RESIDENT MANUAL
2015-2016
MASON EYE INSTITUTE
UNIVERSITY OF MISSOURI – COLUMBIA
SCHOOL OF MEDICINE
TABLE OF CONTENTS
STATEMENT OF PURPOSE/EDUCATIONAL GOALS
ROLES, DUTIES AND RESPONSIBILITIES OF RESIDENTS
INSTITUTIONAL POLICIES, SCHOOL OF MEDICINE. ............................................................TAB DIVIDER
Commitment to Graduate Medical Education ................................................................................................ 4
Primary Verification of Credentials For Applicants to Residency and Fellowship .....................................5-6
Graduate Medical Education Committee – Composition & Responsibilities ...............................................7-9
Internal Review Protocol, GMC Oversight Committee, University of Missouri Hospitals & Clinics .....10-14
Policy on Resident Recruitment, Eligibility & Selection .........................................................................15-16
Supervision of Residents and Fellows .....................................................................................................17-20
Policy Teamwork .......................................................................................................................................... 21
Transitions of Care ...................................................................................................................................22-23
Ophthalmology Monitoring of Patients hand-off(On-Call and In-Patient) ................................................... 25
House Staff Compliance with Timely Completion of Medical Records ..................................................26-27
Resident/Fellow Stipends .............................................................................................................................. 28
Policy: Required ACLS/BLS/PALS Certification ........................................................................................ 29
USMLE Step 3 – defining requirements for passing prior to completion of program .................................. 30
Reporting of Other Learners in a Program .................................................................................................... 31
Moonlighting Professional Activities Outside the Education Program ...................................................32-34
Moonlighting – J1 or H1B Visa Holders ...................................................................................................... 35
Policy for Payment of Fees Associated with an H1B Visa ........................................................................... 36
Professionalism, Personal Responsibility, and Patient Safety ....................................................................... 37
Duty Hour Policy for the University of Missouri ....................................................................................38-39
Alertness Management and Fatigue Mitigation ........................................................................................40-41
Institutional Vacation and Leave Policy ....................................................................................................... 42
Resident Leave Restriction Policy................................................................................................................. 43
Policy for Processing Anonymous Evaluations ............................................................................................ 44
Policy for Educational/Career Counseling ................................................................................................... 45
Professional Assistance Policy ................................................................................................................46-48
Attachment A: Substance Abuse and Impaired Physician Policy .............................................49-51
Attachment B: Financial Advice/Counseling Resources ..........................................................52-54
Policy to Address Resident Concerns ........................................................................................................... 55
Grievance Policy for Residents/Fellows ..................................................................................................56-57
Grievance Procedure ................................................................................................................................58-61
Sexual Harassment ........................................................................................................................................ 62
Drug Testing Policy For Training Physicians ..........................................................................................63-65
Policy to Monitor Residents and Fellows with Prior Issues of Concern/
University of Missouri Health Care .............................................................................................................. 66
Disciplinary Action Policy For Residents/Fellows ....................................................................................... 67
Non-Renewal Of A Resident/Fellow Contract at University of Missouri Health Sciences Center .............. 68
Administrative Support for Programs and Residents in the Event of a Disaster or Interruption of Patient
Care ............................................................................................................................................................... 69
Process for Requesting a Change in Resident/Fellow Complement or Starting a New Program .................. 70
Reduction In Size Or Closure Of A Residency Program/Fellowship Program ............................................ 71
Consensual Amorous Relationships ............................................................................................................. 72
ACGME REQUIREMENT FOR RESIDENCY TRAINING IN OPHTHALMOLOGY.
TAB DIVIDER
AAO CODE OF ETHICS ....................................................................................................................TAB DIVIDER
MILESTONES .....................................................................................................................................TAB DIVIDER
GOALS & OBJECTIVE GME………………………………………………………………………TAB DIVIDER
SUB-SPECIALTY SECTION. ............................................................................................................TAB DIVIDER
Cornea/External Disease and Refractive Surgery Service ........................................................................74-75
Contact Lens Service ..................................................................................................................................... 76
General Clinic and Emergency Clinic Service .............................................................................................. 77
Glaucoma Service ......................................................................................................................................... 78
Intraocular Service ........................................................................................................................................ 79
Low Vision Service ....................................................................................................................................... 80
Neuro-Ophthalmology and Consultation Service .....................................................................................81-82
Inpatient Consults and Emergency Patients Policy at Women’s & Children’s Hospital ............................... 83
Ocular Pathology. .......................................................................................................................................... 84
Ophthalmic Plastic/Orbital Surgery. ........................................................................................................85-86
Pediatric and Strabismus Service. ................................................................................................................. 87
Vitreoretinal Service.................................................................................................................................88-89
CLINIC ROTATION DESCRIPTIONS. ...........................................................................................TAB DIVIDER
First Year Resident (PGY-2) .................................................................................................................90-91
Emergency Service
Cornea/External Disease Service
Oculoplastics Service
Neuro-Ophthalmology/Consults
VA Hospital/General Ophthalmology
Second Year Resident (PGY-3) . ...........................................................................................................91-93
Retina/Vitreous Service
Pediatric/Strabismus Service
Third Year Resident (PGY-4) . .............................................................................................................93-95
Cornea/External Disease Service
Oculoplastics Service
Glaucoma
VA Hospital/General Ophthalmology
PGY-2 & PGY-4 Resident General Clinics. .........................................................................................96-97
Resident Instruction/Supervision
Instruction in Ethical Issues, Socioeconomics of Health Care, Cost-effective Medical Practice
(Narrative Description). .............................................................................................................98-99
Harry S. Truman Memorial Veterans’ Hospital
VA Hospital Statement of Purpose ................................................................................. 100
Narrative Description for Resident Supervision ......................................................101-103
Resident Supervision-Department of Veterans Affairs ................................................ insert
Goals and Responsibilities for VA Ophthalmology Rotation ..................................105-108
Second Year Resident (PGY-3) Responsibilities ......................................105-106
Third Year Resident (PGY-4) Responsibilities .........................................107-108
VA Hospital Policy Memorandum. ............................................................................ Insert
Program Letter of Agreement between the Harry S. Truman Memorial Veterans
Administration Hospital Eye Clinic and the Department of Ophthalmology. ............. Insert
EVALUATIONS ...................................................................................................................................TAB DIVIDER
Evaluation Description. ........................................................................................................................111-112
Clinical Skills and Procedures ..................................................................................................................... 113
360-Degree Evaluations .............................................................................................................................. 114
Ophthalmology Resident Global Evaluation Form. ................................................................................. Insert
Sub-Specialty Evaluations Forms............................................................................................................. Insert
Resident Evaluation of Institution (MEI rotation) .................................................................................... Insert
Resident Evaluation of VA Hospital/Eye Clinic (rotation) ...................................................................... Insert
Resident Evaluation of Clinical & Courtesy Faculty ............................................................................... Insert
Ophthalmic Clinical Evaluation Exercise (OCEX) Form......................................................................... Insert
Ophthalmology Resident Surgical Skills Assessment Form ....................................................................... 117
CLINIC POLICIES AND PROCEDURES ........................................................................................TAB DIVIDER
Attendance. .................................................................................................................................................. 118
Schedules..................................................................................................................................................... 118
Clinic Support Staff. .............................................................................................................................118-119
Technical Staff. ........................................................................................................................................... 119
Paperwork. .................................................................................................................................................. 120
Documentation
Billing Forms
Return Patient Forms
Phone Messages. ......................................................................................................................................... 121
Guest Relations
Patient Injuries/Falls
Difficulties
Triage
Inmates ........................................................................................................................................................ 122
Emergency Patients
Surgical Boarding Procedures. .............................................................................................................122-123
Surgery Log
123-124
Definition of Classes
Lasers
Ultrasound/A & B Scans
IOL Master
Equipment
BILLING AND INSURANCE .............................................................................................................TAB DIVIDER
Diagnosis Coding. ....................................................................................................................................... 125
Encounter Form
Contact Lenses
Surgery Funding. ......................................................................................................................................... 126
Insurance Requirements. ............................................................................................................................. 127
Medicare. ..................................................................................................................................................... 127
Glasses
Secondary Cataract (PCO)
Blepharoplasty/Blepharoptosis. ................................................................................................................... 127
Photography. ............................................................................................................................................... 128
Insurances. ................................................................................................................................................... 128
Cigna, Coventry, Missouri Care, Mercy Health Plan, Healthcare USA, Mercy Care Partners,
Rehabilitation Services for the Blind, Prevention of Blindness Program (POB), Humana
HMO/PPO
GENERAL PROGRAM INFORMATION. .......................................................................................TAB DIVIDER
General Organization of Patient Care at the Mason Eye Institute. ...............................................130-133
Call
Curriculum (didactic instruction)
Research
Conference Attendance Documentation
Participation in Medical Student Teaching
Annual Contract Description. .................................................................................................................. 133
Absences. .............................................................................................................................................134-137
Vacation, Meetings, Sick Leave, Maternity Leave, Paternity Leave, Holidays, Death In Family,
Cancellation of Sub-Specialty Clinics, Unscheduled Time, Unanticipated Absences
Moonlighting Policy for Ophthalmology Residents................................................................................ 138
Resident Call & Call Schedule Policy. ..............................................................................................139-140
Educational Allowances & Benefits. .................................................................................................141-142
Days Away
Research
Cash Professional Allowances
Basic Science Course and Books
Annual Residents & Alumni Day
Ophthalmology Library
Computer and Internet
Office Assistance
Conferences, Exams, and Related Policies. ......................................................................................143-144
Conference Attendance Policy, Attendance Roster, Intra-Department Meetings,
Resident Orientation
OKAP Examination. ..................................................................................................................... 144
CHIEF RESIDENT RESPONSIBILITIES. .......................................................................................TAB DIVIDER
Chief Resident ....................................................................................................................................................145-147
Organize and Conduct Grand Rounds; Coordination and Supervision of Photo Conferences;
Review Resident’s daily schedules; Care of Emergency Patients; Coordination of Consult Service
(absence of consult resident); Call Schedule; Resident Dictation; Resident Recruitment; Clinic
Flow; Co-supervision clinic operations; surgical schedule problems.
PROFESSIONAL RESPONSIBILITIES .............................................................................................................. 148
STATEMENT OF PURPOSE/EDUCATIONAL GOALS
The purpose of residency training in the Mason Eye Institute, University of Missouri, School of Medicine is to
provide an optimal clinical education to physicians in the science and art of ophthalmology; all functions of the
department are structured to maximize this educational mission.
The program is designed to provide a broad foundation in all of the subspecialties of ophthalmology in a 36month curriculum which combines a structured clinical science course in didactic presentations, clinical
conferences and independent study.
The department adheres to the ethical standards and practice guidelines as set forth by the American Academy
of Ophthalmology, and by example, we wish to instill in the residents this code of ethics.
Resident physicians are expected to achieve the 7 ophthalmology competencies of:
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Patient Care – PC
Medical Knowledge – MK
Interpersonal and Communication Skills – ICS
Professionalism – P
Practice-based Learning and Improvement – PBLI
Systems-based Practice – SBP
Technical/Surgical Skill – TS
During the tenure of the residency, residents should accomplish the following:
 develop a personal program of self-study and professional growth with guidance from the teaching
faculty (MK)
 participate in safe, effective and compassionate medical and surgical patient care under supervision,
commensurate with their level of advancement and responsibility (PC,TS,MK,P,SBP)
 participate fully in the educational activities of their program and, as required, assume responsibility for
teaching and supervising other residents and students (PBLI,MK,ICS)
 participate in institutional programs and activities involving the medical staff and adhere to established
practices, procedures and policies of the institutions (ICS,PBLI,P)
 participate in institutional committees and councils, especially those that relate to patient care review
activities (P,ICS,SBP)
 apply cost containment measures in the provision of patient care (SBP)
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Roles, Duties, and Responsibilities of Residents
Ophthalmology Residents
First Year Ophthalmology Resident (PGY-2)
 Comprehensive Eye Examination (including Indirect Ophthalmoscopy,
Manifest and Cycloplegic Refraction)
 Writes inpatient and outpatient orders
 Instrumentation:
o Lensometry, Automated Keratometry, Automated Refraction
o Tonometry, Gonioscopy, Ultrasonic Pachymetry
o Static & Kinetic Perimetry (Humphrey, Goldmann)
o A&B scan Ultrasonography, Specular Microscopy
o IOL Master and Immersion A-scan
o Corneal Topography, Slit-Lamp & Fundus Photography
o Rust ring remover, Electro-epilator
 Injections:
o Intraocular, Periocular/Retrobulbar, Dermal, Intravenous (including
Fluorescein Angiogram) for diagnosis and therapy
 Run codes (ACLS)
 Supervised by 2nd or 3rd year resident (until deemed competent)
 Laser surgery (direct supervision by faculty until deemed competent):
o YAG capsulotomy, Peripheral Iridotomy
o Argon Panretinal Photocoagulation (PRP), Argon Laser
Trabeculectomy (ALT), Peripheral Iridotomy (PI), other
 Surgery (direct supervision by faculty):
o Cataract surgery, Glaucoma surgery, Strabismus surgery
o Eyelid surgery, Retina surgery, Cornea surgery, Temporal Artery
Biopsy
Second and Third Year Ophthalmology Resident (PGY-3 & PGY-4)
 Above independent after deemed competent, plus:
 Surgery (direct supervision by faculty of key components):
o Cataract surgery, Glaucoma surgery, Strabismus surgery
o Eyelid surgery, Retina surgery, Cornea surgery, Temporal Artery
Biopsy
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Insert PDF Dean’s letter of commitment
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UNIVERSITY OF MISSOURI - HEALTH SCIENCES CENTER
PRIMARY VERIFICATION OF CREDENTIALS FOR APPLICANTS TO RESIDENCY AND
FELLOWSHIP TRAINING PROGRAMS
Programs must select applicants on the basis of preparedness, ability, credentials, communication skills
and personal qualities like motivation and integrity. Discrimination by gender, race, color, national
origin and disability is prohibited. Restrictive covenants are not permitted.
Each program director must be certain each resident/fellow candidate meets all ACGME, general
Missouri State Licensing Board criteria and immigration requirements before accepting the individual
into the program. The acceptance of unqualified candidates can lead to withdrawal of
certification by the ACGME. The primary verification process consists of the following activities:
Programs will participate in an organized matching program, such as the National Resident Matching
Program (NRMP), if available.
A.
New US Graduates
I.
Application for residency/fellowship through the Electronic Residency Application Service
(ERAS) serves as primary verification. (Minimum documents required: graduate of MD or DO
medical school in the US or Canada which is accredited by LCMF or AOA respectively;
medical school transcript, Dean’s letter; United States Medical Licensing Examination
(USMLE) Step 1 and 2 scores; reference letters) or:
II.
Completion of the Universal Residency Application with the above stated documents attached.
Transcripts must be verified with the school.
B.
Foreign-Born and International Medical Graduates (IMG: a physician whose basic medical
degree is conferred by a medical school located outside the US, Canada or Puerto Rico) must:
1.
Hold J-1 visa (exchange visitor) H-1B visa (temporary worker), immigrant visa or “green card”
or an Immigration and Naturalization Service (INS) issued or approved work permit if not a US
citizen.
2.
Have a full unrestricted license to practice medicine in a US licensing jurisdiction or hold an
Educational Commission for Foreign Medical Graduates (ECFMG) Standard Certificate, which
is a prerequisite to practice medicine in the US and is an eligibility requirement to take Step 3
of the USMLE. A Standard ECFMG Certificate is issued to an applicant who meets the
examination requirements, fulfills the medical education credentialing requirement and clears
their financial account with ECFMG. This Certificate is considered valid if the “valid through”
dates of the English test and CSA is not later than the program start date. In order for an
applicant to obtain permanent validation of the Certificate, ECFMG must receive
documentation from an official of the program confirming the applicant’s entry to the program,
at which time, ECFMG will provide a “valid indefinitely” sticker to the holder of the Certificate.
C.
Residents Entering a Program After Completing Preliminary Year at Another Institution
- In addition to the requirements of A or B of this policy, requires a:
1.
Letter from the program director of the resident’s preliminary year program indicating he/she
has successfully completed the preliminary year of training.
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D.
Physicians Entering a Fellowship - In addition to the requirements of A or B of this policy,
requires a:
Letter from the program director of the resident’s previous program indicating he/she successfully
completed the residency program.
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1.
2.
Verification that the completed residency program is accredited and meets the ACGME
requirements for entry into that particular fellowship.
3.
Reference letter from the Hospital where the physician previously practiced and a
National Practitioners Data Bank (NPDB) query, if the fellowship start date is not
immediately after residency completion.
E.
Restrictive Covenants
1.
ACGME accredited residencies must not require residents to sign a non-competition
guarantee.
Revisions approved by the GMEOC: 12/4/07
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POLICY
Graduate Medical Education Committee – Composition & Responsibilities
PURPOSE:
To define the composition and responsibilities of the Graduate Medical Education Committee
(hereafter referred to as GMEC) at UMHC, in accordance with the standards established by the
Accreditation Council for Graduate Medical Education (hereafter referred to as ACGME) in the
Institutional Requirements
GMEC Composition and Meetings
The ACGME requires that the sponsoring institution have a GMEC.
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Voting members on the committee include:
 The DIO
 Program Directors (of programs that have 11 or more residents)
 The House Staff Organization President, President-elect, and Counselors (3)
 Representatives from Hospital Administration: Chief Quality Officer and Manager
 UMHC Chief of Staff
 VA Chief/Associate Chief of Staff
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Other (non-voting) members include:
 UMHC Associate Chief Financial Officer and Reimbursement Manager
 UMC School of Medicine Senior Associate Dean for Education and Faculty Development
 UMC School of Medicine Associate Dean for Education and Improvement/Research
Assistant
 GME Instructional Design Specialist
 GME Coordinator
 Meetings are open to any other program directors who wish to attend, as non-voting
members
The GMEC is required to meet at least quarterly; the GMEC at UMHC endeavors to meet
monthly.
The GMEC is required to maintain written minutes of their meetings.
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GMEC Responsibilities
The GMEC establishes and implements policies and procedures regarding the quality of
education and the work environment for residents in all programs. These policies and
procedures include:
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Stipends and Position Allocation
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In collaboration with the GME Resources Committee, the GMEC annually reviews and makes
recommendations to UMHC administration regarding resident stipends, benefits, and
funding for resident positions.
Communication with Program Directors
 The GMEC ensures that communication mechanisms exist between the GMEC and all
program directors within the institution.
 The GMEC ensures that program directors maintain effective communication mechanisms
with the site directors at each participating site for their respective programs to maintain
proper oversight at all clinical sites.
Resident Duty Hours
 The GMEC must develop and implement written policies and procedures regarding resident
duty hours to ensure compliance with the Institutional, Common, and
Specialty/Subspecialty-specific Program Requirements.
 The GMEC will consider for approval requests from program directors prior to submission to
an RRC for exceptions in the weekly limit on duty hours up to 10% or up to a maximum of 88
hours in compliance with ACGME Policies and Procedures for duty hour exceptions.
Resident Supervision
The GMEC monitors programs’ supervision of residents and ensure that supervision is consistent
with
 Provision of safe and effective patient care
 Educational needs of residents
 Progressive responsibility appropriate to residents’ level of education, competence, and
experience
 Other applicable Common and Specialty/Subspecialty-specific Program Requirements
Communication with Medical Staff
The GMEC facilitates communication between leadership of the medical staff regarding the
safety and quality of patient care that includes:
 The annual report to the OMS
 Description of resident participation in patient safety and quality of care education
 The accreditation status of programs and any citations regarding patient care issues
Curriculum and Evaluation
The GME monitors curriculum and evaluation procedures to assure that each program provides a
curriculum and an evaluation system that enables residents to demonstrate achievement of the
ACGME general competencies as defined in the Common and Specialty/Subspecialty-specific
Program Requirements.
Resident Status
The GMEC monitors selection, evaluation, promotion, transfer, discipline and/or dismissal of
residents in compliance with the Institutional and Common Program Requirements.
Oversight of Program Accreditation
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The GMEC reviews all of the ACGME program accreditation letters of notification and monitors
action plans for correction of citations and areas of noncompliance.
 Management of Institutional Accreditation
The GMEC reviews the Sponsoring Institution’s ACGME letter of notification from the IRC and
monitors action plans for correction of citations and areas of noncompliance
 Oversight of Program Changes
The GMEC reviews the following for approval, prior to submission to the ACGME by program
directors:
 All applications for ACGME accreditation of new programs
 Changes in resident complement
 Major changes in program structure of length of training
 Additions and deletions of participating sites
 Appointments of new program directors
 Progress reports requested by any Review Committee
 Responses to all proposed adverse actions
 Requests for exceptions of resident duty hours
 Voluntary withdrawal of program accreditation
 Requests for an appeal of an adverse action
 Appeal presentations to a Board of Appeal or the ACGME
 Experimentation and Innovation
The GMEC provides oversight of all phases of educational experiments and innovations that may
deviate from Institutional, Common, and Specialty/Subspecialty-specific Program Requirements,
including:
 Approval prior to submission to the ACGME and/or respective Review Committee
 Adherence to procedures for “Approving Proposals for Experimentation or Innovative
Projects” in ACGME Policies and Procedures
 Monitoring quality of education provided to residents for the duration of such a project.
 Oversight of Reductions and Closures
The GMEC provides oversight of all processes related to reductions and/or closures of:
 Individual programs
 Major participating sites
 The Sponsoring Institution
 Vendor Interactions
The GMEC supports the UMHC policy that addresses interactions between vendor
representatives/corporations and residents/GME programs.
Internal Review Process
The GMEC develops, implements, and oversees an internal review process. The process is described in
the Internal Review Procedure and Protocol Policy.
Original Effective date: 7/01/07, approved by GMEC 8/28/07
Amended policy approved 1/6/09, 7/2010
Revisions Approved by GMEC 6/7/11
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Internal Review Protocol
Graduate Medical Education Committee
University of Missouri Hospitals and Clinics
All accredited graduate medical education programs (residency and fellowship) sponsored by the
University of Missouri Hospitals and Clinics (UMHC) undergo a periodic internal review as described in
the Institutional Requirements of the Accreditation Council for Graduate Medical Education (ACGME).
The review is conducted under the guidance of the Graduate Medical Education Committee (GMEC),
which reviews the final report of each internal review and makes recommendations as indicated. The
internal review is conducted at approximately the mid-point of the accreditation cycle. (The accreditation
cycle is calculated from the date of the meeting at which the final accreditation action was taken to the
time of the next site visit.)
When a program has no residents enrolled at the mid-point of the review cycle, the following
circumstances will apply:
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The GMEC will demonstrate continued oversight of those programs through a modified internal
review that ensures the program has maintained adequate faculty and staff resources, clinical
volume, and other necessary curricular elements required to be in substantial compliance with the
Institutional, Common and specialty-specific Program Requirements prior to the program
enrolling a resident.
After enrolling a resident, an internal review must be completed within the second six-month
period of the resident’s first year in the program.
Internal Review Subcommittee Membership and Responsibilities
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The GMEC Chair and DIO select the Internal Review Subcommittee for each program being
reviewed.
Each Subcommittee is chaired by the Internal Review Director.
In addition to the chair, the Subcommittee will consist of
 a faculty member (a program director chosen from outside the program being reviewed),
 a Resident (chosen by this program director),
 the GMEC Chair and designated GME Staff (GME Coordinator and GME Instructional
Design Specialist).
 Other members may be appointed at the discretion of the Internal Review Chair.
No member of the committee may have a direct relationship to the program under review.
The responsibilities of the subcommittee are
 to review the Internal Review Packet (described below)
 to conduct interviews with the Program Director, the residents, the program coordinator,
faculty and other staff members of the department
 to provide a final report to the GMEC.
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Required Questionnaires/Interviews
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The Program Director Self-Study Questionnaire
 Includes questions about the educational program, general competencies, evaluation,
supervision, scholarship and research and policies.
 This self-study is sent to the Program Director approximately four months prior to the
internal review along with guidelines for the upcoming internal review.
 The self-study, completed by the Program Director and key teaching faculty, is due one
month prior to the internal review so that it can be distributed to the Internal Review
Subcommittee.
 The Resident Questionnaire
 Includes questions about ACGME Program, Common and Institutional requirements.
 The Resident Questionnaire is sent to the residents approximately four months prior to
the internal review.
 This questionnaire is due two months prior to the internal review.
 The resident member of the Internal Review subcommittee, the Chair of the GMEC or
the DIO and the GME staff meet with a group of residents in the program (all residents
are asked to attend and assure there is at least one from each PGY year) to review the
Resident Questionnaire.
 This meeting occurs approximately one month prior to the internal review meeting so that
all materials may be assembled for the Internal Review Subcommittee. A summary of
this meeting is placed in the internal review packet.
Required Submissions from Program Director to Internal Review Committee
One month prior to the Internal Review Subcommittee meeting, the program is required to submit
 Goals and Objectives for each rotation
 Evaluation forms –
 used by residents to evaluate faculty,
 by faculty to evaluate residents
 by residents to evaluate the program,
 final summative evaluation of a recently finishing resident (name blacked out)
 any other evaluation forms used such as 360, procedure check list, etc.
 List of educational tools and resources currently being used (i.e. education modules,
simulation, etc.)
 List of conferences during the past year ( if required topics are not covered each year,
program should confirm these are part of the didactic curriculum)
 Most recent completed resident case logs, as applicable; national data on averages, if
available
 Most recent Program Annual Review (with most recent ACGME Resident Survey)
 Completed PIF from last site visit
 Program manual
 Duty hour monitoring data
 Program Manual
 Outcome measures (board scores, in-service scores, etc)
 Program Letters of Agreement
 A representative resident’s file
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This material is reviewed by the Chair of the Internal Review Subcommittee, the DIO and GME
Staff. A report is prepared and the materials are available for review by the full subcommittee.
Internal Review Preliminary Meetings
Approximately one month prior to the Internal Review Subcommittee meeting, the Internal Review
Director meets with key teaching faculty and staff of the program under review to discuss goals and
objectives of the program, research opportunities, clinical and didactic teaching, evaluation and feedback,
duty hour issues and recommendations for improving the program. A summary of this meeting is placed
in the internal review packet.
Internal Review Packet Materials
The Internal Review Packet Materials are distributed to all internal reviewers approximately two weeks
prior to the internal review preliminary meeting. It includes:
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The Summary from the last Internal Review; all correspondence/progress reports to the GMEC
The most current ACGME Requirements, including Institutional and Common Program
Requirements
Any correspondence with the ACGME including questions, citations, or progress reports
The Program Director Self-Study Questionnaire
The Resident Questionnaire – Summary of responses
Summary of Faculty Interview
Summary of Resident Interview
The most recent Annual Program Report (including AGME Resident Survey)
Summary of review by the Internal Review Subcommittee Chair, DIO and GME staff of data
submitted by the program
The Internal Review Subcommittee reviews the packet and formulates a list of issues/questions to be
addressed. In addition, a list of additional documents that the committee would like to examine at the
time of the internal review is prepared and sent to the department.
The Subcommittee then meets with the program director, key teaching faculty and staff to discuss its
findings based on the surveys, interviews and review of the submitted materials. They review changes
that have been made based on the RRC recommendations, problems with meeting the Program, Common
and Institutional Requirements, plans for improvement, and any innovations that have been implemented.
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Internal Review Final Meeting
The Internal Review Subcommittee assesses the program’s
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Compliance with the program and institutional requirements
Educational objectives and effectiveness in meeting those objectives
Educational and financial resources to meet those objectives
Effectiveness in addressing areas of non-compliance and concern in previous ACGME letters of
notification and internal reviews
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Effectiveness of educational outcomes in the ACGME core competencies
Effectiveness of using evaluation tools and outcome measures to assess the resident’s competence
in each of the ACGME core competencies
Annual program improvement efforts in resident performance using aggregated resident data,
faculty development, graduate performance on certification exams and program quality
Internal Review Report and Follow-up
Following the meeting, the Chair of the Internal Review Subcommittee prepares an Internal Review
Report, which follows a standard template, which includes
 The name of the program reviewed
 The date of the assigned midpoint and the status of the GMEC’s oversight of the internal review
at that midpoint
 The names and titles of the Internal Review Subcommittee members
 A brief description of how the internal review process was conducted, including the list of the
groups/individuals interviewed and the documents reviewed
 Sufficient documentation to demonstrate that a comprehensive review followed the GMEC’s
internal review protocol
 A list of the citations and areas of non-compliance or any concerns or comments from the
previous ACGME accreditation letter of notification with a summary of how the program and/or
institution subsequently addressed each item
 Commendations and recommendations for improvement.
The summary (report) of the Internal Review is sent to the members of the Internal Review Subcommittee
for review.
Following their review, the report is then sent to the Program Director for clerical corrections.
A final report, with Program Director responses, is then reviewed at the next GMEC meeting.
The Program Director is asked to attend this meeting to respond to any questions by the GMEC, which
becomes part of the record.
Action plans recommended by the GMEC to correct identified deficiencies and recommended monitoring
are included in the final report.
The approved report is then sent to the Program Director and their Department Chair.
The DIO and the GMEC must monitor the response by the program to actions recommended by the
GMEC in the internal review process.
The Sponsoring Institution must submit the most recent internal review report for each training program
as a part of the Institutional Review Document (IRD). If the institutional site visitor simultaneously
conducts individual program reviews at the same time as the institutional review, the internal review
reports for those programs must not be shared with the site visitor.
Revisions Approved by GMEC 6/7/11
14
Cycle of Program Review by GMEC
GMEC monitors corrective action plans and
reviews and approves any required
response or progress report for the ACGME
Internal Review process begins 4 months before
ACGME identified time for IR. Program self-study,
resident questionnaire, faculty and resident
interviews
PD attends GMEC meeting to review
notification letter and present corrective action
plans for any citations. GMEC determines
schedule for follow up of action plans
IR subcommittee reviews materials and develops list
of questions for the program director and list of
documents to be reviewed at IR. This is sent to the
program.
ACGME notification letter received by PD
and DIO. Date for Internal Review and
approximate date for next site visit entered
into GME calendar
Post ACGME Site Visit Survey from program
reviewed by GME staff and periodically
reviewed by GMEC for process improvement
Internal Review – IR committee meets with PD and
coordinator to review the questions and the
requested materials
IR report written and reviewed by committee and
PD, including action plans proposed by the
program to address concerns identified by the
committee.
Site Visit
IR report presented to GMEC by IR subcommittee
chair with PD present to answer questions.
GMEC approves report and determines
monitoring schedule for follow up of action plans.
GME staff helps prepare PIF. DIO reviews
and signs before submission to ACGME
Program notified of ACGME site visit
and prepares PIF
15
POLICY ON RESIDENT RECRUITMENT,
ELIGIBILITY & SELECTION
Programs must select applicants on the basis of preparedness, ability, aptitude, academic
credentials, communication skills and personal qualities such as motivation and integrity.
Discrimination by gender, race, age, religion, color, national origin, disability or any other
applicable legally protected status is prohibited. Restrictive covenants are not permitted.
Each program director must be certain each resident/fellow candidate meets all ACGME,
general Missouri State Licensing Board criteria and immigration requirements before
accepting the individual into the program. The acceptance of unqualified candidates
can lead to withdrawal of certification by the ACGME. The primary verification process
consists of the following activities:
Programs will participate in an organized matching program, such as the National Resident
Matching Program (NRMP), if available.
B.
New US Graduates
III.
Application for residency/fellowship through the Electronic Residency Application
Service (ERAS) serves as primary verification. (Minimum documents required:
graduate of MD or DO medical school in the US or Canada which is accredited by
LCME or AOA respectively; medical school transcript; Dean’s letter; United States
Medical Licensing Examination (USMLE) Step 1 and 2 scores or COMLEX score;
reference letters) or:
IV.
Completion of the Universal Residency Application with the above stated documents
attached. Transcripts must be verified with the school.
C.
Foreign-Born and International Medical Graduates (IMG: a physician whose
basic medical degree is conferred by a medical school located outside the US,
Canada or Puerto Rico) must:
3.
Hold J-1 visa (exchange visitor) H-1B visa (temporary worker), immigrant visa or
“green card” or an Immigration and Naturalization Service (INS) issued or approved
work permit if not a US citizen.
4.
Have a full unrestricted license to practice medicine in the State of Missouri or hold
an Educational Commission for Foreign Medical Graduates (ECFMG) Standard
Certificate, which is a prerequisite to practice medicine in the US and is an eligibility
requirement to take Step 3 of the USMLE. A Standard ECFMG Certificate is issued to
an applicant who meets the examination requirements, fulfills the medical education
credentialing requirement and clears their financial account with ECFMG. This
Certificate is considered valid if the “valid through” dates of the English test and CSA
is not later than the program start date. In order for an applicant to obtain
permanent validation of the Certificate, ECFMG must receive documentation from an
official of the program confirming the applicant’s entry to the program, at which
time, ECFMG will provide a “valid indefinitely” sticker to the holder of the Certificate.
16
C.
Residents Entering a Program After Completing Preliminary Year at Another
Institution - In addition to the requirements of A or B of this policy, requires a:
2.
Letter from the program director of the resident’s preliminary year program
indicating he/she has successfully completed the preliminary year of training and
must obtain written or electronic verification of previous educational experiences and
a summative competency-based performance evaluation of the transferring resident.
D.
Graduates of medical schools outside the United States who have completed
a Fifth Pathway program provided by an LCME-accredited medical school.
A Fifth Pathway program is an academic year of supervised clinical education
provided by an LCME-accredited medical school to students who meet the following
conditions: (1) have completed, in an accredited college or university in the United
States, undergraduate premedical education of the quality acceptable for
matriculation in an accredited United States medical school; (2) have studied at a
medical school outside the United States and Canada but listed in the World Health
Organization Directory of Medical Schools; (3) have completed all of the formal
requirements of the foreign medical school except internship and/or social service;
(4) have attained a score satisfactory to the sponsoring medical school on a
screening examination; and (5) have passed either the Foreign Medical Graduate
Examination in the Medical Sciences, Parts I and II of the examination of the
National
Board of Medical Examiners, or Steps 1 and 2 of the United States Medical Licensing
Examination (USMLE).
E.
Physicians Entering a Fellowship - In addition to the requirements of A or
B of this policy, requires a:
Letter from the program director of the resident’s previous program indicating
he/she successfully completed the residency program.
17
4.
5.
Verification that the completed residency program is accredited and meets the
ACGME requirements for entry into that particular fellowship.
6.
Reference letter from the Hospital where the physician previously practiced and a
National Practitioners Data Bank (NPDB) query, if the fellowship start date is not
immediately after residency completion.
F.
2.
Restrictive Covenants
ACGME accredited residencies must not require residents to sign a non-competition
guarantee.
Revisions approved by the GMEOC: 12/4/07; 10/6/09
18
POLICY
SUPERVISION and PROGRESSIVE AUTHORITY and RESPONSIBILITY
OF RESIDENTS AND FELLOWS
(HEREAFTER REFERRED TO AS RESIDENTS)
AT UNIVERSITY OF MISSOURI-COLUMBIA
HEALTH SCIENCES CENTER
Purpose: To set institutional standards for faculty supervision of residents that assures their
education and our compliance with ACGME institutional standards.
[Note: These standards are not meant to comply with standards required for billing purposes.]
Assuring adequate supervision of residents and fellows is the responsibility of the program
director, faculty physicians, departments, and the institution.
The following are standards for all MU resident and fellow positions, irrespective of where they
are training. These are minimum rules. No program can fall below these standards, but they will
be expanded if:
1. Medical Staff rules at a given institution exceed these.
2. Additional standards are required by JCAHO, CMS, PATH or other regulatory body.
3. An individual program has more stringent RRC requirements for supervision.
4. The clinical setting where the resident physician is training has additional rules. For
example, the Harry S. Truman Memorial Veterans Hospital Policy is described in:
Resident Supervision, VAH Handbook 1400.1, March 21, 2000, available in the Resident
Coordinators Office or at the VA.
Standards
All patient care performed by residents during training will be under the supervision of a
physician faculty member qualified to provide the appropriate level of care. The specifics of this
supervision must be documented in the medical record by the supervising physician or resident.
Residents, fellows, and faculty members should inform their patients of their respective roles in
each patient’s care.
19
Levels of Supervision: Appropriate supervision of residents must be available at all times.
Levels of supervision may vary depending on circumstances or skill and experience of the
resident. Definitions relative to levels of supervision are:
 Direct Supervision: The supervising physician is physically present with both the
resident and the patient
 Indirect Supervision
 Direct supervision immediately available: The supervising physician is physically within
the confines of the site of the patient care and immediately available to provide DIRECT
supervision.
 Direct supervision available. The supervising physician is not physically present within
the confines of the site of patient care, but is immediately available by phone, and is
available to come in and provide DIRECT supervision.
 Oversight: The supervising physician is available to provide review of
procedures/encounters with feedback provided after the care has been delivered.
 Supervising Physician: The supervising physician can be a faculty member or a more senior
resident than the one needing supervision.
Each resident must know the level of supervision required for them in all circumstances. PGY-1
residents must have, at all times, either direct supervision or indirect supervision with direct
supervision immediately available. PGY-1’s may not be alone on a hospital service. PGY-1
residents cannot take at-home call. Senior residents or fellows may serve as a supervisor for a
junior resident, based on the needs of the patient and the skills of the individual.
The supervising physician must be immediately available to the resident or fellow in person or
by telephone 24 hours a day during clinical duty. Programs must assure this occurs: Residents
must know which supervising physician is on call and how to reach this individual. Contact
information and schedules for residents, attending physicians, and other designated patient care
individuals should be readily available to all parties involved with patient care
The attending physician must clearly communicate to the residents when and
under which circumstances they expect to be contacted by the resident
concerning patients. At a minimum, the resident must notify the attending of any
significant changes in the patient’s condition, including but not limited to:







