Northwestern
McGaw Center for Graduate Medical Education
Housestaff Manual
Licensure
Examination RequirementsProgram Closure or Reduction in Complement
Procedures for Addressing Housestaff Concerns & Grievances
Evaluation & Addressing Performance Deficiencies
Hospital Addendums
Northwestern Memorial Hospital
These policies and procedures apply to all housestaff members (residents and fellows) in McGaw training programs. Please note that a web link to hospital-specific policies and procedures on topics such as identification badges, medical record training, pagers, etc. is provided in this Manual. Housestaff members are responsible for complying with any applicable hospital policies and procedures and should review them from time to time, as they may be subject to change.
All housestaff appointments to McGaw Programs are made by McGaw's Office of Graduate Medical Education (“the GME office”).
The decision to offer an initial appointment or to promote a housestaff member to a more advanced level of training is based on the evaluation of the applicant or housestaff member by faculty members of the appropriate academic department. The training contract issued by McGaw specifies the program, level of training, and terms of enrollment. The training contract, once signed by the housestaff member and the Vice President for Academic Affairs, is the basic document that governs the housestaff member’s academic specialty credit and level of training. These GME Policies and Procedures supplement the training contract and contain additional requirements that are binding on all housestaff members. Housestaff members may not initiate or advance in a training year until a signed training contract is on file.
Continuation and promotion in a program depends on the academic and professional performance of the housestaff member as evaluated by faculty members of the appropriate academic department. In addition, all appointments are contingent upon the acquisition and maintenance of proper medical licensure as determined by the State of Illinois Medical Practice Act.
PGY-1 residents start orientation on June 23 regardless of the day of the week on which that date falls. Orientation may vary by specialty program, but continues for up to seven days until the start of training on June 30. Attendance during orientation is mandatory and residents will receive a stipend beginning June 23. Training contracts for subsequent years in the program follow such that each PGY year ends on June 29 and the next year begins on June 30.
Residents who are beginning training at the PGY-2 or later years and all fellows start on July 1 regardless of the day of the week on which that date falls. Training contracts for subsequent years follow such that each PGY year ends on June 30 and the next begins on July 1.
Housestaff appointments and support are administered by McGaw’s Office of Graduate Medical Education, 645 North Michigan Avenue, Suite 1058A, 312/503-7975. Any questions regarding housestaff appointments or support should be directed to this office.
Each housestaff member must have a valid Illinois medical license. No housestaff member shall begin training until a valid license is issued, nor will credit be given for time spent in activities performed prior to obtaining a license. It is the responsibility of each housestaff member to obtain or renew his or her full or temporary license. Temporary licenses are issued for three years, but if the housestaff member has not changed programs (and upon the approval of the Medical Examining Board), can be renewed for the length of the training program. Permanent licenses can be issued only after two full years of training and successful completion of the USMLE examinations. Some housestaff members anticipate a future position in a state other than Illinois following training and thus do not wish to pursue a permanent Illinois license. Housestaff members who choose to complete training on a temporary license should nonetheless plan to complete the USMLE examinations as soon as they are eligible to do so. Failure to complete these examinations in a timely manner may result in a delay in obtaining a permanent license once training is complete.
Examination Requirements
A passing score on both the USMLE Step 1 and Step 2 (Clinical Knowledge) exams - or, Canadian or osteopathic equivalent - is a prerequisite for starting training in any McGaw residency program. All new residents will be asked to submit official score reports to the GME office prior to starting training.
The above requirement also applies to international medical school graduates.
All residents are strongly encouraged to take the USMLE Step 3 exam as soon as they are eligible.
All fellows must pass Step 3 (or equivalent) before starting a fellowship unless they are on a J-1 training visa. All new fellows will be asked to submit an official score report to the GME office prior to starting training.
Part-time or shared training positions in individual training programs may be considered if all the following prerequisites are met:
1. The Program Director of the training program, in conjunction with the Chair of the relevant academic department at Northwestern University’s Feinberg School of Medicine (“FSM”), has deemed the program appropriate for part-time training by a qualified candidate, or shared training by two qualified candidates. In making this decision, the Program Director must take into account the size of the program, the educational resources available to the program, the appropriateness of education over an extended period of time for the candidate, and the impact of alternative training on other full-time residents and/or fellows.
2. The Program Director has written permission from the specialty Residency Review Committee (“RRC”) or other accrediting organization for part-time training, and written acknowledgment from the applicable certifying board that the individual will be eligible to sit for the certifying examination at the completion of the modified training program.
