duty period; 6. signs and symptoms of fatigue not only in oneself, but in other team members; 7. compliance with work hours limits imposed at the various levels of education; and, 8. team development. Yes. Such circumstances include: 1. Continuity of care for patients, such as for: a) a patient on whom a resident operated/intervened that day who needs return to the operating room (OR); b) a patient on whom a resident operated/intervened that day who requires transfer to the Intensive Care Unit (ICU) from a lower level of care; c) a patient on whom a resident operated/intervened that day who is in the ICU and is critically unstable; d) a patient on whom a resident operated/intervened during that hospital admission, and who needs to return to the OR for a reason related to the procedure previously performed by resident; or, a patient or patient s family with whom a resident needs to discuss limitation of treatment/dnr/dni orders for critically-ill patient on whom the resident operated. 2. a declared emergency or disaster, for which the residents are included in the disaster plan; or, to perform high profile, low frequency procedures necessary for competence in the field Accreditation Council for Graduate Medical Education (ACGME) Page 8 of 9

9 Is it considered a night float rotation if a program offers a one-month acute care surgery rotation that has residents working 12-hour shifts alternating weeks of nights and day shifts? Yes. These residents cannot work more than six consecutive nights during the night shift weeks, there must be two months off between such rotations, and the two weeks of night shifts count toward the total time on night float. [Program Requirement: VI.G.6.] Is it considered a night float rotation if a program offers a one-month rotation with four residents where, in lieu of call every fourth night, each resident groups their call into five or six consecutive nights as a night shift? Yes, in part. The consecutive nights would count as one week toward the total amount of night float, but a two-month hiatus would not be required between such rotations. [Program Requirement: VI.G.6.] Is it permissible for a program to offer a rotation for three successive months alternating night shifts for two weeks with day shifts for two weeks? Yes. The six weeks of night shifts would count toward the 15-month maximum allowable for any resident over the five-year residency. There must be two months between such rotations. [Program Requirement: Vascular Surgery VI.G.6.e)] 2016 Accreditation Council for Graduate Medical Education (ACGME) Page 9 of 9