Patient admission to hospital
Transfer of patient to intensive care unit
Need for intubation or ventilator support
Cardiac arrest or significant changes in hemodynamic status
Development of significant neurological changes
Development of major wound complications
Medication errors requiring clinical intervention
20
 Any significant clinical problem that will require an invasive procedure or surgery
 Any condition which requires the response of a special team
 End-of-life decisions
 Any patient request to do so
Inpatient supervision: The supervising physician must obtain a comprehensive presentation for
each admission. This must be done within a reasonable time, but always within 24 hours of
admission. The supervising physician must also require the resident to present the progress of
each inpatient daily, including discharge planning. All required supervision must be documented
in the medical record by the resident and/or the supervising faculty member
Outpatient supervision: The supervising physician must require residents to present each
outpatient’s history, physical exam and proposed decisions. All required supervision must be
documented in the medical record by the resident and/or the supervising faculty member.
Transitions of Patient Care: Covered in Transitions of Care Policy.
Supervision of consultations: The supervising attending must communicate with the resident
and obtain a presentation of the history, physical exam and proposed decisions for each referral.
This must be done within an appropriate time but no longer than 24 hours after notification of the
consultation request. All required supervision must be documented in the medical record by the
resident and/or the supervising faculty member.
Supervision of procedures: The supervising faculty physician must be certain that procedures
performed by the resident are warranted, that adequate informed consent has been obtained and
that the resident has appropriate supervision during the procedure to include sedation. Whenever
there is more than minor risk to the patient, the supervising physician must be present during the
key part of the procedure. All required supervision must be documented in the medical record
by the resident and/or the supervising faculty member.
Supervision of emergencies: During emergencies, the resident should provide
care for the patient and notify the supervising physician as soon as possible to
present the history, physical exam and planned decisions. All required
supervision must be documented in the medical record by the resident and/or the
supervising faculty member.
Progressive authority and responsibility for Residents: Increasing
responsibility for patient care is an integral part of the medical education process.
Specific roles and tasks for patient care must be assigned by program directors
and faculty members.

21
Roles and responsibilities for residents are determined by the program
director. Decisions for individual residents must be based on specific
criteria and evaluation based on specific national standards-based
competencies.


Faculty members in the role of attending/supervising physicians should
delegate portions of patient care to residents based on the needs of the
patient and the skills and experience of the resident.
Each resident must know the limits of his/her scope of authority and
responsibility and the circumstances under which varying levels of
supervision apply.
Faculty supervision assignments to individual residents should be of duration adequate to assess the
knowledge, level, and scope of residents and to delegate and observe the resident in circumstances of
increasing patient care responsibility
V.
Common questions:
VI.
When does the supervising physician have to come in to see a patient? This
would be typical of expected practice, or whenever the resident asks the
supervising physician to be present or whenever CMS or Medical Staff rules
require this.
VII.
To whom are faculty responsible for resident supervision? The program director,
the chair of the department, the GME Oversight Committee and the Dean of the
School of Medicine for educational supervision. The supervising physician is
also responsible for CMS documentation requirements and Medical Staff rules.
Approved by the GMEC: 5/2/00
Revised/Approved by the GMEC: 9/2/03
Revised/Approved by the GMEC: 3/12/04
Revised/Approved by the GMEC: 6/7/11
22
Policy
Teamwork
University of Missouri-Columbia
Residents must care for patients in an environment that maximizes effective communication.
This must include the opportunity to work as a member of effective interprofessional teams that
are appropriate to the delivery of care in the specialty.
Adopted May 2011
GMEC Approved 6/7/11
23
POLICY
Transitions of Care
PURPOSE:
To establish protocol and standards within the Graduate Medical Education
Committee at the University of Missouri to ensure the quality and safety of patient
care when transfer of responsibility occurs during duty hour shift changes and
other scheduled or unexpected circumstances.
STANDARDS: Individual programs must design schedules and clinical assignments to maximize
the learning experience for residents as well as ensure quality care and patient
safety, and adhere to general institutional policies concerning transitions of
patient care.
Transitions of care are necessary in the hospital setting for various reasons. The
transition/hand-off process is an interactive communication process of passing specific,
essential patient information from one caregiver to another. Transition of care occurs regularly
under the following conditions:




Change in level of patient care, including inpatient admission from an outpatient
procedure or diagnostic area or ER and transfer to or from a critical care unit.
Temporary transfer of care to other healthcare professionals within procedure or
diagnostic areas
Discharge, including discharge to home or another facility such as skilled nursing care
Change in provider or service change, including change of shift for nurses, resident signout, and rotation changes for residents.
The transition/hand-off process must involve face-to-face interaction with both verbal and written
communication. The transition process should include, at a minimum, the following information
in a standardized format that is universal across all services:





Identification of patient, including name, medical record number, and date of birth
Identification of admitting/primary physician
Diagnosis and current status/condition of patient
Recent events, including changes in condition or treatment, current medication status,
recent lab tests, allergies, anticipated procedures and actions to be taken.
Changes in patient condition that may occur requiring interventions or contingency plans
Each program must develop components ancillary to the institutional transition of care policy
and that integrate specifics from their specialty field. Programs are required to develop
scheduling and transition/hand-off procedures to ensure that:


24
Residents do not exceed the 80-hour per week duty limit averaged over 4 weeks.
Faculty are scheduled and available for appropriate supervision levels according to
the requirements for the scheduled residents.




All parties involved in a particular program and/or transition process have access to
one another’s schedules and contact information. All call schedules are available
on the MUHC MyApps website and with the hospital operator.
Patients are not inconvenienced or endangered in any way by frequent transitions
in their care.
All parties directly involved in the patient’s care before, during, and after the
transition have opportunity for communication, consultation, and clarification of
information.
Safeguards exist for coverage when unexpected changes in patient care may
occur due to circumstances such as resident illness, fatigue, or emergency.
Each program must include the transition of care process in its curriculum. Residents must
demonstrate competency in performance of this task. Programs must develop and utilize a
method of monitoring the transition of care process and update as necessary.
GMEC Approved 6/7/11
25
26
Ophthalmology Monitoring of Patient Hand-off (On-Call and In-Patients)
The accreditation Committee for Graduate Medical Education (ACGME) requires the following:
a) An effective, structured transition of patient care that facilitates continuity of care and patient
safety;
b) Residents are competent in communicating with team members in the hand-over process; and
c) The availability of schedules that inform all members of the health care team of attending
physicians and residents who are currently responsible for each patient’s care.
In accordance with the ACGME requirements regarding Transition of Care, the Ophthalmology
Department publishes monthly (with updates as needed) a schedule of residents and attending
faculty members who are on-call for emergency outpatients or in-hospital patients.
The following policy is also undertaken:



For patients who are currently in the hospital and whose eye care is being supervised by the
Ophthalmology Department, the resident caring for the patient on a daily basis will discuss the
patient care with the on-call resident, prior to the end of the working day and the following
morning to ensure effective communication and transfer of care;
For patients who are currently in the hospital and who previously had not been evaluated by the
Ophthalmology Department (i.e., new inpatient consult), the on-call resident will discuss the
patient care with the attending faculty on-call at that time or by the following morning, to ensure
effective communication and transfer of care;
For patients who are evaluated through the Emergency Room and who have on-going issues (e.g.,
acute glaucoma, corneal ulcer, etc.), the on-call resident will discuss the patient care with the
attending faculty on-call at that time or by the following morning, to ensure effective
communication and transfer of care.
27
HOUSE STAFF COMPLIANCE WITH TIMELY COMPLETION OF MEDICAL
RECORDS
Objective:
To outline a process that will be used to assure the timely completion of patient medical records
(MR) by House Staff at University Hospitals and Clinics (UHC), in compliance with the Medical
Staff policy MS-01: Suspension of Privileges – Delinquent Inpatient Medical Records.
To provide a process that holds residents accountable for their role in the timely completion of
patient records and therefore facilitates appropriate continuity of patient care and contributes directly
to UHC’s ability to meet regulatory expectations on MAR completion.
Policy:
House Staff must complete all elements of the MR for which they are responsible within fifteen (15)
business days of patient discharge. As directed by UHC’s Medical Staff Rules and Regulations, such
items for completion include signing of the history and physical, discharge summary, operative notes
and verbal orders. Failure to do so may result in negative evaluations citing failure to meet
proficiency in the core competency professionalism.
All requests for verification of affiliation or education during search for employment will include a
response that evaluations during residency training indicate issues identified with regard to timely
MR completion.
Department-specific methods may be used to ensure compliance with this policy. For programs
choosing to develop a different process from that prescribed within this policy, approval of the plan
shall be sought through the Graduate Medical Education Oversight Committee before
implementation.
Proposed Process:
1. All practitioners will have immediate notification of, and access to, all MR items requiring
signature via their electronic MR Inbox.
2. In addition, the Medical Records Department will assure multiple notifications of items requiring
signature by using the following steps:
A. Effective November 7, 2006, all unsigned documents will remain visible in a user's
Inbox until they are either signed or appropriately refused and forwarded back to
medical records.
B. Every Tuesday, Medical Records staff will hand-deliver lists of deficiencies that are
older then 7 days to each department for notification to physicians.
C. Every Tuesday, via e-mail, the Medical Records Document Completion supervisor
will also notify Department Chairs, Department Administrators and Residency
Program Directors (PDs) of all MR items that are delinquent at 15 days or older
requiring dictation.
3. Once a week, Medical Records staff will send a listing of all delinquent record items to the
Residency PDs for final notification to the responsible residents. This will include all
28
unsigned items that are 21 days post-discharge. At this point, following notification by the PDs, the
resident will be expected to complete the records within 10 business days.
4. As these weekly reports continue to be provided, the PDs are encouraged follow the following
steps with residents who have delinquent items reported:
A. Verbal counseling – For the first occurrence, the PD will meet with the resident to
detail the concern, including the date of the event. The resident’s explanation will be
heard and documented.
B. Letter of formal counseling – For the second occurrence, the PD will inform the
resident of the delinquency incident, document the details of the concern in a formal
letter of counseling and then meet with the resident to discuss the event and
expectations for resolution.
C. Formal counseling reevaluation – The PD will meet with the resident for reevaluation
three months following the second occurrence, or sooner if another delinquent record
incident occurs. If the meeting is a result of a third incident, the information will be
documented in a letter that both the PD and the resident will sign. It will then be
forward to the Department Chairman for signature and additional recommendations
for action. At the third incident, formal documentation of failure to meet
professionalism expectations will be included in the resident’s formal evaluation file.
5. If the resident has additional incidents, or shows persistent deficiency in ability to meet
this professional proficiency or other core competencies, the PD may determine the need
to engage disciplinary steps as determined by the program and may result in actions such
as program-level remediation and subsequent formal probation.
Approved by the Graduate Medical Education Oversight Committee - 12/5/06
29
Policy:
Resident/Fellow Stipends
Effective:
July 1, 2007
Approved by the GMEOC:
8-28-07
The GMEOC, in collaboration with the GME Resources Committee, reviews the Association of
American Medical Colleges (AAMC) Council of Teaching Hospitals (COTH) annual resident
stipend report, which is received by the GME Office in November/December each year. This
report is used as a guide in determining salaries for the upcoming academic year, July 1 – June
30. Proposed salaries are based on data reported for the Midwest during the previous year and
are presented to Hospital Administration for final approval.
30
BLS/ACLS/PALS Certification
(Basic Life Support / Advanced Cardiac Life Support / Pediatric Advanced Life Support)
31
All residents/fellows who have direct contact with patients must maintain active certification in
BLS and ACLS which has been endorsed by the American Heart Association.
Exceptions to certification include:
-
-
Pathology residents will not be mandated to take BLS or ACLS.
General Surgery residents will be required to take BLS and ACLS as new residents and
will only be required to maintain current certification in ATLS for the duration of
training.
Pediatrics residents will be required to maintain BLS, PALS and NRP certification for the
duration of training and will not be required to be ACLS certified.
PALS (certification must be endorsed by the American Heart Association):
-
Family Medicine residents must maintain PALS certification (in addition to BLS, ACLS)
Med/Peds residents must maintain PALS certification (in addition to BLS, ACLS)
GMEOC approved 2/5/02
GMEOC approved amended policy 4/3/07
GMEOC approved amended policy 7/1/98
32
Step 3 / COMLEX Exam Requirements
Policy:
To define requirements for passing USMLE Step 3(for MDs) and
COMLEX (for DOs) prior to completing the training program
Effective:
For All New Training Physicians starting July 1, 2009, and after
All residents are required to pass Step 3 of USMLE (for MDs) or COMLEX (for DOs) prior to
starting their final year of residency, and all fellows are required to pass the respective exam
during their first year of training. Evidence of successful completion of this exam must be given
to the program director and kept in the resident’s file. Residents are encouraged to take the exam
by early in the PGY 2 year, in order to allow remediation if necessary. Failure to provide
evidence of successful completion of Step 3 of USMLE for MD physicians or COMLEX for DO
physicians prior to beginning the final year may result in non renewal of the contract and
dismissal from the program. Individual training programs may have requirements for successful
completion of the exam prior to the timeline outlined above.
Approved by the GMEOC: August 5, 2008
Revision Approved: February 3, 2009
33
POLICY:
Reporting of Other Learners in a Program
Effective:
7-1-07
Approved by the GMEOC:
8-28-07
The presence of other learners (including, but not limited to, residents from other specialties,
subspecialty fellows, PhD students and advance practice nursing students) in the training
program must not interfere with the appointed resident/fellow’s education. The presence of other
learners during the current academic year must be reported in the program’s Annual Report to
the GMEOC.
34
Moonlighting
Professional Activities Outside the Educational Program
Policy:
The ACGME requires that the institution assure that each training program maintains
a policy that specifies moonlighting conditions, including both internal and external
moonlighting, and setting forth specific requirements for such activity. The
moonlighting policy, whether it is allowed by individual programs or not, is to be
referenced in each trainee contract.
Purpose:
This policy has been created to:


Provide an institutional policy that guides and provides a basis upon which programs will
develop their own specific policies.
Inform and protect Housestaff who choose to moonlight while training at University of
Missouri Healthcare, Columbia (hereafter referred to as UMHC).
Residents who consider moonlighting and/or other professional activities outside of the
UMHC educational program must adhere to the requirements, standards, and definitions
listed below:
Requirements, Standards, and Definitions:

Housestaff:
 Residents and fellows who are physicians in training for Board certification
 Required to have a temporary or permanent Missouri medical license
 Are provided UMHC malpractice insurance during official training activities.
 Billing, directly or indirectly, for services during such training hours is not permitted

Internal Moonlighting
 Internal Supervised Resident Activity (ISRA)
 Elective resident/fellow participation in patient care within their specialty program and
license that exceeds ACGME and program requirements.
 ISRA includes an additional stipend, but must be voluntary
 Must be on the UMHC clinics and campuses or at a UMHC site where training normally
occurs
 Must be rendered under GME Oversight Committee approval with the same faculty
supervision, attending billing, and documentation rules
 Must be at a level of clinical responsibility that is appropriate for the resident’s level of
training
 An individual resident or fellow may voluntarily choose to participate in this elective
responsibility, if offered the opportunity by their program, upon successful completion of
the PGY-1 year.
35




This activity is counted as part of the resident’s regular duties in the 80-hour per week
duty requirement.
A resident or fellow wishing to participate in internal moonlighting must have written
permission to do so and this documentation must be maintained in the resident/fellow
file.
A PGY-1 resident is not eligible for internal moonlighting at any time or under any
circumstance.
External Moonlighting:


36
External moonlighting is voluntary medical practice/work done by residents or fellows
outside of his or her training program and outside the scope of training.
Standards applicable to external moonlighting:
 Any resident or fellow wishing to moonlight must receive written approval to do so from
their program director
 Written permission from the program director must be stored and maintained in the
resident/fellow file.
 Moonlighting must be approved by the Department Chairman and the Program Director
of the training program of the individual, with determination and assurances that
moonlighting is not detrimental to the resident’s training in any significant way.
 The program director must monitor the moonlighting activity to ensure that the
resident/fellow does not become excessively fatigued.
 The program director may limit or suspend moonlighting activity, either individually or
unilaterally, if excessive fatigue or interference with the required training activities is
found.
 External moonlighters, since they are functioning as attending physicians, must:
 Hold permanent licenses (Missouri medical, Federal narcotics (DEA) and State
Narcotics (BNDD) before beginning any moonlighting work.
 Have medical staff privileges and malpractice coverage for the patient care they
will provide.
 External moonlighting can be a medical practice outside of the training program, but
within a UMHC location or under a UMHC. In this situation, UMHC provides for
malpractice coverage and any related legal representation.
 A permanent State of Missouri license and Medical Staff privileging and
credentialing are still necessary.
 CMS requires that for in-house moonlighting, the training institution must have a
contract with each resident/fellow that specifies the moonlighting is separate
from ACGME training and is done under a regular state license and for CMS
approved medical services.
 A resident/fellow moonlighting at any health care entity which is not a part of
UMHC requires that arrangements be made between the moonlighter and the
health care entity for malpractice coverage and related legal representation. The
moonlighter is operating independently of UMHC and must assume no such
coverage exists unless these arrangements have been completed.
 External moonlighters are subject to all local, state, and federal laws that apply to
attendings when and where they moonlight.
 All moonlighting must comply with Visa guidelines. Certain Visas do not allow work
outside the normal activity of the training program.
 Each program must create a policy that complies with this UMHC Policy and place this
and the institutional policy in the program manual. Programs may choose to permit,
nor permit or limit moonlighting.
 Program policy should require that moonlighting will not interfere with Housestaff
training responsibilities/schedules or contribute to excessive fatigue, as well as
stipulate consequences for Housestaff who do not comply with the training program
policy.
 Moonlighting must not interfere with the ability of the resident to achieve the goals,
objectives, and responsibility of their training program.
 Time spent moonlighting, both internal and external, must be counted in the 80-hour per
week duty hour maximum.
 PGY-1 residents are not permitted to moonlight under any circumstances.
GMEOC Approval 6/15/9
Dean Approval 6/24/99
Revisions Approved GMEC 5/2/00
Revisions Approved GMEC 10/05/05
Revisions Approved GMEC 02/02/10
Revisions Approved GMEC 6/7/11
37
Health Sciences Center Moonlighting Policy
J-1 or H-1B Visa Holders
In the June 30, 1999, Federal Register the USIA (United States Information Agency) outlined policies
regarding moonlighting of non-resident aliens with visas. J-1* visa holders are prohibited to obtain
employment that is not a part of their training program. H-1B** visa holders are also prohibited from
moonlighting unless specifically allowed, as specified, in their visa. Any resident or fellow in a training
program at the University of Missouri who fails to comply with this regulation is at risk for deportation.
To ensure compliance with this regulation, the following process will be followed:
1.
Any resident/fellow wishing to moonlight must receive approval to do so from their program
director. Moonlighting must be approved by the Department Chairman and Resident Program
Director of the training program and these individuals should assure that moonlighting is not
detrimental to training in any significant way. (Please refer to the “Professional Activities
Outside the Educational Program” policy of the Health Sciences Center for moonlighting
requirements.)
2.
The Department Chairman and/or Resident Program Director must verify visa status. If it is
determined that the resident/fellow wishing to moonlight is a J-1visa holder, the Chairman and/or
Resident Program Director will not allow the resident/fellow to moonlight.
3.
If it is determined that the resident/fellow wishing to moonlight is an H-1B visa holder, the
Chairman and/or Resident Program Director must request that the resident/fellow submit his H1B visa documents for review by the University of Missouri Legal Counsel to determine whether
the stipulation for outside employment is written in the visa. If moonlighting is not specifically
allowed in the visa, the Chairman and/or Resident Program Director will not allow the
resident/fellow to moonlight.
4.
Each program must create a policy that complies with this Health Sciences Center Institutional
Policy and place this and the institutional policy in their program manual.
38
Policy for Payment of Fees Associated with an H1B Visa
As part of the H1B petition, the employer, serving as the petitioner of the H1B visa, is responsible for the
INS filing fees, costs and legal fees incurred for the petition of the H1B visa. (All programs must contact
Nancie Hawke, UMC Legal Counsel, to be referred to a list of legal representatives who are approved to
file petitions on behalf of the training physician.)
The following fees will be equally shared between University Hospitals & Clinics and the department
accepting a training physician requesting an H1B visa. These costs will apply to new petitions in addition
to yearly renewals.
1. Application/Filing Fee
2. All legal fees associated with processing the H1B petition
The department will pay all costs initially. Documentation of payments made should be sent to the GME
Office with a request for reimbursement of half the total costs incurred.
The following fees will be the sole responsibility of the training physician. This must be disclosed to the
training physician at the time of inquiry or in discussion about application for H1B visas.
1. Fees to expedite the H1B visa
2. A one-time anti-fraud/homeland security fee of $500*
* If a department chooses, they may pay this fee, in hardship cases. In this circumstance, the cost is the
full responsibility of the department.
Approved by the Graduate Medical Education Oversight Committee 1/3/06
39
Policy
Professionalism, Personal Responsibility, and Patient Safety
Purpose:
Standards:







University of Missouri
To set institutional standards for education of residents and faculty concerning
their professional and personal responsibilities for the safety of their patients.
Programs must work to assure the health and well-being of residents, the safety
of patients and an excellent educational experience for the residents. The
programs must develop scheduling that adheres to the 80-hour per week duty
hour requirements as set forth in the GMEC Duty Hours Policy as well as develop
procedures for transitions of care and education on alertness, fatigue, and sleep
deprivation, in accordance with GMEC policies.
Programs must educate residents and faculty concerning the professional duty of
physicians to appear for duty rested, alert, and ready to provide services to patients.
Programs must develop education and scheduling policies to maximize patient safety
and resident well-being.
Programs must require residents to actively participate in interdisciplinary clinical
quality improvement and patient safety programs.
Programs must provide to residents an appropriate blend of supervised patient care
responsibilities, clinical teaching, and didactic education.
Programs must ensure that there is not an excessive reliance on residents to fulfill nonphysician service obligations.
Programs must include in the curriculum the importance of a culture of professionalism
that promotes patient safety and responsibility and the resident’s personal
responsibility in:
 Assuring the safety and welfare of patients entrusted to their care
 Providing patient- and family-centered care
 Assuring their fitness for duty
 Management of their time before, during, and after clinical assignments
 Recognition of impairment, including illness and fatigue, in themselves and in
their peers
 Attention to life-long learning
 Monitoring of their patient care performance improvement indicators
 Honest, accurate, and timely reporting of duty hours, patient records and
outcomes, and clinical experience data.
Programs must ensure that residents understand their personal responsibility to put the
patient’s needs ahead of their own and that there will be situations when transitioning
the patients care to another physician may be in the best interest of the patient.
GMEC Approved 6/7/11
40
Duty Hour Policy
For the
University of Missouri
Purpose:
To set institutional standards for resident duty hours and in-house on-call frequency that
ensure resident duty hours are not excessive.
Standards:
Resident duty hours should both foster resident education and facilitate the care of
patients. The educational goals of each residency program and the learning objectives of
the residents must not be compromised by excessive reliance on residents to fulfill
institutional service obligations. However, duty hours must reflect the fact that
responsibilities for continuing patient care are not automatically discharged at specific
times. Programs must ensure that residents are provided appropriate back-up support
when patient care responsibilities are especially prolonged or difficult.
Each residency program must adhere to the duty hour limitations set by their individual RRC (Residency
Review Committees) and the ACGME institutional requirements. The structuring of duty hours and oncall schedules must focus on the needs of the patient, continuity of care and the educational needs of the
resident.