3. Except in unusual circumstances, the individual requesting a part-time or shared position should make the request known to the Program Director prior to signing the appointment contract or, in the case of a position obtained through the NRMP, prior to engaging the match process.
4. Except in unusual circumstances, part-time training will be 0.5 of a full-time equivalent. The minimum duration of part-time status will be one full training year.
Program Closure or Reduction in Complement of Trainees
If a decision is made to reduce the complement of trainees in a program, or to close a training program, all trainees in that program will be notified as soon as possible. In the event of reduction of complement, current trainees in the program, including trainees who have not yet initiated training but who have been notified that they are accepted into the program, will be permitted to continue their education until completion of the total number of years defined by the ACGME for that program. In the event of program closure, trainees will be permitted to complete the current training year. The Program Director shall assist the trainees' efforts to matriculate in other ACGME accredited programs.
Housestaff members shall strive for excellence in all aspects of patient care and teaching. This includes professional demeanor and conduct at all times, including but not limited to in direct patient care and in communication with family members, other health care staff members, students, and support staff members. It also includes the matters outlined below in this section.
Housestaff members must be familiar with and adhere to their training program’s supervision policy regarding the manner in which they report to and are supervised by attending physicians or other supervisors in all clinical settings. Among other things, housestaff members must communicate with their immediate supervisors or directly to attending physicians as directed by the Program Director, attending physicians, or other supervisors.
Discussion of a patient’s clinical condition, other than with the patient, should be conducted away from patient care areas. Discussion in hallways, elevators, or any other place within earshot of any patients or visitors is unprofessional and may violate the patient's right to privacy. Housestaff members are responsible for knowing and complying with federal, state, and local laws and any applicable hospital policies governing patient confidentiality. Derogatory remarks about patients or other professional personnel are unacceptable in any setting.
No housestaff member, in his or her actions or attitudes, may mistreat or misuse confidential or proprietary information; release confidential information including electronic passwords to unauthorized persons; leave patients under his or her care unattended; falsify institutional or personal records; steal, remove, or be in unauthorized possession of hospital, medical school, or other persons' property; or exhibit insubordination toward his or her clinical supervisor.
Housestaff members shall not use potentially addictive, abusive, or illicit drugs. Use of such drugs in any environment or in any amount is incompatible with safe clinical performance. Sick leave should be requested for the duration of time a housestaff member needs to use prescription medication(s) that impairs cognitive or motor function. Housestaff members shall not use alcohol when they may be called upon to provide or while providing direct patient care or advice to those providing direct care (for example, when on beeper call).
Housestaff members shall not provide patient care under circumstances of possible physical, mental, or emotional lack of fitness that could interfere with the quality of that care. It is the responsibility of the housestaff member, upon identifying a situation in which he/she or any other housestaff member is impaired to the potential detriment of patient care, to notify the supervising physician to arrange for alternative patient care coverage.
A housestaff member's demeanor should be professional at all times, and his or her neatness, cleanliness, and appearance should fall within accepted professional standards as determined by McGaw.
Housestaff members must comply with the duty hours policy of the training program to which he/she is assigned. From time to time during training, housestaff members may receive surveys from a variety of sources regarding duty hours. Each housestaff member is responsible for answering such surveys promptly and truthfully regarding his/her compliance with the relevant policy.
Housestaff members will receive a Northwestern University Network Identifier (NetID) and email address at orientation. The NetID and password identify the individual to the network and allow the housestaff member to access a variety of resources and services. The NetID is the housestaff member's electronic identity at McGaw. Each housestaff member is responsible for (1) maintaining his/her Northwestern University email address by changing the password whenever requested to do so, and (2) checking his/her mail at this account on a regular basis. This will be the main mode of communication from the McGaw GME office and from Program Directors. .
Procedures for Addressing Housestaff Concerns and Grievances
McGaw is committed to providing a supportive educational environment. An important part of that commitment is to maintain an educational and professional culture that fosters learning for all housestaff members.
Housestaff members who have any concerns regarding their educational and/or professional environment may raise their concerns either in writing or orally to their Program Director without fear of intimidation or retaliation. If a housestaff member does not feel comfortable raising an issue with his/her Program Director, he/she should contact Sharon L. Dooley, M.D., Chairperson of the Graduate Medical Education Committee (GMEC). Alternatively, a housestaff member may bring his/her concern to the attention of Sandra Fernandez, McGaw Director of Graduate Medical Education. Either of these individuals may be reached at the GME office, 312/503-7975.