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of
all in-house call activities and all moonlighting hours. Internal and external moonlighting hours
must be counted as part of the resident’s total work hours. Some specialties do not allow
averaging.

Residents must be provided with 1 (one) day (24 hours) in 7 (seven) free from all educational and
clinical responsibilities, averaged over a four-week period, including conferences. No at-home
call can be assigned during any of these 24-hour periods.

Mandated time off between assigned “shifts” (duty periods) must be provided to allow adequate
time for rest and personal activities.

41
PGY-1 residents must have 8 hours, but should have 10 hours, off between scheduled
shifts.

Intermediate-level residents (defined by program-specific RRC) must have 8 hours, but
should have 10 hours, off between scheduled shifts. Also, they must have 14 hours free
after a 24-hour period of in-house duty.

Senior-level/chief residents (as defined by program-specific RRC) must be prepared to
enter the unsupervised practice of medicine and care of patients over irregular and
extended periods. This preparation must occur within the context of the 80-hour
maximum duty period length and 1-day free in 7 standards. While it is desirable to have
8 hours off between shifts, there may be circumstances when these residents must stay
on duty to care for their patients or return to the hospital less than 8 hours after their prior
shift. These instances must be monitored by the program director.
On-call Activities

No resident may have more than 6 nights of consecutive night-float duty.

Continuous On-Site Duty

PGY-1 residents may not exceed 16 hours of continuous duty. These 16 hours include
educational conferences, hand-offs, etc. No new patients may be accepted after 16
hours of continuous duty.


PGY-2 and higher residents may not exceed 24 hours of assigned continuous duty, but
an additional 4 hours (totaling 28 hours) may be used for hand-offs and educational
activities. However, there should be no additional clinical activities during these
additional 4 hours (clinics, consultations, etc.). In unusual circumstances a senior-level
resident may choose voluntarily to stay beyond his/her assigned duty period to provide
care to a single patient. These instances must be documented as to the educational
validity by the program director. The care of other patients on the service must be turned
over to another physician. No new patients may be accepted after 24 hours of
continuous duty.
Maximum In-House Call Frequency

PGY-1 residents are not eligible for in-house call immediately following daytime duty
hours.

PGY-2 and higher residents can have in-house call no more frequently than every third
night averaged over 4 weeks.
At-home call (or pager call)

The frequency of at-home call is not subject to the every-third-night, or 24+6 limitation. However
at-home call must not be so frequent as to preclude rest and reasonable personal and study time
for each resident.

Residents taking at-home call must be provided with one day (24 hours) in seven completely free
from all educational and clinical responsibilities, averaged over a four-week period.

When residents are called into the hospital from home, the hours residents spend in-house are
counted toward the 80-hour limit.

Internal and external moonlighting must be considered part of the 80-hour weekly limit on duty
hours.

PGY-2 or higher residents may come in at night to see established or new patients and this will
not violate the 8-10 hour rule, but they must count the time in-house as part of their work hours
 PGY-1 residents are not eligible for at-home call.
Sleep Facilities and Safe Transportation Home Options. Refer to Alertness Management/Fatigue
Mitigation Policy.
Continuity of Care. Refer to Transitions of Care policy
GMEC Approved 6/7/11
42
POLICY
Alertness Management and Fatigue Mitigation
It is essential to the education, health and well-being of residents/fellows and the safety of
patients that faculty and residents alike develop awareness of the symptoms and dangers of
physician fatigue. It is a requirement of the ACGME for all residency programs to educate
faculty and residents concerning alertness and fatigue, require that faculty and residents
participate in such educational experiences, and to document and monitor such participation.
Evidence based literature indicates that fatigue impacts resident/fellow learning and well-being.
Duty hour requirements are part of the solution, but such requirements do not address all issues
relevant to alertness and fatigue.
Research indicates that most people do not realize they are sleepy until they are extremely
fatigued. Psychomotor function after 24 hours without sleep is equivalent to a blood alcohol
content level of 0.08%, a level recognized legally as inebriation. As with alcohol impairment,
individuals may not be able to evaluate their own degree of fatigue.
Causes of fatigue include:




Too little sleep. Most adults require an average of 8.2 hours of sleep per night.
Fragmented sleep. When sleep is interrupted, a person may not have sufficient time spent in
the deeper, restorative stages of sleep.
Circadian Rhythm disruption. Circadian rhythms are the body’s internal biological clock,
managing system functions throughout a 24-hour period. Frequent disruption of sleep
schedules, as in extended duty hours or shift changes can result in fatigue and sleep deprivation.
Other conditions, including anxiety, depression, medication, and physical illness.
Sleep debt can occur with as little as 2 hours less sleep than usual. Incidents of less than optimal
sleep time over several nights will increase the deficit. Sleep debt requires several consecutive
nights of optimal sleep for recovery.
Symptoms of sleepiness/fatigue include:







Repeated yawning and “nodding off” at inappropriate times
Microsleep—a few seconds of sleep that an individual may not even recognize
Increased tolerance for risk
Inattention to details
Decreased cognitive functions
Increased errors
Accidents, especially automobile accidents
In the interest of the health and well-being of residents and patient safety, the GMEC requires:

Educational experiences must be developed in each program to educate both faculty and
residents to recognize the causes, symptoms, and remedies for sleep deprivation, including
recognition of impairment in others and their personal responsibility to be well-rested and alert
when on duty.
43









Participation in sleep deprivation educational experiences must be documented and monitored
by each program
In accordance with duty hours and transition of care requirements, each program must have a
process in place to ensure continuity of care in the event that a resident may be unable to
perform patient care duties due to fatigue, illness, or other impairments.
Faculty, residents, and other health care personnel must be trained in the process of recognizing
fatigue, illness, or other impairments in their colleagues and encouraged to intervene when
necessary to maintain the health and well-being of their colleagues and the safety of patients.
Residents must be educated concerning possible short-term strategies for counter-acting sleep
deprivation symptoms, including napping and occasional moderate use of caffeine
Residents must be educated as to their personal responsibility to appear for duty on-time,
appropriately rested, and otherwise fit for duty.
Residents must demonstrate compliance with their responsibility for their own health and wellbeing by careful management of their time before, during and after duty hours.
Accurate and timely reporting of duty hours is mandatory.
Each program must make sure that adequate sleep facilities/on-call rooms are available for their
residents. Such facilities are provided by UMHC. Each program must ensure that residents
know the location and scheduling of the sleep facilities/on-call rooms. These facilities are
available before, during, and after a resident’s duty hours.
To enable residents with the opportunity for safe transportation home in the event of fatigue,
illness, or other impairment, each resident will be given a voucher to use for a taxicab ride home.
The resident is responsible for returning the receipt for the service in a timely manner, including
documentation of the reason for the transportation. (This process is in development at this time
and updates will be provided to GMEC as soon as details are determined.)
Resources
Duke University, Prevention, Identification, & Management of Fatigue in Graduate Medical Education, November
11, 2010. http://www.gme.duke.edu/newsletters/2010December/Fatigue_11-16-2010.pdf
University of Tennessee College of Medicine, Alertness and Fatigue Management Policy, April, 2011.
http://www.uthsc.edu/GME/policies/fatigue2011.pdf
University of Colorado Denver School of Medicine Duty Hours Policy, June 2011.
http://www.ucdenver.edu/academics/colleges/medicalschool/education/graduatemedicaleducation/GMEDocuments/
Documents/4.Policies%20and%20Procedures/GME%20Duty%20Hours%20Policy.pdf
GMEC Approved 6/7/11
44
INSTITUTIONAL VACATION AND LEAVE POLICY
Purpose: The ACGME requires an Institutional Leave Policy that is known to all Residents.
Each program must have its own vacation and professional leave policy that it makes available to its
residents/fellows before they sign their contracts and that:
• Follows ACGME program requirements.
• Complies with MU’s Family Leave Policy.
To review this policy in context, please visit our website at:
http://www.umsystem.edu/ums/departments/hr/manual/
If you have questions or comments about the revisions, please contact your campus human resource
office.
The institution will fund up to one month each year of any combination of vacation and leave for
each resident.
To hold a GME position for their return, residents/fellows must obtain written approval from their
department for leave/vacation that exceeds one month per year. Adverse decisions, as always, may be
appealed through the Policy to Address Resident Concerns, and then as a grievance.
45
Resident Leave Restriction Policy
A program director (PD) may specify the rotations on which their residents may take leave (as
defined by your program).
Residents rotating outside their department may take up to one week (5 week days and one
weekend) of leave on rotations of 4 weeks (or one month) unless a restriction has been mutually
agreed upon by both PDs.
If a resident rotates to another department for longer than 4 weeks (one month), the proportion of
their leave allowed on those rotations should be proportional to the time on those rotations. (e.g.
if a neurosurgery resident rotates for 3 months on general surgery, they should be allowed to take
¼ (3/12) of their leave while on those rotations.
Leave should be scheduled and agreed upon between the two program directors. If no agreement
is reached, the GMEOC will arbitrate. The decision will be determined by a majority vote of the
members present.
Approved by the GMEOC 7/7/09
46
POLICY FOR PROCESSING ANONYMOUS EVALUATIONS
The ACGME requires that faculty members sign evaluations they complete of training physicians.
Programs may elect to have additional health care staff evaluate the training physician, including peers or
other co-workers (i.e., nursing staff, techs). These evaluations should be kept anonymous from the
training physician being evaluated, to the extent possible under the law. Anonymity may be maintained
by having a summary of these evaluations prepared by the program director or coordinator, which is then
placed in the training physician file. The evaluation instrument itself may be destroyed or, if kept,
assurance should be made that the anonymity of the evaluator will be maintained.
Approved by the Graduate Medical Education Oversight Committee1/3/06
47
POLICY FOR EDUCATIONAL/
CAREER COUNSELING
Occasionally, a residency program director will request that a resident receive evaluation and
counseling for a problem they are having. This is usually done by members of the UMC Psychiatry
Department, although a program director may request evaluation by someone outside the department
or outside the University. The following guidelines should be followed.
1. The request for evaluation must be in writing from the program director with a general statement
of the reason for the request.
2. The evaluator will keep a record of the encounter(s) but not as part of the resident’s medical
record. Appropriate confidentiality will be maintained.
3. The evaluator will update the program director regarding the resident’s progress. At the outset, the
resident will be informed that the program director will receive updates from the evaluator.
The resident will discuss with the evaluator what information will be shared to maintain
confidentiality.
4. If a mental health disorder or substance abuse is found during the course of evaluation or
counseling, appropriate referral to the health care system will be made. All University and
State of Missouri requirements for reporting must be followed.
5. The requesting department is responsible for the cost of the evaluation and counseling. If referral
is made to the health care system, the resident’s insurance will be billed, and the resident will
be responsible for any other expenses (just as with any other medical condition).
48
PROFESSIONAL ASSISTANCE POLICY
Policy:
The policy of providing assistance to residents and fellows is delineated for the following
conditions: 1) Mental Health; 2) Physical (Medical) Health; 3) Impaired Physicians; and
4) Financial. All requests for resource information will be treated confidentially.
The Associate Dean for Medical Education will be the safety net to help trainees who feel
they cannot get what they need through their Program Director. The Associate Dean will
also be a resource to Program Directors in solving trainee issues. This individual or
designee may be contacted at any time for emergencies.
Purpose:
Graduate Medical Education can be a stressful time for residents and fellows. It is our
job to nurture and support our trainees so each is the best person and physician that
he or she can be. The program directors are charged by their Residency Review
Committees (RRCs) to monitor stress, depression, mental and/or physical illness of their
trainees, and to assist in obtaining treatment and/or identifying methods of counseling.
The institution is required by the ACGME to facilitate resident/fellow access to
appropriate and confidential counseling, medical, and psychological support services.
This includes the stipulation of written policies describing how physician impairment,
including substance abuse, will be handled.
Definitions:
Substance Abuse: Use of alcohol or drugs with resulting diminution of ability to carry
out responsibilities in the workplace.
Resident Physicians: Resident or fellow trainees
Impaired Physician: Physician is unable to perform trainee duties, in best judgement of
the Health Sciences Center Physician Health Committee.
General Information: All trainees are enrolled in the University of Missouri group plans for life
insurance, long term disability, and medical benefits. This coverage includes medical treatment as well as
psychiatric counseling and treatment. In addition, the Housestaff Organization has arranged for additional
disability coverage at the individual trainee’s expense.
Medical/Physical Health
Time off for treatment of medical or physical conditions will be granted in accordance with the
program’s specifics for medical leave of absence. The trainee may refer to their training manual
for this information or contact their program director.
Emotional/Psychological
Psychological illness such as short term psychological problems of situational distress, anxiety, or
stress, may result in impairing the ability to perform assigned job responsibilities. Please refer to
number 3 above and Attachment A, for information on actions required by the Medical School.
Treatment for such illness is generally covered by existing health benefits.
Impaired Physicians
Residents or Fellows with substance abuse problems should be aware that the Health Sciences
Center’s policy is nonpunitive if the treatment plan is adhered to, except as identified in
Attachment A, item B,5 of the “Substance Abuse Policy for Clinical Faculty and Resident
49
Physicians, ” which states that probable cause of impairment due to substance abuse will result in
a report to the Missouri Physician’s Health Committee (MPHC) for further investigation and
action. In accordance with laws regarding reporting, the MPHC will be required to report
substantiated substance abuse to the National Practitioner Data Bank.
Also, please reference the University of Missouri policy on drug/alcohol abuse – HR508
“Drug/Alcohol Abuse in the Workplace,” University of Missouri, Human Resources Benefits
Manual.
Financial Consultation
Trainees in need of financial advice/counseling are encouraged to make early contact with the
University of Missouri - Columbia Medical School Financial Aid Coordinator. Other private
counseling organizations may be utilized and a list of local organizations is provided in
Attachment B.
Procedure
Trainee:
1. Graduate Medical Education trainees should seek professional help on their own
when they feel this is necessary. If this is a medical/physical or
emotional/psychological condition, the trainees primary physician should be
contacted, or the campus Employee Assistance Program may be contacted at 8826701 to provide free, confidential evaluation and referral for any problem - financial,
medical, psychological, etc.
2. Trainees are strongly encouraged, but not required, to inform their Chief Resident
and Program Director of medical illness, emotional or psychiatric illness when any of
these may interfere with professional performance. Confidentiality will be
maintained unless this is not consistent with good patient care.
Program Director:
1. The Program Director, upon becoming aware of a problem, either through trainee
performance, reports from others, or through communication with the trainee, should
be the first line to help the resident physician resolve any issues. The Program
Director should discuss alternative sources of counseling and/or other care with the
resident physician and assist in initiating the process for counseling.
2. Program Directors may, at their discretion, seek information about alternatives for
handling medical/physical or emotional/psychological problems from other sources,
such as other Program Directors or the Graduate Medical Education Office, while
maintaining confidentiality.
3. If the determination has been made that the trainee is not able to carry out assigned
responsibilities due to substance abuse and, after discussing the identified issues with
the trainee, the trainee is not willing or able to correct the problem, the Program
Director may temporarily remove the trainee from the rotation or change the schedule
pending expedient implementation of Attachment A: “Substance Abuse Policy for
50
Clinical Faculty and Resident Physicians,”. The trainee will continue to receive
pay, fringe benefits, and due process during the impaired physician process of
Attachment A.
Attachment A - Impaired Physician Policy, Clinical Faculty and Resident Physicians
Attachment B - List of Local Counseling Resources.
References:
1.
HR508 “Drug/Alcohol Abuse in the Workplace,” University of Missouri, Human Resources
Benefits Manual.
2.
Housestaff Bylaws, Rules and Regulations
Approved by GMEOC 2/2/99
51
Attachment A
SUBSTANCE ABUSE AND IMPAIRED PHYSICIAN POLICY
UNIVERSITY OF MISSOURI-COLUMBIA SCHOOL OF MEDICINE
HOUSESTAFF PROGRAM
The Dean, University of Missouri-Columbia School of Medicine, has established the following program
to address the issue of substance abuse and impairment by residents /fellows operating under the auspices
of the University of Missouri-Columbia Health Sciences Center. This policy is similar to that in place for
our clinical faculty.
Physicians hold a unique place in society. Professional standards require that persons seeking care can be
assured that their physicians are not impaired by reason of substance abuse or mental illness. The purpose
of this policy is:
1. To assure that patients receiving care from physicians, operating under the auspices of the
University of Missouri-Columbia Health Sciences Center, receive the highest quality health
care from individuals not only well trained and highly motivated, but unimpaired by reason of
substance abuse or mental illness.
2. To assure that individual residents/fellows have access to appropriate health care and
assurance of continued access to employment so long as they comply with institutional
requirements and standards.
A.
HEALTH SCIENCES CENTER PHYSICIAN HEALTH COMMITTEE
1. The Health Sciences Center Physician Health Committee will, as needed, be appointed by the
Dean, School of Medicine, to assume responsibility for oversight of the Health Sciences
Center Physician Health Program to address issues of physician impairment or substance
abuse.
2. Membership of the Health Sciences Center Physician Health Committee will consist of:
a. Two members of the clinical faculty appointed by the Dean, School of Medicine.
Individuals may be reappointed at the discretion of the Dean. One of these individuals
will be designated by the Dean to chair the committee.
b. One resident physician or clinical fellow appointed by THE DEAN FROM
RECOMMENDATIONS BY the House Staff Organization.
3. The Health Sciences Center Physician Health Committee will meet as often as necessary to
fulfill its obligation.
4. All information presented at meetings of the Health Sciences Center Physician Health
Committee, and all actions of the committee will be considered to be confidential except as
provided herein and except that such information will be available to the Dean, School of
Medicine and otherwise as required by law.
52
B.
RESPONSIBILITIES OF THE HEALTH SCIENCES CENTER PHYSICIAN HEALTH
COMMITTEE.
1. The Health Sciences Center Physician Health Committee will initially establish a definition
of impairment. This definition will be utilized by future committees. Following its
establishment, it must be approved by the Dean, School of Medicine.
2. It is the responsibility of the Health Sciences Center Physician Health Committee to receive
any admission of substance abuse or mental health problems by a physician, or allegations of
impairment of physicians due to substance abuse or mental illness.
3. The Health Sciences Center Physicians Health Committee will be responsible for
investigating those allegations. The Committee shall inform the individual in writing of the
allegations and provide him/her an opportunity to respond to the allegations.
4. The Health Sciences Center Physician Health Committee shall inform the Dean if the
Committee suspects the individual is impaired by substance abuse or mental illness, and
presents potential risk to patients.
5. If probable cause to believe that impairment due to substance abuse is present, allegations
related to possible substance abuse must be reported to the Missouri Physicians Health
Committee for further investigation and action.
6. If there is probable cause to believe that impairment due to mental illness is present, the
Health Sciences Center Physician Health Committee shall require psychiatric evaluation by a
psychiatrist approved by the Health Sciences Center Physician Health Committee.
7. Upon determination that a resident/fellow is impaired due to substance abuse or mental
illness, the Health Sciences Center Physician Health Committee will notify the Dean, School
of Medicine.
C.
PERMISSION TO CONTINUE CLINICAL RESPONSIBILITIES
1. If the resident/fellow has been removed from clinical responsibilities by the Dean, permission
to resume clinical responsibilities will be granted only with the agreement of the Health
Sciences Center Physician Health Committee and the Dean.
D.
CONTINUATION OF FACULTY APPOINTMENT
1. Residents/fellows found to be impaired by reason of substance abuse or mental illness may
not be dismissed from employment prior to full evaluation of their impairment. They may,
however, be removed from clinical responsibility. Full evaluation of impairment due to
substance abuse will be made by the Missouri Physicians Health Committee. Full evaluation
of mental illness will be made by a licensed psychiatrist approved by the Health Sciences
Center Physicians Health Committee. The allegedly impaired physician may participate in
determining the identity of that physician.
2. Residents/fellows found to be impaired by reason of substance abuse or mental illness may
not be terminated based upon such substance abuse or mental illness during the term of their
53
contract if they are compliant with the requirements of the Health Sciences Center Physician
Health Committee, and the Missouri Physician Health Committee.
E.
TERMINATION OF APPOINTMENT
1. A resident/fellow who has been found to be non-compliant with the Health Sciences Center
Physician Health Committee or the Missouri Physician Health Committee will be reported to
the Dean, School of Medicine.
2. Noncompliance may be grounds for termination of appointment.
3. Any dismissal shall conform to applicable University procedures.
6/18/91
REVISIONS 2/99/REVISIONS 5//00
54
Attachment B
FINANCIAL ADVICE/COUNSELING RESOURCES
Conway Jones
University of Missouri - Columbia
Medical School Financial Aid Coordinator
MA202 Medical Science Building .................................................................................................. 882-2923
FINANCIAL/COUNSELING ORGANIZATIONS - LOCAL
A. G. Edwards & Sons, Inc.
2100 Forum Blvd., Columbia ............................................................................................ 445-7088
American Express Financial
1316 Old Hwy .63 S, Columbia ......................................................................................... 499-4945
American Express Financial Advisors
601 Nifong, Columbia ....................................................................................................... 499-4880
American Express Financial Advisors, Inc.
2710 Forum Blvd., Columbia ............................................................................................ 446-2744
American Tax Service
311A Bernadette Dr., Columbia ........................................................................................ 445-8364
David Banks, CFP
2611 Luan Ct., Columbia ................................................................................................... 445-4308
Boone County National Bank
Columbia ............................................................................................................................ 874-8490
Boone County National Bank Investor Services
Columbia ............................................................................................................................ 874-8446
Alan Bunch, LUTCF
Principal Financial Group
401 Vandiver Dr., Columbia .............................................................................................. 443-3535
Cambria Financial Management, Inc.
Columbia ............................................................................................................................ 817-3180
Casey and Company, LLC, CPAs
1 E. Broadway, Columbia .................................................................................................. 442-8427
Consumer Credit Counseling Services of Mid-America
(Staffed, in part, by MU Department of Consumer and Family Economics Students)
205 E. Ash, Columbia ........................................................................................................ 443-0303
Dollar-Kuretich Doris Financial Advisor
55
116 S. Jefferson, Jefferson City ......................................................................................... 581-5994
Finance World
601 Business Loop 70 W, Columbia ................................................................................. 815-9700
Financial Architects, Inc.
1000 W. Nifong Blvd., Columbia ...................................................................................... 443-3183
Fundbuilder
4818 Santana Cir., Columbia ............................................................................................. 815-1055
Kammerich Financial Services
1951 Boone Village Plaza, Ste. D, Boonville .............................................................660-882-7620
Thomas Lightfoot
1414 Rangeline, Columbia ................................................................................................. 874-3888
Lincoln Financial Advisors
601 E. Broadway, Ste. 304, Columbia ............................................................................... 443-1654
Merrill Lynch
2804 Forum Blvd., Ste. 2, Columbia……….…………………………..446-7023 or 800-937-0948
Mita Financial Services
1961 Hirst Dr. .............................................................................................................660-263-8096
Money Concepts Financial Planning Center
217 E. Jackson, Mexico ..................................................................................................... 581-4313
Northwestern Mutual Life
The Peter W. Graff District Agency
1900 N. Providence Rd., Ste. 307, Columbia .................................................................... 449-2488
Nova Financial
811 Cherry St., Columbia .................................................................................................. 874-0434
Principal Financial Group
Betty Schuster, CFP
401 Vandiver Dr., Columbia .............................................................................................. 443-0389
Professional Planning Group
Christine Marks, CLU, ChFC
108 E. Green Meadows Rd., Ste. 7, Columbia……..................…………………………………...443-8628
Sims & Associates Insurance & Financial Services
4818 Santana Cir., Ste. B, Columbia ................................................................................. 874-4494
Waddell & Reed, Inc.
1900 N. Providence Rd., Columbia ................................................................................... 875-4494
56
OTHER COUNSELING SERVICES
Employee Assistance Program...................................................................................................... 882-6701
University Physicians Psychiatry Clinic ...................................................................................... 882-2511
57
POLICY TO ADDRESS RESIDENT CONCERNS
Purpose: The ACGME requires that the Housestaff have assurance of an educational
environment in which to raise and resolve issues without fear of intimidation or
retaliation. This policy outlines a process by which residents can address concerns in
a confidential and protected manner.
The Housestaff representatives to the GME Oversight Committee will give a monthly
report of resident issues identified during their monthly meetings, or through
communication among resident(s). This report should include, but not be limited to
concerns of residents about fairness of schedules, treatment, workloads, etc.
Concerns will be addressed as needed in a way that excludes and prohibits retaliation
toward any fellow or resident.
Individual resident concerns should be addressed with the following process.
Process:
Resolution should be attempted at the most local level. If resolution is
not obtained at this level, the resident or fellow may proceed to the next level as
appropriate to the nature of the concern.
1.
Contact the Chief Resident/Fellow of the Program
2.
Contact the Program Director
3.
Contact the Department Chair or Division Chief
4.
Contact the Housestaff Organization
5.
Contact the Associate Dean for Graduate Medical Education / Designated Institutional Official
If the issue is not able to be resolved by this informal mechanism, then a formal grievance may
be filed with the Program Director. See Grievance Policy.
Revisions approved by the GMEOC 3-2-10
58
GRIEVANCE POLICY FOR RESIDENTS/FELLOWS
Purpose
To establish fair policies and procedures for the adjudication of resident grievances related to the
actions which could result in dismissal, non-renewal of agreement of appointment, or any other
action that could threaten a resident’s intended career development.
A grievance procedure shall not be used to question a rule, procedure, or policy established by an
authorized faculty or administrative body. Rather, it shall be used as due process by a resident who
believes that a rule, procedure or policy has not been followed or has been applied in an inequitable
manner. An action may not form the basis of a grievance if the resident merely challenges the
judgment of the faculty as medical educators in evaluating the performance of the resident.
For purposes of this policy, a grievance is defined as an allegation that:
1. There has been a violation, a misinterpretation, an arbitrary, or discriminatory application of
University policy, regulation or procedure which applies personally to the resident physician, relating
to the privileges, responsibilities, or terms and conditions of the residency training program including
academic or other disciplinary actions or the employment of the resident physician; or
2. The resident physician has been discriminated against on the basis of race, color, religion, sex,
national origin, age, disability, or status as a Vietnam era veteran.
Filing a Grievance
A resident physician who has a grievance shall initiate action by filing a signed, written account of the
grievance with the program director within thirty (30) days after the occurrence of the event out of which
the grievance has arisen. The program director shall respond to the grievance in writing within thirty (30)
days after receipt of the written grievance.
Grievance Appeals
Should the resident physician be dissatisfied with the response of the program director, he/she may,
within ten (10) days after receipt of such response, submit a written appeal to the Associate/Assistant
Dean of the School of Medicine having responsibility over graduate medical education. Upon receipt of
the written appeal, the Associate/Assistant Dean shall arrange a meeting with the resident physician and
with the involved residency program director to discuss the allegations and the response. In an effort to
reach a fair decision on the grievance, the Associate/Assistant Dean may elect to meet with others having
knowledge of the circumstances giving rise to the grievance, including those identified by the resident
physician or the residency program director. Upon completion of the Associate/Assistant Dean’s
consideration of the appeal, the Associate/Assistant Dean shall provide a written decision to the resident
physician and to the residency program director.
Appeal to the Dean
59
If the resident physician is dissatisfied with the decision of the Associate/Assistant Dean, he/she may,
within ten (10) days after receipt of such written decision, submit a written appeal to the Dean of the
School of Medicine who shall decide whether the previous decision shall be affirmed, reversed or
modified. In reaching that decision, the Dean may ask to meet with the resident physician, but is not
required to do so; may utilize the services of an ad hoc advisory committee, appointed by the Dean, but is
not required to do so; and may consult with the program director and faculty with whom the resident
physician worked, but is not required to do so. The resident physician shall have no right of appeal from
the Dean’s decision, but may request that the Chancellor exercise his or her discretion to review the
Dean’s decision.
(Also see the University of Missouri Employee Grievance Policy: 380.010 GRIEVANCE
PROCEDURE FOR ADMINISTRATIVE, SERVICE & SUPPORT STAFF)
60
Grievance Procedure
Summary
The University recognizes the right of employees to express their grievances and to seek a
solution concerning disagreements arising from working relationships, working conditions,
employment practices or differences of interpretation of policy which might arise between the
University and its employees. In addition, grievances may be filed alleging discrimination on the
basis of race, color, religion, sex, sexual orientation, national origin, age, disability, and status as
a Vietnam era veteran. This shall not be interpreted in such a manner as to violate the legal rights
of religious organizations or military organizations associated with the Armed Forces of the
United States of America. A regular employee may process a grievance regarding any of these
matters upon completion of his/her probationary period. A probationary or nonregular employee
may process a grievance concerning issues of prohibited discrimination or
application/interpretation of University policies and procedures.
Grievance Definition
Any complaint by an employee concerning any aspect of the employment relationship other than
merit increases, performance evaluations and job reclassifications, unless such exceptions
include an allegation of prohibited discrimination or other illegality.
Procedures
Should an employee or the employee's representative feel, after oral discussion with the
immediate supervisor, that employee's rights under University policy have been violated, the
employee may originate a grievance within ten (10) days of the date the alleged grievable act
occurred by presenting the facts in writing to the proper supervisor, department head, or
designated representative of the University with a copy to the Campus Grievance Representative.
The decision of such official shall be made in writing to the employee within ten (10) days after
receipt of grievance. For an alleged act of prohibited discrimination, an employee has a 180-day
filing period.
Should the employee decide the reply is unsatisfactory, the employee or the employee's
representative shall, within five (5) days, submit an appeal to the Campus Grievance
Representative. The Campus Grievance Representative or designate shall respond in writing to
the grievance within five (5) days from the date of the review. If the grievance is resolved, no
further action will be necessary.
If the grievance is not satisfactorily resolved, the employee or the employee's representative may
appeal within five (5) days after receipt of response to the University Grievance Representative
for the purpose of reviewing the grievance. The decision of the University Grievance
Representative or designate shall be made in writing to the employee and/or employee's
representative within five (5) days after the date of the review.
61
Should the employee decide that the reply of the University Grievance Representative or
designate is unsatisfactory, the matter may be appealed within five (5) days of receipt of the
response through the University Grievance Representative to a grievance committee which shall
be established: the employee or employee's representative may designate one (1) member; the
University through its Grievance Representative, with the approval of the Chancellor of the
campus, shall appoint one (1) member; and the selection of the third member shall be made by
these two (2) members. If mutually agreeable, the two (2) designated members may select the
third member from a list recommended by either and approved by both. Otherwise, selection will
be made from a list of committee members supplied by the Federal Mediation and Conciliation
Service and maintained by UM Human Resources. The selection will be made by reducing the
list in alternate turns. The toss of a coin shall determine the elimination sequence.
A decision of the grievance committee may be reached upon the concurrence of any two (2) of
the three (3) members. A hearing will be scheduled as soon as feasible after selection of the third
committee member. The grievance committee shall keep a complete record of the hearing before
it, including any exhibits or papers submitted to it in connection with the hearing and a complete
record of any testimony taken. Upon the rendering of its decision, the complete record shall be
filed in the Office of the President of the University and shall be available to the employee,
employee's representative and the University Grievance Representative. Any cost of the third
party on the committee and cost of transcript (if requested) shall be paid equally by the employee
and the University.
In the event the decision of the grievance committee is unsatisfactory to either the employee or
the University Grievance Representative, either may, within five (5) days after receipt of the
decision of the grievance committee, file a written notice of appeal to the Board of Curators by
delivering such notice of appeal to the President of the University. Upon the receipt of the notice
of appeal, the President of the University shall cause the record of the hearing before the
grievance committee to be filed with the Board of Curators of the University, who shall review
such record. The decision of the Board of Curators, upon such review, will be final.
Time Limits
The prescribed time limits may be extended by mutual agreement whenever necessary in order
for these provisions to be implemented. The interpretation of "days" within this section is to be
normal workdays (Monday through Friday) exclusive of official University holidays.
University Grievance Representative
Betsy Rodriguez
Vice President, Human Resources
Human Resources
104 University Hall
Columbia, Missouri 65211
(573) 882-8270
62
Designated Campus Grievance Representatives
University of Missouri System
Betsy Rodriguez
Vice President, Human Resources
Human Resources
104 University Hall
Columbia, Missouri 65211
(573) 882-8270
Columbia
Karen Touzeau
Assistant Vice Chancellor
Human Resource Services (MU)
1095 Virginia Avenue, Room 101
Garage #7
Columbia, Missouri 65211
(573) 882-4256
Hospital and Clinics
Phil Shearrer
Staff Development Specialist
Human Resources
University of Missouri Healthcare
1 Hospital Drive, Room 4E55
Columbia, MO 65212
(573) 882-8444
Kansas City
Jill Reyes
Director
Human Resources
226 Administration Center
5100 Rockhill Road
Kansas City, Missouri 64110
(816) 235-1621
Rolla
Randy Stoll
Director, Business Services
210 Parker Hall
Rolla, Missouri 65401
(573) 341-4122
63
St. Louis
Peter Heithaus
Director, Human Resources
222 General Services Building
St. Louis, Missouri 63121
(314) 516-5809
Date Created: 9/26/97
Last Updated: 04/01/11
64
Sexual Harassment
Executive Order No. 20, 3-17-81 (Rev. 7-1-81 and 9-20-83), Bd. Min. 3-18-93.
This University of Missouri policy aims for an increased awareness regarding sexual harassment by making
available information, education and guidance on the subject for the University community.
A.
Policy Statement -- It is the policy of the University of Missouri, in accord with providing a positive
discrimination-free environment, that sexual harassment in the work place or the educational environment is
unacceptable conduct. Sexual harassment is subject to discipline, up to and including separation from the
institution.
Definition -- Sexual harassment is defined for this policy as either:
1. Unwelcome sexual advances or requests for sexual activity by a University employee in a position
of power or authority to a University employee or a member of the student body, or
2. Other unwelcome verbal or physical conduct of a sexual nature by a University employee or a
member of the student body to a University employee or a member of the student body, when:
a. Submission to or rejection of such conduct is used explicitly or implicitly as a condition for
academic or employment decisions; or
b. The purpose or effect of such conduct is to interfere unreasonably with the work or
academic performance of the person being harassed; or
c. The purpose or effect of such conduct to a reasonable person is, to create an intimidating,
hostile, or offensive environment.
B.
C.
Non-Retaliation -- This policy also prohibits retaliation against any person who brings an accusation of
discrimination or sexual harassment or who assists with the investigation or resolution of sexual harassment.
Notwithstanding this provision, the University may discipline an employee or student who has been
determined to have brought an accusation of sexual harassment in bad faith.
D. Redress Procedures -- Members of the University community who believe they have been sexually
harassed may seek redress, using the following options:
Pursue appropriate informal resolution procedures as defined by the individual campuses. These
procedures are available from the campus Affirmative Action/Equal Opportunity Officer.
Initiate a complaint or grievance within the period of time prescribed by the applicable grievance
procedure. Faculty are referred to Section 370.010, "Academic Grievance Procedures"; staff to
Section 380.010, "Grievance Procedure for Administrative, Service and Support Staff" and students
to Section 390.010, "Discrimination Grievance Procedure for Students".
Pursuing a complaint or informal resolution procedure does not compromise one's rights to
initiate a grievance or seek redress under state or federal laws.
E. Discipline -- Upon receiving an accusation of sexual harassment against a member of the faculty, staff, or
student body, the University will investigate and, if substantiated, will initiate the appropriate disciplinary
procedures. There is a five year limitation period from the date of occurrence for filing a charge that may
lead to discipline.
An individual who makes an accusation of sexual harassment will be informed:
at the close of the investigation, whether or not disciplinary procedures will be initiated; and
at the end of any disciplinary procedures, of the discipline imposed, if any.
65
Drug Testing Policy
For Training Physicians
Objective: In order to ensure safe patient care and protect the public, the University of Missouri
Hospitals and Clinics will conduct pre-employment drug testing for all new residents
and fellows. This policy provides guidelines for testing, notification of results and
related employment decisions.
Policy: Before commencing performance of duties, the selected resident or fellow (hereinafter
referred to as “prospective resident”) must undergo drug testing as a condition of
employment, and the drug test shall produce a negative result. No prospective
resident shall begin working until results of the test have been reviewed in Human
Resources. Any prospective resident who refuses to undergo such testing, may, at the
discretion of their clinical department, not be considered qualified for employment,
and previously extended offers of employment and contracts may be rescinded.
A. Definitions
1. “Medical Review Officer” is an individual designated by the Chief Executive Officer of UM
Health Care to review test results and review appeals of positive test results.
2. “Prohibited drug usage” is the illegal use of narcotics, drugs or controlled substances.
B. Scope
1. All prospective residents shall submit to drug testing prior to employment as a condition of
employment.
C. Procedure
1. Testing services will be provided by a certified laboratory. The laboratory shall ensure:
a. Proper maintenance of confidentiality. The name of the individual providing the sample will not be
provided to the laboratory performing the test. Instead, testing numbers assigned to
the specimen at the time of the test will be used for communication with the
laboratory. The laboratory will only provide test results to the Chief Human
Resources Officer of UMHC.
b. Proper maintenance of chain of custody.
c. Proper confirmation of a positive test by an approved confirmation test, such as gas
chromatography/mass spectrometry. The laboratory will only report a positive test of
a particular sample to the Medical Review Officer after both the screening and
confirmation tests are positive. The Medical Review Officer will report confidential
positive results to the Chief Human Resources Officer or designee.
d. Proper specimen collection, labeling and protection from contamination. All specimen collection
pursuant to this program shall be minimally intrusive as
66
follows: a) urine samples will be collected in a confidential environment; b) the collection will be
performed by trained personnel; c) the procedures followed shall be similar to those
required for physical examinations; and d) the personnel conducting the testing shall
not directly observe the prospective resident produce a sample.
e. Proper notification, at the time a specimen is produced, to all prospective residents or the necessity
of declaring any prescription drugs or over-the-counter medication they are currently
taking which may result in a positive drug test.
D. Drugs
1. The certified laboratory will test all samples for the following drugs:
a. Amphetamines: d-Amphetamines, Methamphetamines
b. Cocaine
c. Opiates: Codeine, Heroin, Hydromorphone, Morphine
d. Phencyclidine (PCP)
e. Cannabinoids (Marijuana metabolites)
f. Methadone
g. Propoxyphene
E. Notification
1. Prior to finalizing a contract, the School of Medicine department where the residency program is
housed and/or Human Resources shall inform all residents that UMHC conducts preemployment drug testing for safety-sensitive positions, including residents and fellows.
2. The School of Medicine department and/or Human Resources shall notify prospective residents
that they need to go for a specimen collection. The prospective resident must report to the
designated collection site on the date and time assigned.
3. It is a condition of employment at University of Missouri that residents be, and remain, free of
illegal drugs, controlled substances and alcohol while at work and while performing job
functions related to employment at the University of Missouri. If a confirmatory test reveals
prohibited drug usage for prospective resident, the UMHC Human Resources department
shall notify the Program Director of the School of Medicine department where the
individual’s training program is housed, as well as the Associate Director at the University of
Missouri Health Care who oversees coordination of all residency programs. The Program
Director will be instructed to notify the prospective resident of the positive test results.
4. The Program Director, in consultation with the department chair, Chief of Staff and GME Dean,
will determine if the prospective resident’s employment contract will be terminated. At the
discretion of the department, the prospective resident may be given alternatives, such as
delaying commencement of residency training for a period of time while completing a drug
treatment program. Any costs associated with treatment will be borne by the resident and/or
School of Medicine department.
5. The Program Director should provide a written agreement of a treatment plan and a plan for
returning to the residency program, with copies to the individual resident and his/her
personnel file. The agreement should outline all pertinent information, including, but not
67
limited to, leave status, salary, medical benefits, treatment costs, time period for the resident to be
absent from the training program, and conditions for return to the training program. The plan
will be reviewed and approved by a special committee convened by the GME chair.
6. Any required reporting to outside agencies will be done by the Associate Director at the University
of Missouri Health Care who oversees the coordination of training programs.
F. Compliance
1. Prospective residents will promptly comply with the UMHC’s request for testing.
2. If a prospective resident refuses to submit to testing or engages in any conduct jeopardizing the
integrity of the specimen or the reliability of the drug test, the Program Director of the
training program will be notified and the prospective resident’s contingent offer of
employment may be rescinded.
3. If a prospective resident fails to schedule or to appear for a drug test specimen collection, or
postpones or reschedules specimen collection without good cause, the Program Director will
be notified and the resident’s employment may be terminated.
G. Record Keeping
1. Drug testing records will be kept for a minimum of two years and will be kept confidential to the
extent permitted by law.
H. Appeals
1. A prospective resident who has tested positive for prohibited drugs will, upon request, be provided
an opportunity for a meeting with the Medical Review Officer and Human Resources
representative to explain mitigating circumstances. In order to evaluate said explanation, the
prospective resident may be requested to provide a medical release.
2. If a prospective resident disputes the validity of a positive test result, the prospective resident may
request a re-test of his or her original sample, after agreeing to pay any cost associated with
the second test. If the second test is negative, UMHC will pay for or reimburse the
prospective resident for the cost of the re-test.
3. A prospective resident appealing under provisions 1 and 2 of this section must provide a written
appeal notice to the Human Resources Department within 72 hours of receiving notification
of a positive test result.
GMEOC Approved April 5, 2005
68
Policy to Monitor Residents and Fellows with Prior Issues of Concern
University of Missouri Health Care