If a housestaff member has decided to pursue a grievance by notifying either Dr. Dooley or Ms. Fernandez, the Chair of the GMEC will arrange a meeting between the individual housestaff member and the Chair of the GMEC to discuss the issues involved and to attempt to resolve those issues. If a resolution is successfully reached at this meeting, the Chair of the GMEC will issue a short written statement to the housestaff member setting forth the agreed upon resolution. If a resolution is not successfully reached after a meeting with the Chair of the GMEC, the Chair may refer the matter to the Housestaff Faculty Relations subcommittee of the GMEC or take whatever other action he or she deems appropriate under the circumstances. In the event that the Chair of the GMEC is the subject of the concerns, feels a conflict of interest, or is otherwise unable or unwilling to fulfill this role, the President of McGaw will select a faculty member of the GMEC to fulfill the role of the Chair of the GMEC with regard to the grievance.
Exclusions
Issues relating to housestaff evaluation and actions taken to address performance deficiencies are not covered by these Procedures for Addressing Housestaff Concerns and Grievances. Appeals of such actions are governed by the Evaluation and Addressing Performance Deficiencies section of the Housestaff Manual. Similarly, issues relating to sexual harassment and/or harassment or discrimination based upon sex, race, color, religion, ancestry or national origin, age, disability, marital status, parental status, sexual orientation, veteran status, citizenship status, or other protected group status are not covered by this section and should be addressed through the Non-Discrimination and Harassment provisions of the Housestaff Manual.
Evaluation and Addressing Performance Deficiencies
Introduction
The procedures set below are applicable to all housestaff members in all McGaw training programs. All references to housestaff members shall include both residents and fellows.
Evaluation
Supervising faculty will provide written evaluations and/or oral feedback regarding the performance of housestaff members. Nursing and technical personnel, administrators, fellow housestaff members, medical students, and patients may also provide written and/or oral feedback regarding a housestaff member’s performance. Such evaluations and/or feedback may be provided directly to housestaff members and/or to the Program Director or his/her designee. The Program Director or his/or designee will review any evaluations and/or feedback with the housestaff member at a time or times to be determined by the Program Director or his/her designee in accordance with any applicable accreditation requirements. If the Program Director determines at any time in his or her judgment that a housestaff member’s performance is unsatisfactory, the Program Director will advise the housestaff member regarding the performance deficiencies and the expectations for improvement.
Training Files
The Program Director shall maintain a training file for each housestaff member. Any written evaluations will be included in this file. A housestaff member may review his/her training file by contacting the Program Director.
Basis for Evaluations
Each housestaff member will be evaluated according to his/her performance appropriate to his/her educational level, in the following areas:
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competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice;
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compliance with all terms and conditions set forth in the housestaff member’s training contract and this Manual;
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compliance with other practices, rules, regulations, procedures, and policies of McGaw; and
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compliance with practices, rules, regulations, procedures, and policies in place at any training location, including McGaw member hospitals and non-McGaw clinical sites.
Addressing Performance Deficiencies
If a Program Director determines that a housestaff member’s performance is unsatisfactory and therefore decides that probation, non-reappointment, suspension, dismissal, or termination is appropriate, the Program Director will notify the housestaff member of this decision in writing. The Program Director’s written decision will include a statement of the reasons for the adverse action. Upon request, the housestaff member shall have the opportunity to review his or her training file. In circumstances where the Program Director determines that a housestaff member’s continued presence would pose an unacceptable threat to patient safety, the Program Director may place the housestaff member on summary administrative leave (with pay and benefits) pending a final decision in accordance with the procedures set forth in this section.
To appeal an adverse action, a housestaff member must submit a written request for appeal to his or her Program Director within fourteen (14) days of written notification of the Program Director’s decision. Any request for appeal must include a statement of the precise action being appealed and of the grounds supporting the appeal. The housestaff member may also submit documentary evidence in support of his or her appeal. The Program Director shall then convene an ad hoc appeals committee (“the appeals committee”) comprised of at least three faculty members to review the housestaff member’s training file and any documentation submitted by the housestaff member in support of his/her appeal. The housestaff member may select one faculty member from his/her training program to serve on the appeals committee. The Program Director will not serve as a member of the appeals committee, but the appeals committee may wish to hear from the Program Director in evaluating the housestaff member’s appeal. If requested by the housestaff member or by the appeals committee, the housestaff member will be given an opportunity to appear before the appeals committee. After deliberations, the appeals committee will render a decision by majority vote and report its decision in writing to the Program Director whether to sustain, reverse, or modify the Program Director’s decision. The appeals committee may not impose a harsher sanction than the sanction imposed by the Program Director. The Program Director will notify the housestaff member of the results of the appeal in writing within five days of receiving the decision of the appeals committee.