Residents and fellows who have any issues of impairment identified by the various licensing
agencies (Board of Healing Arts, DEA, BNDD) will have an appropriate monitoring and
supervision plan developed by the program director.

The plan may be proscribed by or in conjunction with the licensing agency. The plan will be
approved by a subcommittee of the GMEOC authorized to act on the committee’s behalf in
closed session.

The medical executive committee or chief of staff at any hospital the resident/fellow is assigned
will be notified of the issue and the monitoring plan prior to the resident/fellow working in that
location.

The chair of the GMEOC should be notified as soon as the issue is identified and preferably
before a contract is offered.
Approved by the GMEOC 9/7/04
Revisions approved by GMEOC 10/5/05
69
DISCIPLINARY ACTION POLICY FOR RESIDENTS/FELLOWS
Resident physicians are subject to disciplinary actions including oral reprimands, written reprimands,
suspensions and discharge for misconduct or for performance which does not meet acceptable standards.
Suspension Without Pay or Termination
Before a resident physician may be suspended without pay or terminated prior to the specified ending date
of his or her appointment, the resident physician should be provided in writing with findings which the
University believes support the proposed suspension without pay, or the termination.
That written notice will be provided by the residency program director and will include details concerning
the findings of misconduct or the performance deficiencies. In addition, the written notice will inform the
resident physician that if he or she disagrees with such findings and desires to contest the proposed
disciplinary suspension or termination, he or she must inform the residency program director in writing
within ten (10) days of receipt of the written notice.
After receiving notice that the resident physician disagrees with such allegations and desires to contest the
proposed disciplinary suspension or termination, the residency program director will schedule a meeting
with the resident physician so that he or she will have an opportunity to present information in support of
his or her position regarding the findings.
After discussing the issues with the resident, the residency program director shall decide whether (1) to
impose the disciplinary suspension without pay or the termination which had been contemplated, (2) to
impose some lesser degree of discipline or (3) that the resident physician should receive no discipline.
That decision shall be communicated to the resident physician in writing as soon as possible.
If the resident physician is dissatisfied with the decision of the residency program director, he or she may,
within ten (10) days of receipt of such written decision, file a grievance in accordance procedures outlined
in the Grievance Policy.
References:
1. Collected Rules & Regulations, University of Missouri, Academic Grievances: Section 370.010.
2. Collected Rules & Regulations, University of Missouri, Grievance Procedure for Administrative,
Service and Support Staff: Section 380.010.
3. Collected Rules & Regulations, University of Missouri, Discrimination Grievance Procedure for
Students: Section 390.010
70
POLICY
NON-RENEWAL OF A RESIDENT/FELLOW CONTRACT AT
UNIVERSITY OF MISSOURI HEALTH SCIENCES CENTER
Purpose:
To provide a procedure in the event a resident or fellow’s contract will not be renewed
for the following year.
1. The Program Director must provide a written notice to the resident/fellow indicating that their
contract for the following year will not be renewed. Justification for non-renewal of the contract must
be adequately outlined. This written intent must be given to the resident/fellow no later than four
months prior to the end of the current appointment.
2. If the primary reason for non-renewal of the contract occurs within four months prior to the end of the
current appointment, the Program Director must provide written notice as early as circumstances will
allow, prior to the end of the appointment.
3. The resident/fellow must be allowed to implement the institution’s grievance procedures, including
those outlined in the Health Sciences Center’s “Policy to Address Resident Concerns.”
71
POLICY:
To Address Administrative Support for Programs and Residents in the
Event of a Disaster or Interruption of Patient Care
Effective:
7-1-07
Approved by the GMEOC:
8-28-07
In the event of a disaster or interruption of patient care, the Designated Institutional Official
(DIO), or his/her designee, will call an emergency meeting of the Graduate Medical Education
Oversight Committee (GMEOC) to assess the effect of the situation on residency/fellowship
education, including the probable duration of the interruption. The DIO will work with Hospital
Administration representatives and the Medical Staff Office to coordinate activities, including
patient care issues. The GMEOC will develop a plan for residency/fellowship education that
will be presented to the ACGME for review. If there is a need for residents/fellows to continue
their training elsewhere, on a temporary basis, the GME Office will assist programs with
arrangements for housing, salary and other issues involved in a temporary transfer to another
program. If a permanent transfer is necessary, the GME Office will work with the accepting
institution to arrange the transfer.
All arrangements will be coordinated through the GME Office, working with the affected
programs. The institution will continue to pay salary and benefits until other arrangements are in
place.
72
POLICY:
Process for Requesting a Change in Resident/Fellow
Complement or Starting a New Program
Effective:
7-1-09
Revisions Approved by the GMEOC:
3-2-10

All requests must first be approved by the School of Medicine Dean and UMHC CEO,
regardless of the source of funding.

In general, requests must be submitted one year prior to the expected start date of the
resident/fellow.
Process:
1. Submit a written request to the GME Office which includes the following:
- brief business plan, including anticipated source of funding
- educational rationale for the increase (or development of a new program)
- brief description of the program including faculty numbers and clinical material
- importance of the division/department to the UMHC, the State of Missouri and the
specialty
2. The Associate Dean for GME/DIO will submit the written request, including the detailed
information above, to the Dean and CEO.
3. If approved to move forward by the Dean and CEO, the request must then be presented to the
GMEOC for approval. (The GME Office will coordinate this as an upcoming GMEOC agenda
item.)
4. If approved by the GMEOC, the program may then submit the request to the ACGME (if
applicable).
New programs will need extensive paperwork submitted to the ACGME and this will need to
be approved by the GMEOC before it is submitted.
73
Policy:
Process for the:
1) Reduction in Size or Closure of a Program or
2) Closure of the Institution – Training Programs at University of
Missouri-Health Care
Effective:
7-1-07
Approved by the GMEOC:
8-28-07
Training Programs:
1. University of Missouri Health Care will inform the DIO, the GMEOC and residents/fellows as soon
as possible when it intends to reduce the size of or close one or more programs.
2. Before any reductions or closures of programs occurs, the GMEOC will be asked for
recommendations and input when there is a perceived need to reduce or close a program. The
Dean will make final decisions.
3. For programs either reducing in size or closing, residents/fellows already in the program will
either be allowed to complete their education or will be assisted in enrolling in an ACGMEaccredited program in which they can continue their education.
4. Notification will be sent to the ACGME, by the DIO, indicating intent to voluntarily reduce or close
a program.
5. Residents will be given final notification of the action by the DIO and the Program Director. This
will include the effective date of the reduction or closure as soon as known.
Institution:
University of Missouri Health Care will inform the DIO, GMEOC and residents/fellows as soon as
possible if it intends to close.
In the event that all training programs under the sponsorship of the University of Missouri-Columbia School of
Medicine should be closed. All training physicians will receive notification of this action and the effective date of
closure by the DIO and their Program Director as soon as possible. They will be assisted by their program director
in finding new GME positions.
In the event that an affiliated institution closes, all efforts will be made to arrange for similar educational
experiences in another setting.
Approved by the GMEOC 3/7/00
Revisions approved 8/27/07; 10/6/09
74
HR-519 Consensual Amorous
Relationships
Summary
The University of Missouri promotes an atmosphere of professionalism based on mutual
trust and respect. The integrity of interaction among faculty, staff and students must not
be compromised. Consensual amorous relationships are prohibited in certain instances
as outlined below.
Conduct
Consensual amorous relationships between members of the University community are
prohibited when one participant has direct evaluative or supervisory authority over the
other because such relationships create an inherent conflict of interest. Examples of
such relationships that are prohibited include, but are not limited to, employee (faculty,
staff or student)/student and supervisor (faculty, staff or student)/subordinate, when
those relationships involve direct evaluative or supervisory authority. In such cases, the
individual in the evaluative or supervisory position has an obligation to disclose the
consensual amorous relationship to his or her administrative superior and to cooperate
with the administrative superior in removing himself or herself from any such evaluative
or supervisory activity in order to eliminate the existing or potential conflict of interest.
Definition
For purposes of this policy, consensual amorous relationships exist when two
individuals mutually and consensually understand a relationship to be romantic and/or
sexual in nature except when those two individuals are married to each other. Direct
evaluative or supervisory authority exists when one participant is personally involved in
evaluating, assessing, grading, or otherwise determining the other participant´s
academic or employment performance, progress or potential.
Violations
Should a violation of this policy be claimed by a person involved in the consensual
amorous relationship, the matter shall be investigated by the appropriate University
official or, if that person elects to file a grievance, under the appropriate University
grievance procedure. Should any employee or student not involved in the consensual
amorous relationship claim to have been adversely affected personally by a violation of
this policy, the situation will be investigated by the appropriate University official or, if
that person elects to file a grievance, under the appropriate University grievance
75
procedure. A violation of this policy, regardless of the manner in which it is brought to
the attention of the University, may lead to disciplinary action as appropriate, up to and
including termination of employment in the most serious circumstances, following
appropriate processes for such discipline.
See Also
HR 507 Conflict of Interest, HR 510 Sexual Harassment
Date Created: 12/15/06
Last Updated: 12/15/06
Contact webmaster@umsystem.edu. Reviewed May 11, 2004
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76
SUB-SPECIALTY SECTION
CORNEAL/EXTERNAL DISEASE AND REFREACTIVE SURGERY SERVICE
Objectives:
A.
First year resident:
1. Complete patient examination, evaluation and proposed therapy. (PC, ICS, PBLI)
2. Diagnosis and management of corneal ulcers. (PC, MK, PBLI)
3. Knowledge and ability to do optical and ultrasonic pachymetry, computerize corneal
topography (Pentacam), specular microscopy, and confocal microscopy. (MK, TS)
4. Microsurgery of animal and human globes in penetrating keratoplasty and refractive surgery
techniques. (TS, PBLI)
5. Become familiar with the operating microscopes, and place sutures in corneal surgeries. (TS,
PBLI)
6. Learn the diagnosis/management of: (MK, PC, ICS, PBLI)
Bacterial corneal ulcers
Chemical Corneal Burns
Herpes Simplex/Herpes Zoster
Ocular Surface Disease
Ocular Adenoviral Infections
Non-infected Corneal Ulceration
Blepharoconjunctivitis
Corneal graft rejection-reactions
Superficial Punctate Keratitis
Keratoconus
Marginal Corneal Ulcers/Degenerations
Corneal Dystrophies
Recurrent Corneal Erosions
Bullous Keratopathy
Keratitis Sicca
7. Learn indications for: (MK, TS, PC, PBLI)
Conjunctival Flap
Superficial Keratectomy
Penetrating Keratoplasty (PKP)
Therapeutic Keratoplasty
PKP with IOL exchange
PKP with ECCE with IOL
Lamellar Keratoplasty, DSAEK, DALK
Refractive Surgery
Astigmatic Keratotomy
Kerato-limbal Allograft
Amnionic Membrane Graft
Excimer Laser PRK LASIK, LASEK
Phototherapeutic Keratectomy (PTK)
Keratoprosthesis (K-Pro)
8. Demonstrate Surgical Skills and knowledge of: (TS, PC)
Corneal Suture Placement
Instrument Tying
Pterygium Removal
Familiarity with Corneal/Trephines/Punches
77
B.
Third year resident:
1. Assisting and performing part, or all, of a penetrating keratoplasty providing enough
experience has been obtained. (TS, MK, P, PBLI, PC)
2. Assisting on refractive surgical procedures including the excimer laser. (TS, MK, PBLI, PC)
3. Assist or perform part of complex corneal procedures including keratoprosthesis, lamellar
keratoplasty, DSAEK, kerato-limbal allografts, amniotic membrane grafts, combined PKP,
ECCE with IOL, conjunctival flap construction. (TS, MK, P, PC, PBLI, ICS)
4. Understand or perform all of the first year objectives. (MK)
5. Learn Contact Lens Fitting in Keratoconus and post PKP patients. (PC, TS, MK, P)
6. Pre-operative Evaluations of Donor Tissue from the Eye Bank for Corneal Transplantation.
(MK)
7. Post Keratoplasty Care (PC, ICS, MK, SBP)
Immediate
Long term
Suture removal
Visual Correction
Recommended Reading & Resources: (MK, P)
AAO Basic & Clinical Science Course, Section 8, External Disease and Cornea
AAO Basic & Clinical Science Course, Section 14, Refractive Surgery
External Infections of the Eye, Helena B. Fedukowicz
Manual of Corneal Surgery, Bruner, Stark and Maumenee
The Cornea, Smolin and Thoft
Contact Lenses – Aquavella and Rao
Corneal Surgery – Brightbill (newest edition)
Grayson=s Disease of the Cornea, Fourth Edition, Robert C. Arffa
Cornea Color Atlas – Krachmer, Palay
Cornea Text, Vol. 2 – Krachmer, Holland, Morris (newest edition)
Home Study Course: Infections of the Eye, Tabbara, Hyndink, and Brown
LASIK – Pallikaris and Siganos
The Cornea – Kaufman, Barron, McDonald, and Waltman
DSAEK – Price, & Price
78
CONTACT LENS SERVICE
Objectives:
1. Properly evaluate a patient's suitability for contact lenses, including appropriate pretesting and
history. (PC, ICS)
2. Understand the advantages, disadvantages, proper fitting and uses of different types and brands of
hard, soft, and specialty lenses. (MK, PC)
3. Insert and remove contact lenses on a patient. (PC, PBLI, TS)
4. Teach a patient to properly handle, clean, center, insert and remove a contact lens. (ICS, PC, P)
5. Properly evaluate an existing contact lens patient, including proper follow up testing and
evaluation. (PC, MK, PBLI)
6. Recognize and remedy contact lens complications and proper intervention for improvement. (PC,
PBLI)
7. Be knowledgeable about the different types, components and brands of disinfection systems,
solutions, their use and potential problems. (MK, P)
8. Understand and be able to calculate the optics applicable to contact lenses including residual
astigmatism, vertex distance, aniseikonia, power and base curve relationships, sagittal depth, etc.
(MK)
9. Demonstrate proficiency in the technique of refraction. (PC, MK, P, ICS)
Required Reading & Resources: (MK, PBLI, P)
CLAO Residents Contact Lens Curriculum Manual, Steis, Preman – entire text
Tyler's Quarterly Soft Contact Lens Parameter Guide
Complications of Contact Lens Wear, T. Onlinson, Mosby, 1992 – Chapters 2, 6, 7, 9, and 10-12
AAO Basic & Clinical Science Course, Section 3, Optics, Refraction, Contact Lenses - Chapters
5 and 7
79
GENERAL CLINIC AND EMERGENCY CLINIC SERVICES
Objectives:
1. The resident physicians will obtain a complete ophthalmological history and an applicable
general medical history. (PC, ICS)
2. The resident will do a complete ophthalmological examination. (PC, ICS, MK)
a. This to include visual acuity testing (and refraction of optical defects of the eye including
retinoscopy as indicated). (TS, MK)
b. Confrontation fields.
c. Orbital and external exam.
d. Ocular motility exam.
e. Pupillary evaluation.
f. Anterior segment exam with slit lamp biomicroscopy.
g. Posterior segment evaluation using direct and indirect ophthalmoscopy (including
biomicroscopy of the fundus as indicated).
h. Intraocular pressure testing.
i. Also, when applicable, learn to do color vision testing, Amsler Grid and Maddox rod
testing, gonioscopy, conjunctival and corneal scrapings, Lacrimal evaluation. A and B
scan techniques, and keratometry.
j. Learn the appropriate indications for ordering automated or quantitative perimetry,
fluorescein angiography, ocular photography, light or pattern evoked electrical potential
tests (ERG, VEP), specular microscopy, corneal thickness measurements, and optical
coherence tomography.
k. Do A-scan for Intraocular lenses and B-scan for pathology.
3. The resident physician will complete a differential diagnosis and treatment regimen. He/she
will discuss the diagnosis and treatment of each patient with an attending ophthalmologist for
final disposition of the patient. (MK, PC, ICS)
The resident will then review, as indicated with the patient, his diagnosis, prognosis and
treatment regimen. (PC, ICS, P)
The resident will review any special tests ordered in a timely manner and discuss these results
with the attending staff. (P, PBLI, MK)
4. The resident will then treat the patients as medically or surgically indicated and see the
patient for appropriate follow-up care. (MK, PC, TS)
5. The resident will complete the medical record, laboratory, x-ray and photographic requests to
include all the above information as appropriate. (P, PBLI, ICS)
6. Understand and complete appropriate CPT and ICD-9 codes. (MK, P)
80
GLAUCOMA SERVICE
Objectives:
1. Obtaining a careful and accurate history. (ICS, P, MK, PBLI)
2. To become comfortable with all aspects of a thorough glaucoma examination (including
gonioscopy and optic nerve evaluation). (MK, P)
3. Master the technique perimetry with appropriate interpretation. (PC, PBLI, MK, P)
4. Perform glaucoma surgery under direct supervision. (TX, MK, PBLI, PC)
5. Perform Argon laser trabeculoplasty, laser peripheral iridectomies and laser suture lysis under
direct supervision. (PC, TS, PBLI, P)
Recommended Reading & Resources: (MK, P, PBLI)
General Textbooks
Weinreb RN, Mills RP. Glaucoma Surgery, Second Edition. AAO Monograph Number 4,
1998.
Netland PA, Allen RC. Glaucoma Medical Therapy, AAO Monograph Number 13, 1999.
AAO Home Study Course, Volume 10: Glaucoma.
Visual Fields
Heijl A, Patella VM. Essential Perimetry Third Edition.
Carl Zeiss Meditec, Inc., 2002.
Gonioscopy
Wallace A. Color Atlas of Gonioscopy. AAO Monograph. 2001.
81
INTRAOCULAR SERVICE
Objectives:
1. Become familiar and competent with a surgical microscope and instruments; perform anterior
segment surgery in the animal lab or in eye bank globes. (MK, TS, PBLI, P)
2. Perform IOL Master and ultra sound A-scan with calculation of IOL power using various
formulas for low, average and high myopic and hyperopic corrections. (TS, MK, PC)
3. Perform extracapsular cataract extraction or Phacoemulsification with intraocular lens, under
direct supervision. (TS, PC)
4. Become proficient with phacoemulsification, clear corneal incisions, anterior segment
reconstruction, and trabeculectomies. (TS, MK, PBLI)
5. Utilize the laser for YAG capsulotomies, peripheral iridectomies, Argon laser
trabeculoplasties, and ciliary body ablation. (TS, MK, PBLI, PC)
Recommended Readings: (MK, PBLI)
Atlas of Ophthalmic Surgery: Techniques, Complications. Edited by Klaus Heilmann, David
Paton, and G. Thieme Verlag. 3 volumes.
82
LOW VISION SERVICE
Growing numbers of ophthalmologists and optometrists are offering low-vision care in their practices
because of an increasing demand for such services from people with irreversible vision loss.
At least 13 million Americans have low vision. With the demographics of the "graying of America," the
number of people with low vision is expected to continue to increase dramatically well into the 21st
century. As people increasingly seize their older years as an opportunity for renewed vitality and
creativity, they are seeking vision care that enables them to continue to pursue a wide range of activities.
At the same time, vision-care professionals are recognizing that something can be done for patients with
low vision. The American Academy of Ophthalmology, American Academy of Optometry, American
Optometric Association, and their related supporting and para-professional groups endorse low-vision
care as an important step in comprehensive vision care. Patients with irreversible vision loss no longer
need be told that nothing can be done for them.
Objectives:
1. Evaluate a patients’ readiness for Low Vision (LV), rehabilitation, including psycho- social
assessment and functional indicators. (PC, ICS, P)
2. Understand the use, advantages, or disadvantages for LV adaptive devices including high add
spectacles, telescopes, binoculars, prisms, magnifiers, non-optical aids, CCTV’S, optical
character recognition and adaptive computing component. (MK)
3. Recognize the impact of environmental factors on vision: glare, figure ground perception,
lighting, and contrast sensitivity. (MK)
4. Describe eligibility requirements for agencies and services (Rehabilitation Services for the
Blind, Social Security, Blind Pension, Tax Credit, Division of Motor Vehicles). (MK, P, ICS,
SBP)
5. Identify local, state and national resources for Low Vision patients. (P)
6. Develop an understanding of the Special Education system and the ophthalmologists role on
the education team. (P, SBP)
Required Reading
The Lighthouse Ophthalmology Resident Training Manual: A New Look at Low Vision Care. (A
copy is available in our department library.)or through Sue Mussatt, RN, CLVT
83
NEURO-OPHTHALMOLOGY/CONSULTATIVE SERVICE
This rotation is one of independent reading, aided by regular guidance and experience. The following
instructions for rotating students and residents are to achieve each goal, complete each objective and
follow all assignments.
Goals
1. Recognize all common forms of neuro-ophthalmic disorders
2. Learn to obtain a thorough neuro-ophthalmic history and conduct a sound neuro-ophthalmic
examination.
3. Institute appropriate diagnostic tests and treatment of all neuro-ophthalmologic disturbances.
Objectives in:
1. The optic fundus
a. Become thoroughly familiar with the normal optic fundus and understand the features of
papilledema and optic atrophy.
b. Know the causes of optic disc edema and pseudopapilledema and the major funduscopic
disorders associated with specific neurological diagnoses.
2. The visual system
a. Be able to diagnose dysfunction of the optic nerve and identify disorders of each segment
of the optic nerve
b. Localize the pattern of visual field defects to each component of the optic pathways
3. The infranuclear ocular motor system
a. Recognize and distinguish disorders causing: six major syndromes of the pupils, third
nerve palsies, unilateral ophthalmoplegias and bilateral ophthalmoplegias
4. The supranuclear ocular motor system
a. Become familiar with the neuroanatomy of the supranuclear ocular motor systems
b. Be able to identify the chief disorders of eye movement and determine their treatment
c. Recognize the various types of nystagmus
Assignments
Tutorial assignments:
1. The Neuro-Ophthalmology Servival Guide, Anthony Pane, Michael Burdon, Neil R Miller
2. American Academy of Ophthalmology Manual: Neuro-Ophthalmology
3. Become regularly familiar with Miller and Newman et al.; Walsh and Hoyt’s Clinical NeuroOphthalmology, Sixth Edition, and Glaser’s Neuro-Ophthalmology, Third Edition
4. Visit NANOS (North America Neuro-Ophthalmology Society) web site for study materials
5. Divide study time into four segments: The ocular fundus, the optic nerve, chiasm and posterior
visual system, the pupil and infranuclear ocular motor system and the supranuclear ocular motor
system
Experimental assignments:
1. Be familiar with all patients within MUHC who have neuroophthalmic disorders
2. Carry out selected inpatient consultations under supervision
3. Read and report on all papers that are pertinent to patient encounters
Neuro-Ophthalmology/Consult Rotation Guide
84
General Conduct
1. Strive for excellence
2. Come prepared
3. Read books or papers which are relevant to patient care
4. Be profession and appear professional
5. Introduce yourself to the patient and each family member
6. Wash hands before starting the interview or when moving to a different room
7. Mind confidentiality: conversation about patients should be taken to a private area, even if that
means suspending an encounter
Interview
1. Use the neuro-Ophthalmology template (new), (follow-up)
2. Please fill the blanks and revise the template accourdingly
3. Please get detailed, thorough, pertinent histories from the patient and family
Examination
1. Check visual acuity at far and at near
2. Check pupils with Dr. Jun for every new patient and any return patients who have new visual
complaints or new findings
3. Dilate eyes as early as possible
4. Check color vision with H-R-R
5. Check stereopsis
6. For double vision, please do Worth Four dots, Three steps test, Double Maddox Rod test
7. For thyroid eye disease, check proptosis (exophthalmometer), lid retraction, lid lag, lateral flare,
scleral show, lagophthalmos, corneal reflex, exposure keratitis
8. For Myasthenia Gravis, check eyelid ptosis, Cogan lid twitch, enhancement of ptosis with
contralateral eyelid elevation
9. If you don’t know, please ask
Documentation
1. Please try to complete your documentation when you finish the interview
2. Please summarize and think what condition you are dealing with
3. Please set up plans for further investigation, management and follow-up
This is revised in 05/2015 by Dr. Jun
85
* Inpatient Consults and Emergency Patients Policy at Women & Children Hospital:
1. Ask if the patient has a private practice ophthalmologist. If affirmative, it should be
suggested that the private ophthalmologist be called first, as a courtesy.
2. If the patient does not have a private practice ophthalmologist or if the ophthalmologist
does not desire to make a hospital visit, then the following should be implemented:
3. Ask if the consult is Urgent or Not Urgent.
4. If not urgent:
a. If the patient is not mobile, indicate to the caller that the ophthalmology resident
and attending at Eye Institute East clinic will see the patient the next day. (Note:
the on-call resident is responsible to inform the EIE Clinic resident/attending
physician of the awaiting consult.)
b. If the patient is mobile, have the patient come to the Mason Eye Institute the next
day though the Emergency Clinic/Consult Services.
5. If the inpatient consult is urgent or the patient is in the Emergency Room at W&C
Hospital:
a. Ask if the patient could be transferred to Mason Eye Institute because we have all
the equipment here that we will need.
b. If unable to be transported and it is daytime, the resident and attending at Eye
Institute East clinic should go. (Note: the on-call resident is responsible to inform
the EIE Clinic resident/attending physician of the awaiting consult.)
c. If unable to be transported and it is after hours, the resident physician on-call
should go to Women & Children Hospital.
d. If there is no attending at Eye Institute East clinic during the daytime, the resident
physician on-call should go.
86
OCULAR PATHOLOGY
Objectives:
Understanding of the normal anatomy and histology of the eye (MK, PBLI, P)
Basic understanding of pathologic processes
How gross and microscopic findings correlate with clinical findings and treatment.
How these findings are used to arrive at a diagnosis and treatment.
Participation and understanding of how specimens are handled in the laboratory
Importance of the clinical history
What the path lab can and cannot do
How to work with the pathologist to ensure optimal processing
Resources: (MK, PBLI)
Ophthalmic Pathology. D.J. Apple, M. Rabb: Ocular Pathology, 5th ed. Mosby, 1998.
M. Yanoff, B.S. Fine. Ocular Pathology, 5th ed. Lippincott, 2002.
Sassani JW (ed). Ophthalmic Pathology with Clinical Correlations. Philadelphia, LippincottRaven, 1997. [At this time, it is the best of the texts for residents.]
Chapter: “Pathology” by Morton Smith, MD, The Requisites in Ophthalmology, ed. Krachmer,
2002.
Eye Pathology: An Atlas and Basic Text. Eagle, 1999.
American Academy of Ophthalmology BCSC, “Ophthalmic Pathology and Intraocular Tumors.”
87
OPHTHALMIC PLASTIC/ORBITAL DISEASE
Objectives:
1. First year resident:
a.
Develop an understanding of the embryology and anatomy of the ocular adnexa,
including the eyelid, lacrimal system, and orbit. (MK)
b. Demonstrate an ability to perform a clinical evaluation of the ocular adnexa. (PC, MK,
P)
c.
Demonstrate an understanding of the principals and techniques applied to the
management of acute adnexa trauma. (PC, MK, P)
2. Third year resident:
a.
Develop a command of the embryology and anatomy of the ocular adnexa, including the
eyelid, Lacrimal system, and orbit. (MK, P)
b. Demonstrate complete capability to perform a clinical evaluation of the ocular adnexa.
(MK, P)
c.
Demonstrate a command of the principals and techniques applied to the management of
acute adnexal trauma. (MK, P)
d. Demonstrate an understanding of the pathophysiology, diagnosis, and management of:
dermatochalasis, brow ptosis, blepharoptosis, entropion, ectropion, trichiasis, eyelid
retraction, facial dystonia, skin neoplasms, Lacrimal gland masses, lacrimal outflow
dysfunction, anophthalmic socket, and orbital inflammatory diseases. (MK, P)
e.
Demonstrate an appropriate knowledge involving surgical anatomy and decision making.
(MK, TS)
Required write-ups:
Provide Dr. Liu with a 2-5 page typewritten write-up detailing what you plan to do in each of the
following situations. Write a detailed management plan beginning with your pre-operative evaluation.
This includes some of the specific tests that you plan to do, what you look for or what to avoid, and so on.
Explain how you prepare the patient and his/her family and how to properly word the consent. Tell me
what specific instruments, equipments, sutures or special materials you need in each situation. Highlight
some of the key steps of your proposed operation and in your pre-, intra- and post-operative orders, and
other precautions you take. These are real life situations which all ophthalmologists face. The knowledge
and skills are essential and of critical importance and should become your second nature. (PC, PBLI)
This is essentially an open-book exam. Unless special provision is made before the start of the
rotation, Dr. Liu must receive your write-up at the halfway point of your rotation, i.e. at the end
of the first month on the service. This allows time to discuss and revise your work.
88
1. First year resident: (MK, TS, P)
a. ruptured globe
b. lacerated eyelids, involving lid margin and canaliculus
c. orbital foreign body injury, metallic and non-metallic
d. must be turned in before end of rotation
3. Third year resident: (MK, P, TS)
a. dog bite to lids/face
b. orbital blow out fracture
c. chemical/burn injuries to the globe/lids/face
d. must be turned in before end of rotation
Resources: (MK, PBLI)
Techniques in Ophthalmic Plastic Surgery with DVD: A Personal Tutorial Nerad Jeffrey A.,
Saunders Elsevier, Philadelphia, 2010
Disease of the Orbit: A Multidisciplinary Approach Rootman .J, Lippincott Williams & Wilkins,
Co, Philadelphia, 2002 2nd Edition.
Ophthalmic Pathology Yanoff M., Fine. B, Mosby –Wolfe, Philadelphia, 1996 4th Edition.
Color Atlas of Oculoplastic Surgery Tse, David T. Lippincott Williams & Wilkins, Philadelphia,
2011.
Required Reading:
A suggested reading list will be available to the resident at the onset of the Oculoplastics rotation.
It is the resident’s responsibility to acquire the list from Dr. Liu or his secretary during the first
week of the rotation. Successful completion of the Oculoplastics rotation requires the reading and
understanding of a minimum of thirty (30) articles from the suggested reading list. A completed
readings citation form will be available from Ms. Stock. This form should be completed as each
article is read. The completed form will be submitted to Ms. Stock or Dr. Liu at the rotation’s
end.
In-service Examination:
An in-service examination will be given during the final week of the Oculoplastics rotation. The
scope of examination will include all aspects of lacrimal, orbital, and ocular adnexal disease.
Successful completion of the rotation requires a passing grade of 70% or greater on the
examination.
89
PEDIATRIC AND STRABISMUS SERVICE
Objectives:
1. Examine and evaluate infants in the intensive care nursery for retinopathy of prematurity. (PC,
ICS)
2. Examine and evaluate children and adults with strabismus. (PC, ICS)
3. Perform strabismus surgery under direct supervision, usually recess-resect, transposition
procedures as well as oblique procedures. (TS, PC)
4. Microscopic surgery for cataract and glaucoma. (PC, TS)
5. Nasolacrimal duct probing and intubation. (PC, TS)
6. Recognition of the genetic and metabolic eye diseases. (MK)
7. Systemic disease with ocular manifestations. (MK)
8. Develop a clinical research project for presentation at a national meeting. (P)
Recommended Reading: (MK, PBLI)
Ophthalmic Pathology. Yanoff M, Fine, B; Mosby-Wolfe 2002
Binocular Vision and Ocular Motility: Theory and Management of Strabismus. Gunter K. Von
Noorden., CV Mosby.
Atlas of Ophthalmic Surgery: Techniques, Complications. Edited by Klaus Heilmann, David,
Paton and G. Thieme Verlag. Thieme-Stratton, 3 volumes.
Journal of Pediatric Ophthalmology & Strabismus (in the department library – published 6 times
per year.)
90
VITREORETINAL SERVICE
Objectives:
1. Development of Basic Skills Including: (MK, PC, ICS, P)
Understanding importance and techniques of history taking
Retinal documentation, including formal fundus drawings and description of retinal
findings
Slit lamp examination
Comprehensive retinal examination using indirect ophthalmoscopy, scleral depression,
fundus and contact lens techniques
Fluorescein angiography
Basic electrophysiology and psychophysics
Diagnostic Ultrasonography
2. Vitreoretinal Complications of Anterior Segment Surgery (MK,P, TS)
Endophthalmitis
Retained lens fragments
Dislocated IOL
Choroidal hemorrhage/effusion
Cataract surgery and uveitis
3. Diagnosis/Management of Diabetic Retinopathy (MK, P, TS)
Diabetic macular edema
Proliferative diabetic retinopathy
Surgical decision-making
Rubeotic Glaucoma
4. Retinal Vascular Disorders (MK, P, TS)
Hypertensive retinopathies
Central retinal vein occlusion
Branch retinal vein occlusion
Central and Branch retinal artery occlusion
Radiation Retinopathy
Hemoglobinopathies
Radiation Retinopathy
5. Diagnosis and Management of Macular Disease (MK, P, TS)
Age-related macular degeneration
Genetic maculopathies
Macular holes
Cystoid macular edema
Central serous chorioretinopathy
Epiretinal Membranes
6. High Myopia (MK)
7. Peripheral Retinal Disorders (MK)
Lattice and other vitreoretinal degenerations
Genetic abnormalities
Retinal tears
Subclinical retinal detachments
91
8. Retinal Detachments (MK, P, TS, PC)
Rhegmatogenous retinal detachments
Tractional retinal detachments
Exudative retinal detachments
Surgical decision-making
9. Uveitis/Endophthalmitis (MK, P)
Anterior uveitis
Intermediate uveitis
Posterior uveitis
Ocular complications of AIDS
10. Genetic Chorioretinal Diseases (MK, P)
11. Ocular Tumors (MK, P)
12. Surgical Skills (MK, TS, PC, ICS)
Correlative anatomy
Management of ocular trauma
Laser techniques:
Panretinal photocoagulation
Focal and grid macular laser photocoagulation
Ablative photoablation of choroidal neovascular membranes
Retinal hole prophylactic laser
Laser management of branch and central retinal vein occlusions
Retinopathy of prematurity
Retinal Detachment and Vitrectomy Surgeries
Resources: (MK, PBLI)
American Academy of Ophthalmology, Basic and Clinical Science Course, Section 11: Retina
and Vitreous, Section 9: Intraocular Inflammation and Uveitits.
Benson WE. Retinal Detachment: Diagnosis and Management, 2nd Edition. Lippincott.
Peyman GA and Schulman JA. Intravitreal Surgery: Principles and Practice, 2nd edition.
Appleton-Century-Crofts.
Ryan SJ. Retina (2nd edition). Mosby.
Jalkh A and Celerio W. Atlas of Fluorescein Angiography. WB Saunders.
Freeman WR. Practical Atlas of Retinal Disease and Therapy. Raven.
Nussenblatt RB, Whitcup SM, Palestine AG. Uveitis: Fundamentals and Clinical Practice.
Mosby.
Hampton GR, Nelsen PT. Age Related Macular Degeneration: Principles and Practice. Raven.
Shields JA and Shields CL. Intraocular Tumors: A Text and Atlas. Saunders.
Gass J. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment, 4th edition. Mosby.
Yannuzi, Guyer, Green. Retina Atlas. Mosby.
92
CLINIC ROTATION DESCRIPTIONS
First Year Residents (PGY-II)
Rotation:
Emergency Service
Months:
Days:
2 rotations of 2 months each (not consecutive)
All days covering Emergency Clinic.
Duties and Responsibilities – Emergency Service:
1)
2)
3)
4)
Rotation:
Patient examination and evaluation.
Obtain necessary tests.
Determine and execute treatment plan, with faculty input.
Read and know the “Uveitis” and “Lens” sections of the AAO Basic Science
handbooks. (You will be the expert in uveitis.)
Cornea/External Disease
2 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Cornea/External Disease Service:
1)
2)
3)
4)
Rotation:
Superficial keratotomy
Entire responsibility for keratoplasty for those interested and who have sufficient
supervised micro surgery on animal eyes.
Assisting experience in human keratoplasty.
Observe and assist in refractive surgery.
Oculoplastics
2 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Oculoplastics Service:
1)
2)
3)
4)
93
Interview and evaluate patients with conditions pertaining to the ocular adnexa.
Develop an understanding and expertise in the anatomy of the eyelid, orbit and
lacrimal outflow system.
Develop an understanding of the pathophysiology of conditions pertaining to the
ocular adnexa.
Develop treatment plans and assist in ocular adnexal surgeries.
Rotation: Neuro-Ophthalmology/Consults and Low Vision/
Optometry Services
2 rotations of 2 months each (not consecutive)
(Please refer to the detailed rotation schedules for the year.)
Wednesday afternoon rotation will be in Low Vision / Optometry Services.
(Residents may be eligible for early completion of Low Vision rotation based on meeting
course objectives and required reading assignments, attendance and a score of 86% or better on
rotation exam. Please discuss any request for early completion with Low Vision Coordinator.)
Duties and Responsibilities – Neuro-Ophthalmology Service:
The Neuro-Ophthalmology/Consults resident spends four half-days in the NeuroOphthalmology outpatient suite with Dr. Johnson, our neuro-ophthalmologist. The
resident will obtain comprehensive histories and perform complete neuro-ophthalmologic
examinations on all new neuro-ophthalmologic outpatient consults. The resident also will
evaluate return (follow-up) neuro-ophthalmologic patients, but in a more directed/tailored
manner. Evaluation and management plans will then be jointly formulated by Dr.
Johnson and the Neuro-Ophthalmology/Consult resident. The resident will dictate for
new patients only a detailed letter to the referring physician, including current journal
references when appropriate. These letters are reviewed by Dr. Johnson with the residents
thereby promoting increased knowledge of Neuro-Ophthalmology and community
physician interactions.
The Neuro-Ophthalmology/Consult resident, in general, will obtain comprehensive
histories and perform complete ophthalmologic examinations on all inpatient consults.
The resident will then formulate an assessment and management plan for each consult.
Thereafter, the resident and Dr. Johnson, the faculty member chiefly responsible for
supervising inpatient consults, will jointly evaluate the patients. The inpatient consults
reflect a wide spectrum of diseases with primary emphasis on orbital/facial trauma, posttraumatic brain injury, strokes, and systemic diseases with ophthalmologic manifestations
(e.g. diabetes mellitus). Although listed as four half-days per week, inpatient consults are
evaluated daily during the work week and after regular clinic hours.
Second Year Residents (PGY-3)
Rotation:
Retina/Vitreous
4 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Retina/Vitreous Service:
1)
2)
3)
4)
5)
6)
94
Obtain relevant histories.
Document ocular findings and progress notes.
Slit lamp examination of the anterior segment.
Gonioscopy.
Direct ophthalmoscopy.
Indirect ophthalmoscopy with scleral indentation and drawing of the retina.
7)
8)
Slit lamp fundus biomicroscopy with contact lenses.
Interpretation of fundus fluorescein angiography.
All residents are expected to perform panretinal laser photocoagulation for various
proliferative retinopathies. Depending on the volume of retinal detachment cases,
occasionally residents will be able to perform scleral buckling procedures under direct
staff supervision. Residents will also do many of the steps in a routine pars plana
vitrectomy under the direct supervision of the attending.
Rotation:
Pediatrics (If no pediatrics please see General Ophthalmology below)
4 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Pediatric/Strabismus Service:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
Examine and evaluate infants in the intensive care nursery for retinopathy of
prematurity.
Accurately measure children and adults with strabismus.
Perform strabismus surgery under direct supervision.
Recognition of the genetic and metabolic eye diseases.
Perform induced tropia test for preverbal visual acuity.
Perform prism convergence test for motor fusion.
Perform W4D, Bagolini, and stereo acuity to monitor sensory status.
Retinoscopy
Evoked saccades/confrontational VF.
ICARE IOP testing.
Retcam photography.
Pediavision screening.
Forced ductions.
VEP interpretation.
Counsel patching therapy.
*****Note- No more than 2 weeks off Pediatric rotation(including vacation and meeting time).**
Rotation:
VA/General Ophthalmology
4 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – VA/General Ophthalmology:
1)
2)
95
The resident physician will obtain a complete ophthalmological history and an
applicable general medical history.
The resident will do a complete ophthalmological examination.
a)
This to include visual acuity testing (and refraction of optical defects of
the eye including retinoscopy as indicated).
b)
Confrontation fields.
c)
Orbital and external exam.
d)
Ocular motility exam.
e)
f)
g)
3)
4)
5)
6)
7)
8)..
Pupillary evaluation.
Anterior segment exam with slit lamp biomicroscopy.
Posterior segment evaluation using direct and indirect ophthalmology
(including biomicroscopy of the fundus as indicated).
h)
Intraocular pressure testing.
i)
Also, when applicable, learn to do color vision testing, Amsler Grid and
Maddox rod testing, gonioscopy, conjunctival and corneal scrapings,
lacrimal evaluation, A and B scan techniques, and keratometry.
j)
Learn the appropriate indications for ordering automated or quantitative
perimetry, fluorescein angiography, ocular photography, light or pattern
evoked electrical potential tests (ERG, VEP), and specular microscopy.
k)
Prescribe glasses or contact lenses as dictated by findings.
The resident physician will complete a differential diagnosis and treatment
regimen. The resident will review with the patient, his diagnosis, prognosis and
treatment regimen. The resident will review any special tests ordered in a timely
manner and discuss these results with the attending staff.
The resident will treat the patient as medically or surgically indicated and see the
patient for appropriate follow-up care.
The resident will complete the medical record to include all the above
information as appropriate.
The resident will become familiar and competent with a surgical microscope and
instruments; perform anterior segment surgery in the wet lab.
The resident will perform extracapsular cataract extraction or
phacoemulsification with or without intraocular lens, under direct supervision.
The resident will become proficient with phacoemulsification anterior segment
reconstruction, trabeculectomies, and glaucoma tube shunts.
Third Year Resident (PGY-4)
Rotation:
Cornea/External Disease
2 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Cornea/External Disease:
1)
2)
3)
4)
Rotation:
Superficial keratotomy.
Entire responsibility for keratoplasty for those interested and who have sufficient
supervised micro surgery on animal eyes.
Assisting experience in human keratoplasty.
Observe and assist in refractive surgery.
Oculoplastics
2 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Oculoplastics Service:
1)
2)
96
Interview and evaluate patients with conditions pertaining to the ocular adnexa.
Develop an understanding and expertise in the anatomy of the eyelid, orbit and
lacrimal outflow system.
3)
4)
97
Develop an understanding of the pathophysiology of conditions pertaining to the
ocular adnexa.
Develop treatment plans and assist in ocular adnexal surgeries.
Rotation:
Glaucoma
4 Month Rotation (Please refer to the detailed rotation schedules for the year.)
Duties and Responsibilities – Glaucoma Service:
1)
2)
3)
4)
5)
Rotation:
Patient examination and evaluation.
Visual fields.
Gonioscopy.
Laser therapy.
Glaucoma surgery.
VA Hospital/General Ophthalmology
4 Month Rotation
Duties and Responsibilities:
1)
The resident physician will obtain a complete ophthalmological history and an
applicable general medical history.
2)
The resident will do a complete ophthalmological examination.
a)
This to include visual acuity testing (and refraction of optical defects of
the eye including retinoscopy as indicated).
b)
Confrontation fields.
c)
Orbital and external exam.
d)
Ocular motility exam.
e)
Pupillary evaluation.
f)
Anterior segment exam with slit lamp biomicroscopy.
g)
Posterior segment evaluation using direct and indirect ophthalmology
(including biomicroscopy of the fundus as indicated).
h)
Intraocular pressure testing.
i)
Also, when applicable, perform vision testing, Amsler Grid and Maddox
rod testing, gonioscopy, conjunctival and corneal scrapings, lacrimal
evaluation, A and B scan techniques, keratometry and IOL Master.
j)
Learn the appropriate indications for ordering automated or quantitative
perimetry, fluorescein angiography, ocular photography, light or pattern
evoked electrical potential tests (ERG, VEP), and specular microscopy.
k)
Prescribe glasses or contact lenses as dictated by findings.
3)
The resident physician will complete a differential diagnosis and treatment
regimen. The resident will review with the patient, his diagnosis, prognosis and
treatment regimen. The resident will review any special tests ordered in a timely
manner and discuss these results with the attending staff.
4)
The resident will treat the patient as medically or surgically indicated and see the
patient for appropriate follow-up care.
5)
The resident will complete the medical record to include all the above
information as appropriate.
6)
The resident will become familiar and competent with a surgical microscope and
instruments; perform anterior segment surgery in the Wet lab.
7)
The resident will perform extracapsular cataract extraction or
phacoemulsification with or without intraocular lens, under direct supervision.
98
8)
9)
The resident will become proficient with phacoemulsification anterior segment
reconstruction, trabeculectomies, and Glaucoma tube shunts.
The resident will be proficient in the use of the electronic health record at the VA
including CPRS and MedFlow.
First, Second and Third Year Residents (PGY2-PGY4)
General Ophthalmology/Resident General Clinics
Residents are assigned some general clinics at the university each year, as listed in the
monthly rotation schedules.
Duties and Responsibilities:
1)
2)
3)
4)
5)
6)
99
The resident physician will obtain a complete ophthalmological history
and an applicable general medical history.
The resident will do a complete ophthalmological examination.
a)
This to include visual acuity testing (and refraction of optical
defects of the eye including retinoscopy as indicated).
b)
Confrontation fields.
c)
Orbital and external exam.
d)
Ocular motility exam.
e)
Pupillary evaluation.
f)
Anterior segment exam with slit lamp biomicroscopy.
g)
Posterior segment evaluation using direct and indirect
ophthalmology (including biomicroscopy of the fundus as
indicated).
h)
Intraocular pressure testing.
i)
Also, when applicable, learn to do color vision testing, Amsler
Grid and Maddox rod testing, gonioscopy, conjunctival and
corneal scrapings, lacrimal evaluation, A and B scan techniques,
and keratometry.
j)
Learn the appropriate indications for ordering automated or
quantitative perimetry, fluorescein angiography, ocular
photography, light or pattern evoked electrical potential tests
(ERG, VEP), and specular microscopy.
k)
Prescribe glasses or contact lenses, or low vision aid as dictated
by findings.
The resident physician will complete a differential diagnosis and
treatment regimen. The resident will review with the patient, his
diagnosis, prognosis and treatment regimen. The resident will review any
special tests ordered in a timely manner and discuss these results with the
attending staff.
The resident will treat the patient as medically or surgically indicated and
see the patient for appropriate follow-up care.
The resident will complete the medical record to include all the above
information as appropriate.
The resident will become familiar and competent with a surgical
microscope and instruments; perform anterior segment surgery in the
animal lab.
7)
8)
The resident will perform extracapsular cataract extraction or
Phacoemulsification with or without intraocular lens, under direct
supervision.
The resident will become proficient with phacoemulsification anterior
segment reconstruction, trabeculectomies, and Molteno valves.
The rotations as listed above are standard. Naturally, due to vacation, Basic Science
Course (San Antonio, Wills or other) and other external meetings (such as AAO or
ARVO), some modifications occur during the year. Residents in each year are allowed
three weeks’ for vacation or interviews and one additional week for meetings.
Resident supervision in the General Clinic is the primary responsibility of Geetha Davis, MD,
Theodore Wills, MD and Kathy Lentz, MD. In the absence of the primary supervising attending,
other supervising faculty persons are assigned. See Ophthalmology Attending Coverage Calendar
for Residents General Clinic for attending assigned to supervise the general clinics for each half
day. Residents in sub-specialty clinics are supervised by the attending physician of the service.
Patients are scheduled with the attending physician for all sub-specialty clinics. For sub-specialty
clinics, the attending assigns the resident to initially see most of the patients on the schedule.
When this occurs, the attending sees the patient after the evaluation. The resident progressively
assumes greater responsibility during pre-evaluations.
All patients who are admitted to the hospital are admitted to the service of a specific attending
physician and the care is closely supervised by that physician. The resident is involved in the dayto-day care of the inpatients with daily discussions of the treatment plan with the attending
physicians.
Residents are responsible for daily rounding with progress notation for all inpatients receiving
primary or consultatory care through the ophthalmology services. On patients admitted to
ophthalmology services, the resident is responsible for the ophthalmic and general medical H/P,
and discharge summary.
100
RESIDENT INSTRUCTION/SUPERVISION
Instruction in Ethical Issues, Socioeconomics of Heath Care, Cost-Effective Medical Practice
(Narrative Description for Resident Supervision)
University of Missouri-Columbia
The following is a list of programs that enable our residents to develop an understanding of ethical,
socioeconomic and medical-legal issues.