If the appeals committee sustains the initial adverse action, or if the housestaff member is otherwise dissatisfied with the decision of the appeals committee, the housestaff member may appeal the decision of the appeals committee to the President of McGaw. A written request for appeal must be submitted by the housestaff member within seven (7) days of written notification of the appeals committee’s decision. The President shall consider the information in the housestaff member’s training file and any other documentation presented to or considered by the appeals committee, as well as the appeals committee’s decision, and any other information that the President deems relevant. The President may, in his or her discretion, interview the housestaff member, the Program Director, the chair of the appeals committee, and the Vice President for Academic Affairs, as well as any faculty members responsible for the supervision of the housestaff member or any other individuals with knowledge regarding the housestaff member’s performance.
The President may accept, reject, or modify the decision of the appeals committee. The President will notify the housestaff member and the Program Director of his or her decision in writing. This decision will be final.
McGaw will make every effort to convey a decision not to reappoint or promote a housestaff member at least four months prior to the end of his/her current training year, but any failure on the part of McGaw to do so will not be grounds for challenging or overturning the decision not to reappoint a housestaff member.
All actions regarding performance deficiencies shall be documented in the housestaff member's permanent file. If this information is requested, it shall be part of the information released to support future applications for licensure, clinical privileges, or accreditation to the extent permitted by law.
Housestaff must remain fit for duty at all times, which means that they must be able to perform their duties in a safe, appropriate, and effective manner. McGaw, through a clinical department chair or a Program Director, may require that a housestaff member undergo a fitness-for-duty evaluation at any time if apparent cause or reasonable suspicion exists to believe that a housestaff member is impaired or otherwise unfit.
A fitness-for-duty evaluation may include a comprehensive medical and psychological assessment and drug and alcohol screening. The examination results will be released to the Program Director and Vice President for Academic Affairs. Housestaff members shall comply with this policy and cooperate fully with its provisions.
A housestaff member found to be impaired due to suspected alcohol or drug use will be removed from patient care responsibilities pending further evaluation in accordance with the provisions described below.
Drug and alcohol abuse is defined as the use of any potentially addictive, abusive, or illicit drug or the use of alcohol to the extent of even minor impairment of cognitive or motor function.
A drug test result will be considered positive if drugs are detected in an amount above the detection limits established by the testing laboratory; a test will be considered negative if drugs are detected in an amount below these limits. Impairment of cognitive or motor functions is defined as a situation of unusual or aberrant behavior including but not limited to slurred speech, unsteady gait, abusive language, disheveled appearance, or diminution of fine motor coordination.
If a Program Director has apparent cause or reasonable suspicion to believe that a housestaff member may be under the influence of drugs or alcohol or otherwise impaired, the housestaff member may be removed immediately from his or her duties and immediately required to submit to a fitness for duty evaluation that may include testing for drugs or alcohol, a medical evaluation, a referral for a psychological or psychiatric evaluation, or any other evaluation or testing deemed necessary. Apparent cause or reasonable suspicion may be based upon the Program Director or a faculty member’s own observations or information obtained from other McGaw representatives, any McGaw hospital member institution, or any non-McGaw clinical site. Housestaff members must cooperate fully with the fitness for duty evaluation process.
A housestaff member who refuses to undergo a drug or alcohol test, or any other aspect of a fitness for duty evaluation, as outlined above or to sign a release authorizing disclosure of the results of the evaluation to McGaw, will be subject to disciplinary action, up to and including termination in accordance with the procedures set forth in the Evaluation and Addressing Performance Deficiencies section of this Manual. In addition, a housestaff member who tests positive for drugs or alcohol may be terminated by his or her Program Director in consultation with the Vice President for Academic Affairs in accordance with the procedures set forth in the Evaluation and Addressing Performance Deficiencies section of this Manual. If permitted to remain in the program, the housestaff member may be required to enroll in a chemical dependence program selected by the Program Director or, at the Program Director's discretion, the housestaff member may propose a program for review and approval by the Vice President for Academic Affairs. Prior to returning to clinical duties, McGaw may, in its sole discretion, require the housestaff member to submit to and pass a fitness for duty examination and/or sign a contract that specifies and requires expected behaviors.