Each year a medical-legal conference is presented in the department by legal counsel member
of the University of Missouri System.
In July a “compliance” conference is moderated by the Office of Corporate Compliance
regarding University Physicians Compliance and federal regulations covering medical billing.
University Risk Management speaks with the new residents at the Hospital Orientation in
July.
The practice of medicine in an ethical manner is reflected in part in the quality of care that is
perceived by our patients. The Chairman of the Department of Ophthalmology Quality
Assurance Committee provides information to the residents about quality assessment and
improvement in our Ophthalmology Program.
Monthly Resident Practice Management Meetings are conducted by the Resident Program
Director and Resident Program Coordinator. A formal agenda is prepared. Ethical,
socioeconomic, and cost containment issues are included.
Each new resident receives a Resident Orientation. This orientation provides formal training
in cost containment issues by our billing and coding specialist, as well as a session in risk
management.
The ethical nature of performing surgery or prescribing medical management of patients is
discussed on an individual basis and in case conferences. Ethical issues and socioeconomic
issues are an ongoing issue with every patient.
The first year residents receive, the American Academy of Ophthalmology Basic & Clinical
Science Course books, which includes The Profession of Ophthalmology: Practice
Management, Ethics and Advocacy and Basic Principles of Ophthalmic Surgery
1. Faculty assignments
Faculty assignments are handled through the Chairman’s office. Dr. Theodore Wills has the
primary responsibility for supervision of General Clinics and functions in this role. In his
absence, other faculty (active or courtesy) are assigned. A monthly assignment schedule is
distributed at the end of the preceding month. The name of the daily supervising attending is
visibly displayed in the clinic. All residents are aware by both methods who the supervising
attending is on any day.
2. Faculty Location and Activity
Faculty assigned to direct supervision in the clinic are physically located in the clinic or adjoining
faculty offices, while surgery supervisors are physically present in the operating room for, most
or all of the procedures are expected to function in that role. At times faculty supervision may be
diverted or delayed due to a patient call, etc. When emergencies occur necessitating the absence
of the supervising physician, an alternate supervising attending physician is assigned.
101
3. Selection of visits for direct faculty supervision
Direct faculty supervision is provided for nearly all patients examined by the residents. The
extent of re-examination of patients by faculty depends on the level of experience of the resident.
Patients assigned to the resident clinic are initially evaluated by the resident then presented to the
attending. Sub-specialty patients are generally seen in conjunction with the faculty person.
4. Techniques of faculty supervision
The faculty members:
a.)
Review of resident’s findings within patient exam room.
b.)
Review of resident’s findings within discussion with patient.
c.)
Patient examined with the resident.
5. Emergency care (faculty supervision)
Monday-Friday, during regular hours:
The assigned faculty supervisor provides supervision. (Please also refer to #1. Faculty
Assignments.)
Evenings and Weekends:
The attending on call is available by telephone; the attending comes in to see the patient
when direct faculty supervision is necessary, as deemed by the faculty or at the resident’s
request. Whenever there is any question as to need for direct faculty supervision, the oncall faculty member will come in to evaluate the patient with the resident.
Residents on-call have approval from the faculty to accept all referrals from referring
physicians.
6. Documentation of faculty supervision
*Faculty write notes and sign the medical records at the time of patient evaluation.
Monthly, the residents are given a copy of the following:
*Ophthalmology Resident Clinic Attending Calendar
*Ophthalmology Call Schedule
*Ophthalmology Lecture & Event Calendar
*Ophthalmology VA Attending Calendar
102
OPHTHALMOLOGY: VA HOSPITAL
STATEMENT OF PURPOSE
The purpose of ophthalmology residency training at the Harry S. Truman Memorial Veterans Hospital, is
to provide an optimal clinical education to physicians in the science and art of the specialty of
ophthalmology; all functions of the department are structured to maximize this educational mission.
Resident physicians are expected to: develop a personal program of self-study and professional growth
with guidance from the teaching staff. Participate in safe, effective and compassionate patient care under
supervision. Participate fully in the educational activities of their program and, as required, assume
responsibility for teaching and supervising other residents and students; participate in institutional
programs and activities involving the medical staff and adhere to established practices, procedures and
policies of the institutions, participate in institutional committees and councils, especially those that relate
to patient care review activities, and apply cost containment measures in the provision of patient care. The
VA ophthalmology resident rotation is designed to foster independent patient evaluation and management
commensurate with their level of advancement and responsibility.
Resident physicians are expected to achieve the 7 ophthalmology competencies of:







Patient Care – PC
Medical Knowledge – MK
Interpersonal and Communication Skills – ICS
Professionalism – P
Practice-based Learning and Improvement – PBLI
Systems-based Practice – SBP
Technical/Surgical Skill – TS
During the tenure of the residency, residents should accomplish the following:
 develop a personal program of self-study and professional growth with guidance from the
teaching faculty (MK)
 participate in safe, effective and compassionate medical and surgical patient care under
supervision, commensurate with their level of advancement and responsibility
(PC,TS,MK,P,SBP)
 participate fully in the educational activities of their program and, as required, assume
responsibility for teaching and supervising other residents and students (PBLI,MK,ICS)
 participate in institutional programs and activities involving the medical staff and adhere to
established practices, procedures and policies of the institutions (ICS,PBLI,P)
 participate in institutional committees and councils, especially those that relate to patient care
review activities (P,ICS,SBP)
 apply cost containment measures in the provision of patient care (SBP)
103
Participating Institution - VA Hospital
(Narrative Description for Resident Supervision)
1.
Faculty assignments. How are supervising faculty assigned? For what time period? In what
way are they identified to the residents concerned?
Faculty assignments are handled through the Chairman’s office. Dr. Frank Rieger, the Local
Director, has the primary responsibility for supervision of clinic and surgery. All residents are
aware of his role. For sub-specialty cases, the resident contacts the appropriate attending for
consultation and, as necessary, supervision. Dr. Rieger maintains general oversight, however, of
all patient care. Other faculty (active or courtesy) are assigned to supervise clinic or surgery as
well. A monthly assignment calendar is distributed for VA clinic and surgery days.
2.
Faculty Location and Activity. Where are supervising faculty physically located during
assigned supervision periods? Are such faculty involved in activities other than direct
supervision during these period?
Clinic Supervision:
Dr. John Cowden (cornea) covers VA clinic (2, 4) and an as needed basis when a faculty
member is scheduled out.
Dr.Davis (general ophthalmology) covers VA surgery (1 & 5 Thursday AM) alternating
with Dr. Reyes) covers VA clinic (1, Friday Morning)
Dr. Dean Hainsworth (retina/vitreous) covers VA retina surgery (2, 4) Wednesday
mornings and clinic (2, 3, 4, 5) Thursday mornings.
Dr. Bokkwan Jun (neuro-ophthalmology) covers the VA Clinic (1,3) Tuesday mornings
Dr. Don Liu (Oculoplastics) covers VA clinic every Monday morning, surgery (1, 3, 5)
Wednesdays, clinic (2, 4) all day Wednesday; staff clinic Thursday morning and every
Friday afternoon.
Dr. Marcos Reyes (glaucoma) VA clinic (2, 4) Wednesday afternoons, and glaucoma
surgery (2, 4) Thursday mornings.
Dr. Frank Rieger Chief of Eye Service at the VA Hospital and is onsite and available
100% of the time. He sees his own patients (cornea & general) on Monday, Wednesday
and Friday afternoons and all day Thursday. He is available to staff surgery and clinic all
day Tuesdays.
Dr. Scott McKnight, Courtesy Faculty staffs VA surgery the third Tuesday of most
months all day.
Dr. Jeff Wongskhaluang , Courtesy Faculty staffs VA surgery the third Thursday of most
months all day.
Please note: For any potential new faculty members joining the Department of
Ophthalmology their schedules at the VA have not been finalized by the date of this
manual printing.
Surgery Supervision:
All Ophthalmology surgeries in the OR are staffed by an attending physician. (See VA
Week-day Attending Calendar)
If a doctor is assigned to the VA (either OR or eye clinic), he/she should be physically at
the VA. University subspecialists, not assigned to the VA Hospital Eye Clinic, are
available for telephone consultation and sometimes on site consultations.
3.
Selection of visits for direct faculty supervision. What is departmental policy as to which
patient visits are to have direct faculty supervision? What instructions are given as to when to
104
initiate such direct supervision? Is the initiation of direct supervision primarily the responsibility of
faculty or of residents?
In the weekday operation of the outpatient clinic at the VA the attending must be personally
present in the clinic. Direct faculty supervision, as mandated by the Department of Veterans (see
attachement) Affairs, is provided for all patients examined by the residents. The patient is either
seen by the attending or discussed with the resident.
There is at least one attending physician assigned to the VA Eye Clinic every morning and
afternoon Monday-Friday. Residents have ready access to any of the faculty members at the
University for Telephone Consultation or direct consultation virtually any time during the day or
evening hours. This can be done by having the faculty member see the patient at the VA Hospital
or presenting a difficult or particularly challenging patient at grand rounds which are held once a
month. Subspecialty patients are evaluated by the respective attending prior to scheduling
surgical procedures. Cataract surgery patients are evaluated by the clinic attending preoperatively.
Dr. Frank Rieger is onsite and available to see patients with the residents 100% of the time.
4.
Techniques of supervision. In what way is direct faculty supervision provided? What
provision is made to provide for consistent faculty supervision of post-operative care of
Class 1 patients?
a.
b.
c.
5.
Direct faculty supervision at the VA Hospital is provided by having the faculty member
physically present in the clinic at all times and providing resident supervision according
to VA guidelines.
The resident can also obtain a telephone consultation from a faculty member concerning
a patient once the initial evaluation is done by the resident. This is typically a patient in
need of subspecialty care and the needed subspecialist is not assigned to the VA clinic
that day.
Post-operative care for routine cases (cataract extractions) is administered by the
residents with supervision by the attending physician assigned to the VA clinic.
Subspecialty procedures are supervised postoperatively by the subspecialist involved in
the surgical care of that patient.
Emergency care. What special provision is made for direct faculty supervision of emergency
visits?
Monday-Friday, during regular hours:
The assigned faculty supervisor is physically present at the VA Hospital Eye Clinic to
provide supervision.
Evenings and Weekends:
The attending on call is available by telephone; the attending comes in to see the patient
when direct faculty supervision is necessary.
6.
Documentation. In what way is direct faculty supervision identifiable and documented?
*Faculty note and electronic signature on chart in accordance with VA guidelines for resident
supervision.
Monthly the residents are given a copy of the following calendar/schedule:
105
*Ophthalmology Resident Clinic Attending Calendar
*Ophthalmology Call Schedule
*Ophthalmology Lecture & Event Calendar
*Ophthalmology VA Attending Calendar
106
Insert “Resident Supervision Pocket Card – Office of Academic Affiliations”
United States Department of Veterans Affairs
http://www.va.gov/oaa/res-supervision-card-test.asp
107
VA Hospital Goals and Responsibilities for VA Ophthalmology Rotation
Goals
1.
To provide excellent medical and surgical ophthalmic care to the veterans using state of-theart knowledge and technology.
To foster a teaching environment that allows the residents to progressively gain autonomy in
their medical and surgical skills.
To promote leadership skills that will become a part of the residents’ future practice patterns.
To teach teamwork and respect for each member of the team.
To ensure each resident is exposed to a vast array of ophthalmic problems and surgical cases.
To promote an adequate hands-on surgical experience so that each resident is confident in
their own surgical skills and cognizant of their own limitations.
To provide continuity of care during the four month rotation and the one month post
operative clinic.
To teach the entire spectrum of patient care to include administrative duties, electronic
medical record management as well as surgical and clinic scheduling.
To be knowledgeable of advancements in information technology with an emphasis on
medical practice.
2.
3.
4.
5.
6.
7.
8.
9.
Duties
These duties are progressively applied to the 2nd and 3rd year resident. A higher level expertise is expected
in the 3rd year resident.
Second Year Resident (PGY-3) - VA Hospital Duties and Responsibilities
VA/General Ophthalmology
Months:
Days:
4
Mon AM – VA Clinic
Tues AM – VA Surgery
Wed AM – VA Clinic
Thurs AM – VA Surgery
Fri AM – VA Clinic
PM – VA Clinic
PM – VA Surgery
PM – VA Clinic
PM – VA Surgery
PM – VA Clinic
Duties and Responsibilities:
1)
2)
108
The resident physician will obtain a complete ophthalmological history
and an applicable general medical history.
The resident will do a complete ophthalmological examination.
a)
This to include visual acuity testing (and refraction of optical
defects of the eye including retinoscopy as indicated).
b)
Confrontation fields.
c)
Orbital and external exam.
d)
Ocular motility exam.
e)
Pupillary evaluation.
f)
Anterior segment exam with slit lamp biomicroscopy.
g)
Posterior segment evaluation using direct and indirect
ophthalmology (including biomicroscopy of the fundus as
indicated).
h)
Intraocular pressure testing.
i)
j)
k)
l)
m)
n)
o)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
109
Also, when applicable, learn to do color vision testing, Amsler
Grid and Maddox rod testing, gonioscopy, conjunctival and
corneal scrapings, lacrimal evaluation, A and B scan techniques,
keratometry, and IOLMaster and Lenstar.
Learn the appropriate indications for ordering automated or
quantitative perimetry, fluorescein angiography, ocular
photography, light or pattern evoked electrical potential tests
(ERG, VEP), and specular microscopy.
Prescribe glasses or consults for contact lenses as dictated by
findings.
Ocular Coherence Tomography (OCT).
Wavefront analysis (OPD)
Pentacam
Confocal microscopy and specular microscopy
The resident physician will complete a differential diagnosis and
treatment regimen. The resident will review with the patient, his
diagnosis, prognosis and treatment regimen. The resident will review any
special tests ordered in a timely manner and discuss these results with the
attending staff.
The resident will treat the patient as medically or surgically indicated and
see the patient for appropriate follow-up care.
The resident will complete the medical record to include all the above
information as appropriate.
The resident will become familiar and competent with a surgical
microscope and instruments; perform anterior segment surgery in the wet
lab.
The resident will perform extracapsular cataract extraction or
phacoemulsification with or without intraocular lens, under direct
supervision. They will also learn about pre-op evaluation and biometry
and post-op care.
The resident will become proficient with phacoemulsification anterior
segment reconstruction, trabeculectomies, and glaucoma tube shunts.
Oculoplastics procedures, Pterygium removal,Laser photocoagulation for
CSME (clinically significant macular edema) and proliferative diabetic
retinopathy
YAG Laser
Posterior capsulotomies
Iridectomies
Assist and perform some steps of penetrating kerotoplasties and DSAEK
procedures.
Minor in-office procedures
Third Year Resident (PGY-4) - VA Hospital Duties and Responsibilities
VA/General Ophthalmology
Months:
Days:
4
Mon AM – VA Clinic
Tues AM – VA Surgery
Wed AM – VA Clinic
Thurs AM – VA Surgery
Fri AM – VA Clinic
PM – VA Clinic
PM – VA Surgery
PM – VA Clinic
PM – VA Surgery
PM – VA Clinic
Duties and Responsibilities:
1)
2)
3)
4)
5)
6)
7)
110
The resident physician will obtain a complete ophthalmological history
and an applicable general medical history.
The resident will do a complete ophthalmological examination.
a)
This to include visual acuity testing (and refraction of optical
defects of the eye including retinoscopy as indicated).
b)
Confrontation fields.
c)
Orbital and external exam.
d)
Ocular motility exam.
e)
Pupillary evaluation.
f)
Anterior segment exam with slit lamp biomicroscopy.
g)
Posterior segment evaluation using direct and indirect
ophthalmology (including biomicroscopy of the fundus as
indicated).
h)
Intraocular pressure testing.
i)
Also, when applicable, learn to do color vision testing, Amsler
Grid and Maddox rod testing, gonioscopy, conjunctival and
corneal scrapings, lacrimal evaluation, A and B scan techniques,
keratometry, and IOL Master and Lenstar.
j)
Learn the appropriate indications for ordering automated or
quantitative perimetry, fluorescein angiography, ocular
photography, light or pattern evoked electrical potential tests
(ERG, VEP), and specular microscopy.
k)
Prescribe glasses or contact lenses as dictated by findings.
The resident physician will complete a differential diagnosis and
treatment regimen. The resident will review with the patient, his or her
diagnosis, prognosis and treatment regimen. The resident will review any
special tests ordered in a timely manner and discuss these results with the
attending staff.
The resident will treat the patient as medically or surgically indicated and
see the patient for appropriate follow-up care.
The resident will complete the medical record to include all the above
information as appropriate.
The resident will become familiar and competent with a surgical
microscope and instruments; perform anterior segment surgery in the wet
lab.
The resident will perform extracapsular cataract extraction or
phacoemulsification with or without intraocular lens, under direct
supervision.
8)
9)
10)
11)
12)
111
The resident will become proficient with phacoemulsification anterior
segment reconstruction, trabeculectomies, and glaucoma tube shunts.
Oculoplastics procedures,Pterygium removal,Laser photocoagulation for
CSME (clinically significant macular edema) and proliferative diabetic
retinopathy
YAG Laser
Posterior capsulotomies
Iridectomies
Assist and perform some steps of penetrating kerotoplasties and DSAEK
procedures.
Minor in-office procedures
Insert (yellow) VA Hospital Policy Memorandum
112
Insert “Program Letter of Agreement
Between Harry S. Truman Memorial Veterans Administration Hospital Eye Clinic
and the Department of Ophthalmology”
113
RESIDENT EVALUATIONS
Resident performance is an agenda item for discussion at the monthly faculty meeting. This gives a
frequent forum to bring up issues of concern, without waiting for the more formal evaluation process
which occurs at the end of each four-month rotation. Issues which surface at the monthly faculty meetings
help the faculty to pay attention to and work with the resident to improve any deficit.
Global Evaluation
A resident evaluation meeting is held every four months (November, March, and June). Prior to
the meeting, each clinical faculty member submits an electronic Global Evaluation evaluating the
competencies of each resident. This is submitted through the hospital resident program software
New-Innovations. The completed evaluations for each individual resident are printed and
distributed to the clinical faculty as a beginning point for discussion at the meeting. Each resident
receives a copy of their compiled evaluation, followed by a meeting with the program director to
review his/her evaluation. The program director and the resident sign the evaluation form and this
document becomes a part of the resident’s permanent evaluation record.
Sub-specialty Evaluation
Sub-specialty rotation evaluations at the end of each rotation period also occur. These evaluations
are conducted by the attending of that sub-specialty rotation, signed by the resident and attending,
and become part of the resident’s permanent evaluation file.
The faculty member will submit an electronic Sub-specialty Evaluation. That evaluation will then
be forwarded to the resident to review and sign. A copy of this evaluation will be signed by the
attending and the resident on service. This sub-specialty evaluation becomes part of the resident’s
permanent evaluation record.
Please see the following examples of the Global Evaluation and the Sub-specialty Evaluation
forms. The evaluation questionnaires are loaded into the hospital resident software program New
Innovations. However, will not appear in this format but the questions and rating will be the
same.
Clinical Skills and Procedures
A list of clinical procedures and skills in which the residents check whether they “have done” or
“can interpret” the items on the list. The skills list is given to the residents in March of every
year, after the first year residents have gone through several months of clinical experience and
education.
360-degree Evaluation
The Accreditation Council for Graduate Medical Education (ACGME) has mandated that
residents are to be evaluated on clinical skills and medical knowledge by teaching faculty and
others. The ACGME has identified that patients, nurses, resident peers, and other MD and nonMD professional associates interact with residents in different contexts and situations that are
unique. These “perspectives add relevance, credibility, and scope to the assessment of residents.”
114
The 360-degree evaluation will be given once a year during February and presented at random to
faculty, patients, technicians, support staff and resident peers.
Ophthalmic Clinical Evaluation Exercise (OCEX)
The OCEX is an observed encounter between a resident and a new patient. The attending is
present in the exam room for the entire interactions. The intent is to rate the resident in interview skills,
examination, interpersonal skills/professionalism, case presentation, and provide immediate feedback.
Ophthalmology Resident Surgical Skills Assessment Form
Residents are to give this form to the physician they are working with on their surgical specialties
rotation. A minimum of 2 evaluations are expected during a 4-month rotation and one evaluation is
expected during a 2-month rotation.
Residents are evaluated on:
Preparation for operative procedure
Operative procedure
Procedure specific skills
Postoperative care
Educational Purpose of Evaluations
They are used for performance improvement opportunities. The resident should have a clear
picture of what performance and knowledge are expected of him/her by review of their
evaluation. As well, review of the evaluation form itself as a guide to expected performance and
knowledge. It should enhance residency education through outcome assessment.
115
CLINICAL SKILLS and PROCEDURES
□ 1st Year Resident
□ 2nd Year Resident
□ 3rd Year Resident
Please check whether you have performed the procedure/technique or you can interpret
the results.
Have done
Can interpret
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
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□
□
□
□
□
□
□
□
□
□
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□
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□
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□
□
Comprehensive eye examination
Gonioscopy, tonometry - all types
Indirect Ophthalmology with scleral depression
Contact lens fitting, lensometry
Automated keratometry - Humphries
Automated refraction - Humphries
Low Vision examination, use of aids
Retinoscopy, manifest and cycloplegic refraction
Humphrey visual fields
Goldmann visual fields
Tangent screen visual fields
Ultrasonic pachymetry
A&B scan ultrasonography
Specular microscopy
Computerized corneal topography - Pentacam
Slit lamp photography
Fundus photography
Fluorescein angiography
Electrophysiological Studies - ERG, EOG, VER
Optical coherence tomography (OCT)
Intraocular lens (IOL) master
YAG laser - capsulotomies, P.I.
Argon Laser - PRP, ALT, PI, etc.
Minor Surgical Procedures and Operating of Equipment e.g.
Cryotherapy Unit
Microscopes All Types
Rust ring remover
Electro-epilation
Print Name:_______________________ Signature: ____________________________ Date : ________
116
360-Degree Evaluation: Thank you for taking the time to complete this important survey. Please circle the
number that best reflects the qualities that Dr. _________________has displayed.
Questions/Statements
Much Improvement
Outstanding
Needed
The physician demonstrates or displays
Average
Not
Applicable
N/A
1.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Caring and Respectful behavior to
a. Patients
b. Family
N/A
N/A
2. Compassion and sensitivity to the needs
of the patient
1
2
3
4
5
N/A
1
1
2
2
3
3
4
4
5
5
N/A
N/A
1
1
2
2
3
3
4
4
5
5
N/A
N/A
1
1
2
2
3
3
4
4
5
5
N/A
N/A
9. Professional appearance (dress,
grooming, interpersonal relationship)
1
2
3
4
5
N/A
10. Good hygiene practice (hand-washing,
cleanliness, wiping instruments)
1
2
3
4
5
N/A
11. Commitment to excellence
1
2
3
4
5
N/A
3. Attentive listening to patient’s concerns
4. Satisfactory medical explanation to
patient’s problems/concerns
5. Excellence in clinical care/knowledge
6. Consideration of patient’s privacy
7. Commitment to ethical principles
8. Good working relationship with other care
provider staff
Additional comments:
______________________________________________________________________________
______________________________________________________________________________
Please indicate your position: Patient_____ Staff_____ Technician_____ Physician____ Other____
Thank you for completing the survey.
117
Insert New-Innovations Global evaluation questionnaire, Subspecialties evaluation
questionnaires, Resident evaluation of rotations (Mason Eye Institute & VA
Hospital Eye Clinic, and Resident evaluation of faculty
118
Insert OCEX form
119
OPHTHALMOLOGY RESIDENT SURGICAL SKILLS ASSESSMENT FORM
Resident Name: ___________________________________ G first-year G second-year G third-year
Attending Physician Name: __________________________
Patient Medical Record Number: _____________________ Name of Procedure: __________________________
The following form is to be completed by an attending physician that has observed you perform one of the following
procedures: cataract surgery, glaucoma surgery, eye muscle recession or resection, eyelid surgery (ptosis, entropion,
ectropion), retina or glaucoma laser.
Legend: 1 = below expectations
2 = meets expectations
3 = exceeds expectations
I.
1 2 3
GGG
GGG
GGG
GGG
GGG
GGG
GGG
Preparation for operative procedure:
II.
1 2 3
GGG
GGG
GGG
Operative procedure:
III.
Procedure-specific skills: Please list at least four different maneuvers performed during the surgery that
the resident either performed well or had some difficulty with i.e. wound construction, lens insertion, eye
muscle isolation, scleral sutures, placement of skin sutures, etc.
Aware of indications for procedure
Knows the order of steps to perform procedure
Familiarity with alternative approaches to procedure
Familiarity with instrumentation and machinery when applicable
Prepares OR appropriately
Adequately performs and understands the implications of informed consent
Aware of indications and contraindications for procedure
Interacts with non-physician staff appropriately
Able to perform all critical steps of the procedure while mindful of personal limits
Understands common complications and how to handle them
1 2 3
G G G _______________________________________________________________________________________
G G G _______________________________________________________________________________________
G G G _______________________________________________________________________________________
G G G _______________________________________________________________________________________
IV.
Postoperative care:
1 2 3
GGG
GGG
GGG
GGG
Familiarity with appropriate coding for procedure
Aware of appropriate times for postoperative care
Aware of important symptoms and signs to be observed in the postoperative period
Has appropriate interaction with patient and family postoperatively
I, ______________________________ (attending physician), have observed the above resident perform the
procedure described above, and we have discussed the procedure at length, as well as specific areas of mastery and
any areas of concern.
___________________________________
Attending physician signature
120
___________________________________
Resident signature
_____________
Date
CLINIC POLICIES AND PROCEDURES
The goals of the clinic are to provide our patients with the best medical eye care possible and to provide
you with a comprehensive educational experience. The structure of the clinic is designed to achieve these
goals. Other factors that influence decisions regarding the structure of the clinic are room availability,
staffing needs, operating room availability and requirements for accreditation.
ATTENDANCE
Attendance is mandatory during your scheduled clinic.
Clinic begins at 9:00 a.m., Monday, Wednesday and Friday, and at 8:00 a.m. on Tuesday and Thursday.
You are responsible for the preliminary work-up of your patients, and for this reason it is important that
you arrive on time.
Surgeries must be scheduled to be performed at times other than your scheduled clinic times.
Plan your vacation/conference time well in advance so that your schedules can be cleared. Confer with
Chief Resident to insure coverage if you are on the Emergency or Consult Rotation.
IF YOU ARE ILL: Contact a live voice, if possible, first thing in the morning.
Sheri Samp Office: 882-4688, Cell: 660-676-9390
E-mail: plasters@health.missouri.edu
Laverne Fisher Office: 882-3179, Home: 474-0562, Cell: 529-0803
E-mail: FisherLK@health.missouri.edu
Melissa Hines Office : 884-4366, Cell: 573-424-3923
E-mail: proctormd@health.missouri.edu
Jen Tisone Office: 884-9140, Cell: 424-7453
E-mail: DavisLG@health.missouri.edu
SCHEDULES
Your schedules are structured to allow for new, return, post-op, contact lens and new to doctor patients.
The basic schedule for first year residents allows for four patients per half day clinic. At times it may be
necessary to schedule additional patients. A copy of your schedule is available for your review before
each clinic session. Reviewing your schedule may help you to pace yourself through the day. Note: The
number of patients on your schedule will increase as you progress through the program.
If you anticipate difficulty with your schedule, please speak with the Laverne Fisher, Supervisor, or
Dr. Fraunfelder, Medical Director/Chairman.
CLINIC SUPPORT STAFF
The clinic clerical staff consists of Laverne Fisher, Supervisor, Outpatient Services and Facilities
Coordinator, Melissa Hines, Service Coordinator and Patient Service Representatives.
The Outpatient Services Supervisor and Service Coordinator are responsible for programming
your master schedule, "bumping" your schedule when you take vacations or attend conferences,
and supervising the work of the Clerical Staff.
121
Patient Service Representatives are responsible for greeting your patients and processing the
paperwork necessary for the clinic visit. They gather patient demographic and insurance
information, and prepare the progress notes and billing forms university guidelines require.
Ronnie Greenwell and Melissa Hines are Patient Service Representatives responsible for
obtaining medical records.
Incoming patient calls are answered here in clinic in the reception clerical area (front desk). All service
representatives rotate through this duty.
All patient visit appointments made at the end of a visit are scheduled through the Patient Service
Representatives.
TECHNICAL STAFF
The technical staff consists of Ophthalmic Technician Certified, Ophthalmic Imagers, Ophthalmic
Technician Non-Certified and Licensed Practical Nurses (LPN).
The technical staff will provide as much support to the Residents as time allows. They will provide initial,
limited work-up of patients when the resident gets backed up (if staffing levels permit). They will also
conduct HVF analyses, prepare the minor surgery room for procedures, clean instruments, review your
completed problems and procedure forms (these are your responsibility), and assists you with any patient
who is difficult to examine. Many of our technical staff are exceptionally skilled at using the equipment
and performing testing, and are readily available to assist in familiarizing and assisting in your training.
Please note patient care assistants are often new and in training, and thus benefit greatly from any
attention and medical instruction you can provide.
The technicians and LPN staff provide technical support to the faculty physicians. They conduct the
preliminary work-up on all patients and will perform any ancillary tests requested by the supervising
physician. They will be assigned to assist residents when staffing levels permit.
Chuck Hamm and Vonda Cross (Ophthalmic Imagers) are responsible for all patient photography
including external, slit lamp, fundus and fluorescein angiography studies. The ophthalmic imager also
provides endothelial cell counts, processes the fluorescein angiography studies and prepares for
presentation material at the weekly photo conference. All patient photo files and records are maintained
by the ophthalmic imager’s office.
All technical staff is responsible for cleaning and stocking examination rooms each morning. If your room
needs to be cleaned or restocked, please see the technical staff.
Please remember, this is a resident training program. The Accreditation Council for Graduate Medical
Education requires you, during your three years of residency, to personally complete an established
number of examinations, refractions, etc. Technical support will be provided to Residents on a limited
basis when staffing levels permit. Should you encounter delays of difficulty seeing your patients in a
timely manner, please feel free to ask Laverne Fisher, Supervisor, if tech support is available.
122
PAPERWORK
It is your responsibility to stay current with dictation, telephone messages, and insurance or disability
forms.
Please empty your mailbox and respond to messages daily. The clerical staff will take telephone
messages and sort your mail and will help retrieve any medical records needing a response. In the
evening, the chart completion crew may search the clinic and remove the medical records you need
resulting in a lost form or message. Avoid the possibility of alienating a referring physician or patient
because of neglect regarding referral letters.
When you see patients "after hours" or on the weekend, please use an After Hour Patient Packet located
on the wall holder of EC125. It can be identified by its bright blue color.
Please record, legibly, the patient's first and last name, date of birth telephone number, and date of
service. The clerical staff will contact the patient the next business day for any additional necessary
information. All after hour or weekend patients are to be discussed with the attending ophthalmologist on
call or the appropriate sub-specialist.
DOCUMENTATION
Document all patient complaints.
Document all examination findings.
Document all services rendered.
Document all patient instructions.
Document all risks and benefits explained.
Document all prescriptions given for glasses or medications.
Document all plans/dispositions.
Document all telephone conversations.
BILLING FORMS
There are five billing forms used in the clinic.
Encounter forms will be attached to each patient's medical record and should be used to record
the professional services rendered.
RETURN PATIENT FORMS
Form 281 is a white form on which the physician can write any follow-up requests with comments for
future testing. Form 281 can also be faxed to referring physicians as a means of communication. It is very
important that any clinic attending changes be noted on Form 281 and sent to the front desk. THE MORE
CLEAR, CONCISE INFORMATION THAT IS WRITTEN ON THIS FORM, THE BETTER ABLE
STAFF ARE TO PROPERLY SCHEDULE FOLLOW-UP APPOINTMENTS AND TESTING.
123
PHONE MESSAGES
Often, Patient Service Representatives will take a call from a patient that they cannot resolve. They will
then generate an email through the Power Chart System. These messages can be found in the physician’s
inbox for review and any other action needed. The patient’s hard chart may need to be ordered if the
information that you need cannot be found in Power Chart. If the Hard chart is needed you would forward
this request to Ronny Greenwell (MEI patients) or Melissa Hines (UEIE patients).
GUEST RELATIONS
Occasionally, a patient may be unhappy with the service we provide in the clinic. If a patient should
express dissatisfaction with our clinic, for any reason, please contact Laverne Fisher, Supervisor, and
Outpatient Services. Often patient dissatisfaction was a result of miscommunication which can be easily
resolved. If you hear a patient complaining to staff, please contact Laverne. If a patient is creating a
disturbance or becomes extremely agitated they may also be escorted to Guest Services across the hall for
resolution of their issues. When in need of assistance by Laverne, please call her at 882-3179.
PATIENT INJURIES/FALLS
Please report all patient injuries or fall to Laverne Fisher for entry and resolution in the Patient Survey
Net System.
DIFFICULTIES
Should you have any difficulties with clinic staff, please privately talk to Laverne Fisher, Clinic
Supervisor, who will mediate and review the problem. Occasionally your patients will not be scheduled
according to guidelines, should you have any problems please bring this to the attention of Laverne
Fisher.
TRIAGE
All patients who walk in to the clinic must be triaged. Most times the technicians or PSR’s can make a
decision to register an emergent walk-in patient when symptoms are obvious. Occasionally, a patient will
arrive and wish to be seen for a non-emergent complaint (cataract, presbyopia, etc) and will need to be
first triaged at the desk by a resident. We will always try to accommodate patient’s wishes, however, due
to clinic congestion, non-emergent patients may at times need to be scheduled to a routine appointment if
the screening residents feel this is appropriate. Each emergent patient who walks in our clinic is given a
sheet describing our policy and informing them of a possible long wait. The resident on the Emergency
Rotation is strongly encouraged to meet with the front office staff at the start of their rotation. This has
been a successful way of ensuring everyone’s expectations are met throughout the rotation.
124
INMATES
We often care for patients who are incarcerated and brought to our facility under guard. Clinic policy is
they be transported in a wheelchair and legs covered with a blanket. They are not allowed to walk from
room to room due to their leg shackles. When inmates arrive, the clinic policy is they not be left in a
common waiting area. Ideally inmates are immediately moved by staff to room 118 if available.
For security purposes, please, never indicate to an inmate patient the time frame of their follow-up
appointments or surgeries. These are scheduled from the facility by them calling us secondary to your
progress note given to the guard at the end of the visit.
Inmates who are being seen at UEIE need to notify front desk by phone that they have arrived. The
inmate is then let in through the side door only. Inmates are not to come through front lobby.
EMERGENCY PATIENTS
Residents seeing patients in the clinic after hours and on weekends should be especially attentive to the
whereabouts of the patients and their families as there may be protected patient information in the
reception clerical area (front desk) and in the department offices. There is also expensive equipment on
the clinic counters and in the examination rooms.
SURGICAL BOARDING PROCEDURES
All surgical boarding and pre-certification is done by Chantell Monzingo. If the surgery boarding person
is very busy or unavailable, their business card can be given to the patient. Chantell will call patients
within 2 business days or scheduling. Surgical boarding includes these following locations:
Missouri Center for Outpatient Surgery
Surgery – Women’s and Children’s Hospital (WCH)
Main OR
 Special Clinic Procedures should be scheduled through the attending's secretary to insure there
is no conflict with the attending’s schedule.
Each of the above surgery locations have different procedures which must be completed before surgery
can take place. If you are uncertain about any procedures, please see Chantell.
A.
Missouri Center for Outpatient Surgery/Main OR Procedures
1. Complete Surgery Boarding Form/packet (which is in PowerChart). This must be done with
all information provided.
2. Include your request for any special equipment needed.
3. Intraocular Lenses that MCOS does not stock must be special ordered. Please indicate the
type, model number and dioptric power. A Lens Chart is located on the A-scan to assist you
with your lens selection.
4. History, Physical, and Consent forms must be completed before surgery. Our History,
Physical and Consent forms are good for 7 days.
5. For WCH the patient/guardian fills out a health questionnaire which is then faxed to
pre-op clinic. The nurses then determine the patients’ needs. If we know that they
will need a chest x-ray or cardiac clearance the attending physician has to order
these.
125
6. HMO-POS patient must have a referral from their primary care physician with states surgery
as an option for treatment. Complete the correspondence required by the primary care
physician. Cataract surgery patients must complete a cataract surgery Medicare only
questionnaire prior to surgery. These are in the surgery boarding packets.
7. Give the completed surgery packet to Chantell Monzingo to schedule the surgery. They will
make all other arrangements for the case. If a special time or special instructions are needed,
please note this on the Surgical Boarding Form.
NOTE: Prisoners surgeries are performed at MCOS and must be scheduled with that
facility’s nurse. For security reasons, never indicate to an inmate the dates they may be
returning for surgery.
B.
Minor Surgery Room
1. Ensure attending coverage is available if booking procedure for a special time. This can be
done by checking with the attending’s secretary.
a. If pre-certification is needed, or you are not sure, contact Melissa Hines.
SURGERY LOG
The Resident Review Committee for Ophthalmology of the Accreditation Council for Graduate Medical
Education requires documentation of the surgical experience of each resident. The surgical log covers the
36 month period of your residency and includes surgical experience at UMC and VA.
The log, therefore, is in two sections (UMC and VA), and separated by year within each section.
UMC
A monthly computer-generated print out will be supplied. This includes all UMC activity
– surgical and clinic. It contains all information required by the Accreditation Council
except surgery class. Therefore, each month you will be given your log to add the
appropriate class following the surgery description (1,2,3, or 4). Procedures will be
highlighted prior to insertion to aid in location.
VA
The VA will print out a report for surgeries performed in the OR. It is the responsibility
of the resident to keep a list of all procedures performed in the clinic minor room and
lasers.
DEFINITION OF CLASSES
CLASS 1:
This is for procedures that are done primarily by the resident (over 50%) with direct supervision
by faculty present in the operating or minor surgery room.
CLASS 2:
This is for procedures that are done by the resident without faculty present.
CLASS 3:
This is for procedures that are done primarily by the faculty (over 50%) with the resident as first
surgical assistant.
Only classes 1 and 3 are counted by the ACGME relative to fulfilling your surgical experience
requirements. Few Class 2 should occur.
126
LASERS
When any laser is performed on a patient, the information must be filled out in the respective laser book.
ULTRASOUND A & B-SCAN
When an ultrasound is performed, fill out the Facility Fee Sheet (yellow). Place the thermal tape or
printed calculations in the chart. This provides proof of service performed. Be sure to type the patient’s
name into the machine, as well as specifying the correct eye so it will print. Also, please initial each scan
to signify authenticity.
IOL MASTER
When an IOL Master is performed, fill out the Facility Fee Sheet (yellow). Be sure to type the patient’s
name into the machine, as well as specifying the correct eye so it will print. Place copy in the patient’s
chart.
EQUIPMENT
Should any clinic equipment fail or is missing, please contact Chuck Hamm , or Laverne Fisher
immediately.
1. Removal of Equipment from Clinic
We recognize that often equipment must be taken to an in-patient floor or to another facility for
patient consultation or care. However, all residents should be especially mindful of returning all clinic
equipment, including but not limited to Tonopens and indirect or portable slitlamps to the clinic
immediately after use.
127
BILLING INFORMATION
This section is provided to give you an overview of the billing procedures and forms that we use in our
daily activities.
CHARTS AND PROGRESS NOTES. Patient records, whether in charts or loose notes should
NEVER be removed from the premises. Records must stay at the location where they were created.
Please do not hold billing/notes. If you need a chart back to dictate or for some other reason, please put a
note on the chart and it will be returned after billing is complete.
Coders read and audit each note. If items are missing or incomplete, you will be paged to come to the
billing room. If you haven’t come down after 3 pages, then the attending on the service you are rotating
with will be notified and asked to send you down.
DIAGNOSIS CODING
Proper coding of patient services is extremely important. With the recent legislation regarding medical
services, it has become increasingly important for us to code all diagnoses to the highest degree of
certainty. What this means to you is that if becomes necessary for you to be very specific when you list a
patient's condition. DO NOT USE diagnoses such as "probable", "suspect", "questionable", or "rule out".
Use instead the principle reason for the encounter, such as symptoms, signs, patient or family history,
abnormal test results or other reason for visit, such as headache, blurred vision, family history of
glaucoma, etc. The only exception to this rule is "glaucoma suspect". It is acceptable to use this as a
diagnosis.
Another diagnosis to be avoided is "Refractive Disorder". Please list the patient's eye problem, such as
myopia, presbyopia, astigmatism, etc. These codes should never be listed as the primary diagnosis unless
there is no other diagnosis listed. Insurance companies do not pay for any type of refractive disorder
under medical plans. Some plans are now providing one vision exam per year. Those should be so noted
on the progress note so we can bill them appropriately.
You will see many diagnoses in which a blanket term may seem appropriate without being more specific.
Please remember to always be as specific as possible. One example of such a case is: melanoma of the
eye. There are actually nine different types of melanoma of the eye. List which area is affected in those
types of cases.
As we approach the October 2014 deadline for implementation of ICD-10, specificity in documentation
will become even more important.
ENCOUNTER FORM
The encounter form is used for billing outpatient visits to the clinic.. A sample Encounter Form will be
provided to you during orientation. Proper procedure for choosing visit levels will be discussed at the
orientation. Please do not quote patients charges. Never promise a reduced fee or free services to a
patient. If patients are in financial difficulty, please refer them to Financial Counseling. Their offices
are over at the Admissions area and their phone number is 573-884-9900.
When you mark the diagnoses on the encounter form, please number them in the order of importance for
this visit. Do not list diagnoses which are long resolved or are being managed by another physician (i.e.
retina vs. glaucoma vs. cornea). Should you perform any procedures or diagnostic test during the visit,
please be sure to mark the appropriate box or write the procedure in the spaces provided. All tests
require and order and interpretation to be billable.
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CONTACT LENSES
When you see a patient who is interested in contact lenses, provide them with a Contact Lens brochure to
read. Explain that any questions they have regarding Contact Lens prices will be answered by Norman
when they meet with him (after you have fit the lenses). Be sure to explain to the patient that they will be
charged an initial contact lens fitting fee and a minimum of one follow-up visit. Remember, children less
than 18 years-of-age must have parents accompany them for contact lenses.
SURGERY FUNDING
Should a patient who has no insurance coverage require surgery, they must be screened for eligibility for
funding prior to scheduling the surgery. Discounts are available from Hospital and UP for self pay
patients. Funding for medically indigent patients usually takes ten day to two weeks. Do not schedule
surgery until funding is secured.
INSURANCE REQUIREMENTS
The University deals with many different types of insurance, each of which has its own guidelines and
requirements. The following are some of the more common requirements for the different insurances:
MEDICAID
Prior authorizations are required for the following procedures:
Ocular surface reconstruction (CPT 65780 – 65782)
Repair of blepharoptosis (CPT 67901-67908)
Entropion repair by blepharoplasty (CPT 67916 & 67917)
Ectropion repair by blepharoplasty (CPT 67923 & 67923)
Blepharoplasty of upper or lower eyelid (CPT 15820 -15823)
Any other procedure that may be considered cosmetic.
The surgical boarder will initiate a prior authorization form and must be completed and
submitted along with a copy of the visual fields to Medicaid. They will review and return
an authorization form. Only then may we proceed with the surgery.
MANAGED MEDICAID PLANS
Missouri Care, Healthcare USA and Home State Health are all managed medicaid plans. Each of
these plans has their own rules and list for pre-certifications and prior authorizations. For
example, Missouri Care requires prior authorization on all muscle surgeries.
MEDICARE
Cataract Surgery - Cataract surgery may be performed without Medicare review as long
as the following are documented:
1.
Patient's desire to have the procedure due to decreased visual acuity is
documented.
2.
Ophthalmic examinations (slit lamp, dilated ophthalmoscopy, intraocular
pressure) is performed by the operating surgeon within two months of
the surgical procedure documenting a cataract and one of the following:
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a.
Etiology of visual loss felt to be the cataract, and best corrected
Snellen distance vision of 20/50 or less. Glass testing visual
acuity of 20/50 or less is also acceptable.
b.
Phacogenic glaucoma
c.
Phacoanaphylactic endophthalmitis
d.
Cataract and foreign body
e.
Cataract and ocular trauma
f.
Cataract extraction and corneal transplant
g.
Dislocated or subluxated lens causing glaucoma, monocular
diplopia, aphakia, severe hyperopia (over +8 diopters), or
astigmatism.
3.
Documentation as to specific improvement in quality of life to be
expected after cataract surgery.
4.
Complete cataract surgery questionnaire. Forms are included in the
surgery packets.
Glasses - Medicare will partially pay for the patient's first frame and each lens following
cataract surgery only. The Optical shop will submit a claim to Medicare. The patient will
be responsible for their copay, deductible and any extra options which are non-covered.
Medicare does not pay for glasses for any other reason.
Secondary Cataract (PCO) - Discission of secondary membranous cataract ("after
cataract") and/or anterior hyaloid laser surgery (one or more stages).
Indications for surgical procedure
1.
Decreased vision to 20/40 or less secondary to:
a.
b.
2.
Cataract with pearls and/or fibrosis of posterior capsule.
Membranous cataract.
A time period of at least ninety days should have elapsed between the
time of the initial cataract extraction and the performance of the
discission of the secondary membranous cataract.
Blepharoplasty/blepharoptosis - Blepharoplasty is a surgical procedure to remove excess upper
or lower eyelid skin and fat. Reimbursement can be allowed if the procedure is considered
reconstructive to improve impaired vision. This is usually manifested in the upper or peripheral
field of vision or on forward gaze by skin resting on the upper eye lashes. Lower lid
blepharoplasty is generally not reimbursable since it is usually performed for cosmetic reasons.
Payment can be allowed, however if medical necessity for reconstructive reasons is demonstrated.
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Blepharoptosis is a surgical procedure to repair levator muscle abnormality. Reimbursement can
be allowed when it is evident that lid ptosis interferes with vision.
Pre and post-operative photographs and/or visual field are required to support medical necessity
and must be available upon request by insurance.
Symptoms of lid heaviness, excessive tearing and visual impairment sufficient to impede daily
living activities should be documented, if possible.
Substantial visual loss exists when there is loss of the superior field to 20 degrees or less from the
horizontal visual axis.
Photography - Medicare has a list of diagnoses for which photos are allowed. If you request
photos be taken and the diagnosis is not on the approved list, the patient will be required to sign a
waiver indicating they will be responsible for the cost of the photos.
Cigna – requires prior authorization on Botox injections.
Missouri Care - A prior authorization must be obtained for all procedures performed in the
clinic. This includes lasers as well as procedures performed in the minor surgery room. They
require prior authorization on muscle surgery.
Mercy Health Plan - Mercy requires prior authorization on Botox injections and all lasers
performed in the clinic.
Healthcare USA – Precertification must be received prior to surgery.
Mercy Care Partners – We are NOT contracted providers.
Rehabilitation Services for the Blind (RSB) - Rehabilitation Services authorizes all services
provided prior to their being performed. If you have a patient in for an exam and feel additional
diagnostic testing or a procedure is needed, you must call and obtain authorization prior to
performing it.
The phone number to call for authorization is: 573-751-2714
Prevention of Blindness Program (POB) - POB is a state agency which provides financial
assistance to patients who meet financial and visual eligibility criteria. Once a patient has been
approved, office visits and diagnostic tests are automatically covered. Procedures must be prior
authorized.
The phone number is: 573-751-3428
Humana Gold (HMO) Medicare & Coventry HMO Medicare- While these insurances do not
require referrals to be seen in clinic, they do require a referral from the PCP to perform a
procedure.
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NOTE: IT IS THE RESPONSIBILITY OF THE ADMITTING PHYSICIAN AND
THE HOSPITAL TO OBTAIN PRECERTIFICATION APPROVAL. IF
PRECERTIFICATION IS NOT OBTAINED AND THE PATIENT ENTERS THE
HOSPITAL, NO BENEFITS WILL BE PAID FOR HOSPITAL OR PHYSICIAN
EXPENSES AND THE PATIENT CANNOT BE HELD FINANCIALLY
RESPONSIBLE.
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GENERAL PROGRAM INFORMATION
General organization of the patient care services at the Mason Eye Institute
The three-year residency program has a total of nine positions, with three residents in each
postgraduate year. Residents in each year have clinic and surgical assignments.
All rotations are two or four-month blocks. The Resident Rotation Schedule is by ½ day
assignments Monday - Friday. Although the resident is assigned to a particular subspecialty
rotation (i.e., pediatric ophthalmology), residents continue to have other primary patient care
responsibilities as well. Most rotations include ½ day assignments among the sub-specialty
clinic(s), general clinics (also referred to as resident clinics), and surgery. The inclusion of
general clinics allows residents the opportunity to provide continuity of patient care throughout
the three years. In some cases a patient sees the same resident (under the supervision of the
attending physician) for the three-year residency duration. This establishment of a prolonged
patient-physician relationship and observance of long-term disease course are considered valuable
components of the training experience.
Call
All residents participate in evening and weekend on-call assignments. The call
assignment schedule is developed among the residents. Normally, a second-year resident
assigns call for first and second year residents; a senior resident assigns call for third-year
residents. Each day the schedule includes three physicians on call (designated as firstcall, second-call, and third-call which is attending call). First call is handled by PGY-II
and PGY-III residents. Therefore, first call is shared among 6 residents (the three first
year residents and three second year residents). This means that during years one and
two, each resident is assigned to first-call 1/6th of the time. PGY-IV residents take backup (or second) call. Therefore, senior residents are on call 1/3rd of the time. Attending
call is normally assigned one week at a time (Monday-Sunday). The first-call resident
handles the case as appropriate for his/her level of training; the senior resident is called to
assist as necessary. The senior resident calls in the attending physician as necessary (or
directs the resident on first-call to do so). In those situations where the attending’s
services are not required, residents are required to discuss all such evening and weekend
cases with either the attending on call or attending most appropriate for that particular
case on the next work day.
The University of Missouri-Columbia, Department of Ophthalmology does not recognize
a separation of private and non-private patient populations. All patients, whenever
possible, are evaluated by residents unless the patient specifically requests no resident
involvement.
Curriculum (didactic instruction in the basic and clinical sciences)
The didactic sessions for the residents consist of Monday and Wednesday
Conferences (days/times may vary and are subject to change) -- held between
7:30 and 9:00 am which are conducted by the clinical faculty. These are usually
formal presentations. Topics as outlined by the American Academy of
Ophthalmology Basic Science Course are used as a guide. Recent publications in
peer reviewed journals are an important resource to help provide the most up-todate information.
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Grand Rounds are held the first Friday at UMC and the third Friday at VA of
each month from 7:30 to 9:00 am. Attending physicians, fellows, residents, and
medical students, will examine selected patients whose clinical presentation pose
interesting, heuristic, medical or surgical problems. This is followed by extended
discussion.
Photo Conference/M&M Conference is held on the fourth Friday of the month
from 7:30 to 9:00 am. This conference includes the presentation and discussion
of selected University of Missouri Eye Clinic and/or VA Eye Clinic patients
(through 35mm slide/digital presentations). This conference covers a
comprehensive array of ophthalmological disorders. Specific cases are discussed
regarding findings and management.
Fluorescein Conference is held on Thursdays from 7:00 to 8:00am at the VA eye
clinic and is conducted by Dr. Hainsworth.
Pathology Webinar Course: Webinar interactive sessions conducted on the
second Friday of the month with Dr. Deepak Edward offers 36 hours in
microscopic examination of pathological specimens.
Deepak P. Edward, MD, FACS, is Professor of Ophthalmology and Director of
Research at John Hopkins/Baltimore at King Khaled Eye Specialist Hospital in
Riyadh, Saudi Arabia.
Dr. Edward’s credentials:
• Fellowship in Glaucoma, Washington University, St. Louis 1995-1996
• Residency in Ophthalmology, University of Illinois College of Medicine
1992-1995
• Internship in Pediatrics, University of Illinois Hospital, Chicago 1992
• Fellow in Ophthalmic Pathology, University of Illinois College of
Medicine 1987-1989
• Master of Surgery (Ophthalmology) Post Graduate Institute of Medical
Education and Research, Chandigarh, India 1984
• Bachelor of Medicine; Bachelor of Surgery, St. John’s Medical College,
Bangalore, India 1980
Ocular Pathology Grossing and Specimen Review: Douglas Miller, MD, PhD,
Professor of Pathology will conduct Ocular Pathology Grossing and Specimen
Review Conferences 4 times annually.
Journal Club meets monthly (ten per year) on Tuesday evenings from 5:15 to
8:30 pm. Residents are assigned articles for review and an active or courtesy
faculty member moderates discussion of these articles.
Invited Visiting Professor Conferences are held approximately two – three times
per year on Saturdays -- usually 8:00 am to 12:00 Noon. These CME conferences
usually include two hours of didactic lecture and one hour of case presentation
and discussion by a visiting professor. Community ophthalmologists,
optometrists, faculty, residents, fellows and medical students are present.
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OKAP Study Lectures conducted by Dr. Geetha Davis, Clinical Instructor will be
three – four sessions prior to the OKAP exam in April. The study lecture content
is taken from the American Academy of Ophthalmology Basic & Clinic Science
Course books.
Resident and Alumni Day is held the weekend third weekend in May which is the
weekend before the Memorial Day weekend. The usual schedule includes Friday
afternoon and Saturday morning scientific conference. Each resident is required
to present at this conference on a fifteen minute topic of their choice, generally
pertaining to their research project for the year. Faculty and guest alumni speaker
presentations are also given during these scientific sessions. The Resident and
Alumni Day weekend ends with a banquet Saturday evening. Residents are
required to attend all scientific sessions and the graduation/awards banquet.
Research
At the end of each year, our residents are required to present a research project
during the Annual Resident & Alumni Day (“RADay”) Conference. The
residents are encouraged to begin working with a faculty member on the research
project by October/November of each year. The residents undertake a literature
review using information technology provided by the Ophthalmology department
and the University of Missouri’s Health Science Library (e.g., PubMed, Ovid,
ONE Network). They conduct their research projects, analyze the data with
members of the Biostatistics Department, and again review the scientific studies
to support and improve their research findings and conclusions. The residents are
encouraged to present their research findings at national meetings (e.g.,
Association of Research and Vision in Ophthalmology [ARVO], American
Academy of Ophthalmology [AAO], etc.) and also to publish their research
findings.
As an incentive, the residents are provided up to 1 week of additional meeting
time when presenting at a national meeting. Residents are reimbursed for travel
expenses related to their presentations. However, residents are required to write a
1st draft of the manuscript and provide the faculty mentor a copy before an
abstract is submitted for national presentation. The residents are informed that if
the 1st draft of the manuscript is not completed before departing to the meeting,
then travel expenses for this meeting will not be reimbursed, and vacation and/or
meeting time may be deducted.
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Conference Attendance Documentation
An Attendance Roster is prepared for each conference. The typed roster has the name of
each resident and attending with a section for their signature. The roster sheets are kept in
a hanging file folder just to the side of the conference room TV monitor. The Chief
Resident is responsible for ensuring these sheets are signed and given to the residency
program coordinator (Sheri Samp).
Resident Participation in Medical Student Teaching
The residents participate in second year medical student education of ophthalmic physical
diagnosis of the eye. We have third and fourth year medical students, both from the
University of Missouri-Columbia and from other universities who choose to come to the
University of Missouri-Columbia for their ophthalmology electives. The students are
assigned to a resident and/or faculty member to observe in clinic and surgery.
Annual Contract
Each resident signs an annual contract for the July-June period. The contract specifically
addresses the following:
Medical licensure
Responsibilities
Performance appraisals and reappointment criteria
Non-regular academic appointment
Passing Step 3 of USMLE prior to starting final year of residency
Comply by the Rules and Regulations of the University of Missouri, Medical Staff
Bylaws and the Rules and Regulations of the Hospital and Clinics.
Immunization documentation
Drug screening
Bylaws and Rules and Regulations of the House Staff Organization, including the
procedures for discipline and redress of grievances
Complying with departmental policies.
Missouri Patient Care Review Foundations (Missouri’s PRO)
Department policy regarding moonlighting
Annual stipend and associated benefit programs
University’s Medical, Professional and Patient General Liability Plan
Annual vacation and meeting time
Americans with Disabilities Act (ADA)
Appointment jurisdiction
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Absences
1. Submit requests to Sheri Samp (Linda Davis in Sheri’s absence) at least 30 days prior to
your requested absence, however 60 days or more is preferred if clinic(s) will need to be
closed (blue half sheet). The request will be returned to the resident noting approval or
disapproval status. Days away from the office should be planned as far ahead as possible. It is
never “too soon” to submit a request for time away.
All requests for a change in your 8:00 a.m.-5:00 p.m. schedule must go through
Sheri Samp or Linda Davis. Clinic staff, per direction by the Residency Program
Director, does not have the authority to approve changes.
2. A “Cancellation Request” must be submitted no less than 30 days prior to the cancelled
date(s). This will be returned to the resident noting approval or disapproval status.
3. It is preferable no more than 3 residents be allowed leave at any one time.
2 Residents at Mason Eye Institute
1 Resident at VA Hospital
We may make exceptions during Holidays and other periods on a case by case basis. The
assigned Emergency Clinic Resident and Consult Resident are not allowed to be absent
at the same time.
Residents are allowed to take time away during the VA rotation, but because of the
greater amount of surgery available at the VA, this probably will be considered
undesirable for most residents. VA residents must coordinate their time away with their
VA colleague.
4. No leave one (1) week prior to the annual OKAP Exam.
The annual OKAP Exam is taken on a Saturday (usually around the 3rd weekend in
April). An attending or fellow will cover call during the exam, but residents resume call
immediately following the exam.
5. All residents are to use vacation time between the last two weeks of July and the first
two weeks of June each year.
No vacations will be approved for the last two weeks of June or the first 2 weeks of
July unless absolutely necessary, and approved by the program director.
Vacation
1. Residents are entitled to three (3) weeks of vacation during each year of the program (15
weekdays). Vacation days are not interchangeable with meeting days.
2. No more than 2 weeks absence during a 4-month rotation and 1 week absence during a 2month rotation.
3. In the best interest of resident education taking two 5-day blocks and 5 days at optional times
is encouraged.
Each of the 2 vacation periods normally begin on Friday at 5:00 p.m. and ends at 8:00
a.m. on the 2nd Monday. The timing of the other five business days (M-F) is flexible. Time
does not accrue and therefore must be used each year.
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Meetings
1. There is one week of education/meeting time (5 weekdays).
2. Some residents elect to spend their meeting time attending a basic science course in their
second year.
3. Residents who are first-authors and are invited presenters at a meeting are awarded additional
meeting time – the meeting day(s) and, if applicable, travel days to/from the meeting. (See
presentation grant for first authors page).
Sick Leave
1. House officers accrue sick leave at the rate of eight (8) hours (one working day) per month
which may be used for personal sick leave and/or family leave. This may be in conjunction
with the Family and Medical Leave Act (FMLA). Time does not accrue from one contract
year to the next. Additional sick leave may be granted at the discretion of the Program
Director and Department Chairman, however an extension of your residency may be required
to meet educational objectives.
2. Sick leave should be reported promptly to the Resident Program Coordinator (Sheri Samp)
and Clinic Supervisor (Laverne Fisher). Some sick leave may be anticipated (such as
scheduled surgery). In such cases, at least 31 days advance notice is preferred. The resident
will submit the “Residency/Fellow Report of Sick Leave Absence” [pink] form prior to the
absence in this case. In the case of an unanticipated absence, the resident will submit this
form on the first day following the leave.
Maternity Leave
Maternity leave is provided to residents to the extent that such a leave is reasonably necessary.
Available time includes accrued sick leave and vacation leave. Although this should provide
sufficient leave in most cases, the provision exists for special situations where further time shall
be provided without pay and the resident will be permitted to return to the program for the
completion of training. This may require that the resident extend training by the amount of nonsalaried time off to satisfy the requirements of the American Board of Ophthalmology for Board
Eligibility (36 months of formal residency training, which includes reasonable absences for
vacation leave, etc.)
Paternity Leave
Paternity leave is provided to residents to the extent of available accrued sick leave and vacation
time; additional time shall be permitted without pay in accordance with the terms of Maternity
Leave policy described above.
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Holidays
1. There are eight University holidays and these are the only days observed as holidays for
the purposes of this residency program:
New Year’s Day
Martin Luther King Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day
2. There will be no scheduled clinic on these days, but residents will take call as usual.
3. When a holiday falls on Saturday, the preceding Friday is observed as the holiday. When a
holiday falls on Sunday, the following Monday is observed as a holiday.
4. The VA observes three holidays the University does not: Presidents’ Day, Columbus Day and
Veterans Day. Residents on the VA rotation for these days are reassigned to UMC.
Residents are required to be available to help out if necessary and they must notify the clinic
director and/or clinic supervisor of their whereabouts and always be available by pager.
Residents must also attend all scheduled conferences, etc. If a resident prefers to take a
vacation day for any of the above three holidays, this is certainly acceptable with submission
of the appropriate form and approval.
5. The Friday following Thanksgiving is not a VA holiday; however, we annually request
cancellation of the VA clinic on this date so all residents may observe the University Holiday.
Absence Due to Death in the Immediate Family
If a death occurs in your immediate family, you will be granted a maximum leave of three
working days. Such leave may be taken at any time during the period beginning on the date of
death and ending on the second calendar day after the funeral. No salary deduction or accrued
vacation time will be taken for these days of leave. If schedule allows, additional days may be
approved and will be charged to vacation or taken as excused leave without pay. “Immediate
Family” as defined by the University guidelines is husband, wife, parent (including step-parent)
grandparent, great-grandparent, grandchild, son, daughter, brother or sister, mother-in-law, fatherin-law and foster children who have become members of the family.
Cancellation of Sub-Specialty Clinics
When faculty clinics are canceled due to the absence of the faculty member, the resident is
reassigned to their research project or OKAP studies, assist with emergency clinic, or cover
emergency clinic in the absence of the emergency clinic resident, or help in another attending’s
clinic. In all instances the resident is required to be available to help out as necessary, and must
notify Sheri Samp, Coordinator, Resident Program, and the Chief Resident of their whereabouts
and always be available by pager. In their absence, notify Laverne Fisher, Clinic Supervisor.
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Unscheduled Time
Occasionally, clinics will be canceled and/or a surgery will be canceled and residents will have
unscheduled time. Residents are required to be available to help out if necessary and they must
notify Sheri Samp, Coordinator, Resident Program, and the Chief Resident of their whereabouts
and always be available by pager. In their absence, notify Laverne Fisher, Clinic Supervisor.
For example: Residents should not leave for lunch until they have checked
with the Emergency Service to help see the emergency patients as needed.
Likewise, no resident should leave for the day until they have checked with the
Emergency Service to help see the emergency patients as needed.
This team work will provide better patient flow and management of our patients. Our motto
is, “Perfect Patient Care.”
Unanticipated Absences (sickness, death in family, etc.)
Confusion often exists regarding what to do in emergency situations when the need for an
unexpected leave occurs.
Please do both of the following. Where you call may depend on whether it is a weekday or
weekend. During the weekends, please call us at home.
1.
Call: Sheri Samp
Work: 882-4688
Cell: 660-676-9390
2.
Call: Laverne Fisher
Home: 474-0562
Work: 882-3179
Pager: 441-4311
If you get a voice mail at work, exercise the option that transfers you to the attendant. It is
important that you reach someone and not just voice mail.
If you get voice mail at our home(s), leave a message, but still attempt to call until you speak
directly with at least one of us. If you cannot reach Sheri or Laverne, please try Linda
Davis at home (268-6718) or work (882-1020).
The sooner you let us know an emergency has occurred, the sooner we can begin doing what
is necessary regarding clinic cancellations, etc. Residents should also contact the attending of
their rotation.
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MOONLIGHTING POLICY
The Department of Ophthalmology, University of Missouri-Columbia, moonlighting policy is defined as
specified in the ACGME Ophthalmology Program Requirements: Section VI-D (copied below), and in
compliance with the sponsoring institution’s written policies and procedures regarding moonlighting (see
Institutional Policies).
1. Because residency education is a full-time endeavor, the program director must ensure that
moonlighting does not interfere with the ability of the resident to achieve the goals and objectives
of the educational program.
2. The program director must comply with the sponsoring institution’s written policies and
procedures regarding moonlighting, in compliance with the ACGME Institutional Requirements.
3. Any hours a resident works for compensation at the sponsoring institution or any of the sponsor’s
primary clinical sites must be considered part of the 80-hour weekly limit on duty hours. This
refers to the practice of internal moonlighting.
141
RESIDENT CALL & CALL SCHEDULE POLICY
Resident Call Responsibilities
1. Residents should keep a telephone log of all calls while on evening or weekend call.
2. The resident on first call (first or second year resident) will contact the resident on
second call (senior resident) to discuss all cases for disposition. If further input or
consultation is necessary, the third year resident will contact the attending on call
for disposition.
3. All recent post-operative cases will be discussed with the attending physician on call.
4. All cases requiring admission to the hospital or surgery will be discussed with the attending
physician on call prior to admission.
5. All patients who were seen or who called during the night will be discussed with the attending on
call or the appropriate faculty member the next morning.
6. Responsibility for the patient’s care rests with the attending faculty on call or the attending
notified of the patient’s condition.
7. Exceptions to this policy must be specifically made by the attending physician on call or the
department chairman.
Call Schedule
1. All residents remain on the call schedule July 1- June 30 of each year, unless the resident has
received approved leave.
2. Generally speaking, First or Second year residents takes first call. Senior Resident takes second
call. Both residents on call (first and second call) must remain available by beeper. Call is athome call; residents are not required to remain within the hospital but must remain immediately
accessible by beeper.
3. The call schedule is worked out among the residents themselves.
4. First and second year residents’ and the third year residents’ work out call among themselves.
The schedule must be submitted to (Edna Green) by the 20th of each month. If not received by the
20th of the month, Edna will remind the responsible physician and the Chief Resident. If not
received by then, Edna will complete the first and second year call schedule for the month and no
changes will be accepted after the call being published.
5. The call schedule is required by various departments within the University and VA Hospitals.
Delays and changes waste time, are costly, and cause frustrations for many individuals. Concerns
regarding frequent delinquencies in residents submitting the call schedule on a timely basis will
be brought to the attention of the Program Director.
142
6. Edna Green will type and distribute the call schedule once each month. Subsequent changes will
be handled by Edna. Please anticipate changes before the new schedule has been distributed. If
there are changes to the schedule do not call the hospital operator, give them to Edna Green.
UMC
(Call list sent via e-mail)
Telecommunications- Hospital UMCHC
Dan Crouch, Assistant Manager
Zammone Lasker, Office Supervisor
UMC Emergency Room
Staci Walters, Assistant Manager
UMC Registration
Brenna Begemann
UMC Nurses
Mary Christine Engel
Kathy A. Greenslate
UMC Surgery Services
Jeanne M. Campoli
Jean R. Locke
Amy Tinsley
Dorothy M. Williams
UMC Revenue
Sandra L. Reynolds
VA Hospital
Jayna Hofstetter – SC/SURG
(Jayna.Hofstetter@va.gov)
Mary Ann Chandler
(MaryAnn.Chandler2@va.gov )
Deana Griffin – VA Switchboard
(deana.griffin@va.gov)
Sarah Olson
(sarah.olson2@va.gov )
Darlayna Scott
(darlayna.scott@va.gov)
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EDUCATIONAL ALLOWANCES & BENEFITS
Days Away
Meeting Days Away - One week
Presentation Bonus Day(s): (See “Presentation Grant for First Authors” below.)
Cash Professional Allowance – FY 15/16 (reviewed annually)
A professional allowance is provided for the current fiscal year (7/1/15 – 6/30/16). The purpose of this
allowance is to assist with continuing education costs, such as meetings/travel, books, journals, indirect
lenses, etc. The department purchases indirect lenses for use in the clinic and in surgery.
The department must place all orders on your behalf in keeping with university guidelines.
NOTE: Residents must purchase their own indirect lenses for use in the clinic and in surgery.
Upon arrival, see the clinic medical director (Dr. Reyes) for input on ordering (approximate cost
$300 - $500). You must obtain these by November 1 of your first year.
Research
Please see attached Research form. This is the first step in requesting research time and funds.
The Department of Ophthalmology pays all expenses associated with research projects–poster
preparations, slides, literature searches, animals, etc., up to $1,000.00 per resident/per year. Costs must be
pre-approved in conjunction with the attending that mentors the project.