Medical leave for chemical dependence shall be documented in the housestaff member's permanent file. If this information is requested, it shall be part of the information released to support future applications for licensure, clinical privileges, or accreditation to the extent permitted by law.
Moonlighting/Extra Call for Pay
The term "moonlighting" refers to employment outside of the activities of the training program for the purpose of providing medical services regardless of whether it is performed at one of the McGaw affiliated hospitals or at another non-affiliated institution. The official policy of McGaw and its member hospitals is that "moonlighting" must not interfere with the housestaff member’s ability to achieve the goals and objectives of his or her training program. Furthermore, "moonlighting" constitutes the unlicensed practice of medicine unless the trainee has been issued a permanent medical license by the state in which the moonlighting occurs.
McGaw and its affiliated hospitals are not responsible for any professional activities in which housestaff members participate outside the scope of the training program to which they are appointed. Professional liability and workers' compensation insurance provided by McGaw affiliated hospitals do not cover these activities.
The desire to perform moonlighting activities must be reported to the housestaff member's Program Director, and may occur only with written permission. The written permission will be maintained in the housestaff member's training file. The Program Director will monitor the housestaff member's performance to ensure that the moonlighting activities are not excessive and do not impair the housestaff member's ability to carry out assigned McGaw responsibilities. If the Program Director denies or withdraws permission to moonlight, any failure to comply with the Program Director’s decision shall be considered insubordination and may lead to the housestaff member being placed on probation, suspended, dismissed, or terminated as outlined in the Evaluation and Addressing Performance Deficiencies section of this Manual.
Some training programs may offer pay for taking additional call. When such an opportunity is offered by a program, participation by housestaff members is voluntary and shall not be required. When a housestaff member is taking additional call for pay within his/her training program, the same supervision policy applies as when the housestaff member is taking regular training call, and the time spent taking such additional call must be included in calculating total duty hours.
Housestaff members enrolled in McGaw GME training programs who have completed at least 12 months of satisfactory performance as determined by the program director are eligible to receive a certificate for that training.
Duplicate certificates will be issued on proof of loss or theft. There is a fee for duplicate certificates.
Completion of Training Program
Housestaff members are responsible to their training program until the date of completion determined by their signed training contract. In addition to successful completion of all program requirements, certification of completion of the program will be contingent upon the following: (i) return of all McGaw and affiliated hospital property such as books, keys, equipment, etc.; (ii) completion of all medical records for which the housestaff member is responsible; and (iii) settling any other professional or financial obligations to McGaw or any affiliated hospital.
Effective Summer, 2007, a passing score on both the USMLE Step 1 and Step 2 (Clinical Knowledge) exams - or, Canadian or osteopathic equivalent - will be a prerequisite for starting training in any of our residency programs. This follows the lead of most medical schools including FSM which require a pass on Step 2 in order to graduate, and of most GME institutions which analogously have this as a prerequisite for initiating residency training. This change will be indicated in the Housestaff Manual. It is important that you mention this when interviewing candidates for 2007 in the coming months. All new residents will be asked to submit an official score report to the GME office prior to starting.
The above requirement also applies to international medical graduates, who must pass Steps 1 and 2 in order to get ECFMG sponsorship for a J-1 visa.
USMLE Step 3 Exams
All residents are strongly encouraged to take the Step 3 exam as soon as they are eligible after the PGY-1 year. Please reinforce this proactive stance with your residents. A large proportion of GME institutions require passage of Step 3 before promoting residents to the PGY-3 year. We are not yet doing so and hope instead for voluntary compliance of residents in taking the exam during their PGY-2 year of training. They must eventually pass this exam in order to get a permanent license in any state, and the chances of passing are highest in their earlier years of training given that this exam tests general management skills.
We do not require fellows to have a permanent license in Illinois because it is an unnecessary expense for those who already know they will be practicing in another state. However, all fellows must have passed Step 3 (or equivalent) before starting fellowship unless they are on a J-1 training visa. Beginning in 2007, we will ask all new fellows to submit an official score report to the GME office prior to starting training.