Guidelines to be met before a resident presents at a national meeting:

Research Projects: Residents will have to present their research projects at Resident and Alumni Day.
It generally takes at least 5 months to produce a good project. Therefore, the residents are encouraged
to begin working on their projects by November-December of the academic year.

Presentation of Research Projects at National Meetings: Residents are encouraged to present their
projects at national meetings (e.g., ARVO, AAO, etc.).
Residents are encouraged, to see the coordinator of Ophthalmology Resident Research, Dr. Rajiv R.
Mohan, PhD. for guidance on a project accessing research institutional resources (animal labs, IRB
approval, etc.). All clinical and basic science faculty are willing to serve as mentors with residents on
their research endeavors.
Presentation Grants for First Authors
A presentation travel/meeting grant of up to $1,000 (actual expenses up to allowance) is available for first
authors attending a meeting (approved by the Residency Program Director) at which they have been
invited to present a paper or poster. Additional meeting time is also awarded – the meeting day(s) and, if
applicable, travel days to/from the meeting.
Books
The department provides the following:
*Thirteen Volume Set of Basic and Clinical Science Course Books for each new resident – $1025
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Annual Residents and Alumni Day Research Award
These awards are sponsored by John Aure Buesseler and Cathryn Anne Hansen Buesseler Foundation,
Inc., in memory of John Aure Buesseler, M.D.,the founding Chief/Chairman of Ophthalmology(19591966).
*Outstanding Resident Presentation Award (Annual Research Project) – $500
*First Runner Up Award (Annual Research Project) - $200
Ophthalmology Library
The Department of Ophthalmology maintains an up-to-date library and electronic journals for the benefit
of residents, medical students, and faculty. Suggestions for additions to the library should be discussed
with a faculty member for their recommendation for purchase. It is advisable to make use of the valuable
internal resource, as well as the J. Otto Lottes Health Science Library in the School of Medicine.
Computer, Internet and Worldwide Web
The Department of Ophthalmology provides four computers in the residents’ rooms which contain a
variety of software. In addition, laptops are available for clinic patient care.
Our web address is: http://medicine.missouri.edu/ophthalmology
Office Assistance
The Department of Ophthalmology provides secretarial assistance to the residents as follows:
1.
2.
3.
4.
5.
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Transcription of patient dictation.
Publications - - these should be submitted to the secretary of the attending physician
included in the publication, in final form, preferably typed.
Assistance in slide preparation for Residents and Alumni Day and external meetings such
as ARVO, MoSEPS, etc.
Crystal Peterson compiles the travel expense vouchers and vouchers for reimbursement.
Please be sure to keep all receipts and other documentation of your expenses.
Mandatory: All purchases from your professional allowance must be made on your
behalf by the department office, in keeping with university guidelines.
CONFERENCES, EXAMS, AND RELATED POLICIES
Conference Attendance Policy
The following policy was established by the Clinical Faculty at their regular meeting on June 11, 1996.
Effective Date: 7/1/96:
Residents are expected to attend all conferences. Un-excused absences greater than 25% in one
month will result in the loss of OR privileges for one week. The Program Director will designate
the week(s) OR privileges will be withdrawn.
Attendance Roster
Conference attendance must be attested to by the Program Director or Chairman at the conclusion of the
training program.
Attendance rosters are available in the conference room to indicate your presence or absence from
meetings. The chief resident forwards the attendance roster to the Resident Program Coordinator (Sheri
Samp) immediately following the conference for permanent record keeping. Attendance at all
conferences, etc., must be PROMPT; chronic tardiness may be considered an absence.
Second and third year residents may follow the attending to surgery, but are responsible for securing and
studying the education material given at conference. A resident present in conference can only be called
away from any teaching activity for the delivery of patient care in the case of an emergency which cannot
await the conclusion of that activity.
Excused absences will be noted through submission of the Absence Request form or Report of Absence
form, which are submitted to the Resident Program Coordinator (Sheri Samp).
Intra-department Meetings
1.
Journal Club
Excluding May or June (depending on Raday date) and December, the Journal Club
meets on the third Tuesday of each month at 6:00 pm. A moderator is selected who
assigns journal articles to the residents to review.
2.
Photo Conference and M&M conferences
Photo Conference and M&M conferences are held the fourth and fifth Friday.
3.
Subspecialty Lectures
Held every Monday and Wednesday (dates and times are subject to change) from 7:30 9:00 am. Each faculty member is designated to give a series of lectures on the topic of
their choice.
4.
Pathology Conference
Dr. Deepak Edward’s pathology webinar is held the second Friday of each month 8:009:00 a.m.
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5.
Grand Rounds
UM Grand Rounds is held the first Friday of each month.
6.
Residents’ Meeting
Held each month usually 8:00- 9:00am on Monday or Friday. The Program Director and
Resident Program Coordinator also participate. If needed the Chairman, Clinic
Supervisor will participate as well.
7.
Visiting Lectureships
A guest lecturer is invited for a half-day Saturday conference and sometimes part of the
prior Friday afternoon, approximately once each quarter.
8.
Residents and Alumni Weekend
Held one of the last weekends (Friday afternoon and Saturday morning and evening) of
May or June each year. Each resident is required to present a fifteen-minute presentation
of their research project at the scientific session, held during the day. A dinner/dance
honoring our senior residents is held on Saturday evening. The Outstanding Resident
Presentation Award of $300 and 1st Runner Up award of $200 is presented that evening.
9.
Fluorescein Conference
Held on Thursdays from 7:00 to 8:00am at the VA eye clinic.
Resident Orientation
UMC resident orientation 1 – 2 weeks is conducted for new residents beginning the first business day in
July. Residents also attend a VA orientation in July of their first year.
OKAP Examination
The Ophthalmic Knowledge Assessment Program (OKAP) was established in the late 1960s for the
purpose of providing individual residents and training programs with a mechanism to measure academic
performance, specific subject areas of success and any area needing improvement. This examination is
taken by all ophthalmology residents each year. A median OKAP score of 70%ile or higher for the
residents as a group is the goal established by the class year 2010.
The results will be used by the Program Director as one of the many criteria in performing periodic
resident evaluations. The results are used by the department in identifying programmatic strengths and
weaknesses.
The OKAP examination reports individual subject scores, overall scores and “core knowledge” scores as
a percentile for all residents at the same level of training across the country.
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CHIEF RESIDENT
NOTE: Each 3rd year resident will serve as Chief Resident at Mason Eye Institute for an assigned
period (usually 4 months). This resident will be expected to complete the following responsibilities:
1.
Read “The Chief Resident As Manager” by Neal Whitman, Ed.D. and Elaine Weiss,
Ed.D.
2.
Organize and Conduct Grand Rounds - MEI:
Coordinate with the attending ophthalmologist assigned for that day, prior to Grand
Rounds, the particular patients to be discussed. Obtain three (3) patients with teaching
potential.
Assign a presenting resident for each patient’s evaluation and presentation. Note: If
possible, use the resident who originally worked up the patient.
It is the presenting resident’s responsibility to have the history and physical posted at
the patients examining room. The presenting resident will review the patient’s record and
discuss the patient with the attending assigned to Grand Rounds for that day. He/she will
have available appropriate photographs, X-rays, fluorescein slides, and pathology slides.
The presenting resident will review the literature pertinent to the particular disease
process and then lead the discussion at Grand Rounds. Presentations will be with
PowerPoint slides that will maximize learning. The presenting resident will question all
the resident staff regarding pertinent history and physicals findings, a differential
diagnosis, and an appropriate disposition of the patient regarding further diagnostic
studies and treatment. Discussion: Maximum of 20 minutes per patient.
It is the chief resident’s responsibility to ensure the presenting resident is prepared and
available. If the presenting resident is unprepared or unavailable, it is the chief resident’s
responsibility to conduct the discussion as indicated above.
3.
Coordination and Supervision of Photo Conference:
It is the Chief Residents responsibility to discuss each photo conference’s agenda with
the assigned attending ophthalmologist. The attending ophthalmologist will direct each
photo conference as he/she desires. However, it is the Chief Residents responsibility to
ensure the correct photographs and patient charts are available. The photographer will
pull the photos and obtain the patient charts as directed by the attending ophthalmologist
and/or chief resident.
4.
Review Resident’s daily schedules:
If you feel the scheduling is inappropriate or not ensuring expeditious patient care,
discuss with Laverne Fisher, Supervisor, Outpatient Services, or Sheri Samp.
5.
Care of Emergency (Walk-in) Patients:
You are responsible for ensuring these patients are seen appropriately and expeditiously.
If the Emergency Resident is over 1 hour behind arrange for patients to be seen by
another resident and/or coordinate with Sheri Samp. If the Emergency Resident is on
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vacation or unavailable, it is your responsibility to organize the residents’ schedule (with
the Clinic Supervisor) to ensure all Emergency patients are being seen expeditiously.
6.
Coordinate Consult Service (when Consult resident is unavailable):
A problem occurs primarily during the period when first year residents are attending the
Basic Science Course or are on vacation. Coordinate with the Consult Attending
regarding appropriate resident coverage of the Consult Service.
7.
Resident Call Schedule:
Ensure timely completion of the call schedule and submit to Edna Green by the 15th of
the month. Any changes in the call schedule of resident’s times must be submitted to
Edna in writing.
8.
Responsible for: Resident’s Patient Charts, General Dictation and Letters to Primary Care
Physicians
Each week check to ensure all resident’s patient charts, general dictation regarding
patient care, and letters to the Primary Care Physician are completed and submitted to the
attending ophthalmologist in a timely manner.
9.
Participate in Resident Selection Process:
The Chief Resident, who is the designated member on the Residency Education
Committee, will participate in the interview and selection procedure of potential resident
applicants.
10.
Monitor Clinic patient flow:
The Chief Resident is responsible for ensuring all patients in all services of the
Ophthalmology Clinic are seen in an expeditious manner. If he/she feels this is not
occurring, discuss the problem with the attending ophthalmologist or Sheri Samp.
11.
Co-supervision of the daily clinic operations:
Co-supervise with Laverne Fisher, Supervisor, Outpatient Services the daily clinic
operations involving all technical, photographic, and clerical staff. Ensure each
technician is being utilized to their maximal potential. Each subspecialty clinic will have
a lead technician and other technicians as determined by Laverne Fisher, Supervisor,
Outpatient Services. However, if the Chief Resident feels a technician can be best utilized
temporarily in another capacity for the most expeditious operation of the Ophthalmology
clinic, the chief resident has the authority to direct a particular technician’s duties as
he/she feels necessary.
12.
Discuss problems regarding Resident Surgical Schedules:
If a problem arises with the resident’s surgical schedules, resulting in conflicts of time,
discuss with the appropriate attending ophthalmologists and then make changes as
necessary.
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13.
Monthly Resident/Fellow Practice Management Meeting with the Resident Program
Director, Resident Program Coordinator and Residents/Fellow.
Attend a monthly meeting with the Resident Program Coordinator regarding the overall
operations of the Ophthalmology Clinic. Be prepared (after prior discussion with fellow
residents) to discuss any problems relating to clinic operation.
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PROFESSIONAL RESPONSIBILITIES
1. Residents in Ophthalmology are fully trained physicians who have chosen to pursue advanced
education beyond the minimum requirements for the practice of medicine. As such, they are expected
to deport themselves at all times as colleagues of all other health professionals and relate to them in
an appropriate fashion. Courtesy and respect are essential components of such relationships. In like
manner, the faculty and staff are expected to relate to the residents in an appropriate professional
manner.
2. A clean lab coat and your University of Missouri Health Care identification badge are to be worn
when engaged in any clinic or patient care activities.
3. Residents must dress themselves in a manner which is appropriate to the profession of physicians at
times when patient contact is anticipated. Appropriate dress for male residents is shirt and tie for
weekday clinics or for weekend rounds. Appropriate attire for female residents is dress slacks with
professional looking sweater or blouse, or professional looking dress. This attire is also required for
visiting professor conferences. Blue jeans, shorts, tee-shirts, and athletic shoes are not appropriate
attire for patient care or conferences.
4. For emergency visits, residents may wear scrub suits as appropriate attire if acceptable to the
attending physician with whom you are working.
5. Attending physicians may set additional standards for their rotations. These standards should be
adhered to by the resident on that service.
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