RESIDENT HANDBOOK DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH

Revised 6/22/06

EDUCATIONAL PROGRAM NARRATIVE DESCRIPTION

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Description of the Program 1. Introduction The University of Utah Health Sciences Center comprises the School of Medicine, University of Utah Medical Center (UUMC, which includes the University Hospital and the Huntsman Cancer Hospital), Primary Children's Medical Center (PCMC), and the Salt Lake VA Hospital. It is the major medical teaching complex in the Intermountain West, a large geographic area extending from the Canadian border to northern Arizona and from the Rocky Mountains to western Nevada. We serve as the major referral hospital complex for patients with neurological and neurosurgical diseases and provide primary neurosurgical care for many patients within Utah and the adjacent states. All of the hospitals, which are in close proximity to each other, offer advanced state-of-the-art technology and facilities. The physicians staffing the neurosurgical service are all full-time faculty at the School of Medicine and all are board certified or eligible. All of our faculty have specific subspecialty interests assuring the residents of exposure to the full scope of neurosurgical problems and procedures. We have individuals who focus their professional efforts and research on neuro-oncology, pituitary tumors, cerebrovascular disease, complex skull base surgery, pediatric neurosurgery, spine surgery and spinal instrumentation, neurotraumatology and neurointensive care, epilepsy and functional neurosurgery, and pain. Indeed, we believe that this balance, coupled with adequate volume, and the quality of the faculty are the main strengths of our program. The Department supports active laboratory research programs in neuro-oncology and skull base surgery. Residents and Department members actively participate in spinal biomechanics research in conjunction with our Orthopedic spine colleagues in the Orthopedic Biomechanics Lab. Clinical research in spine instrumentation, neuroendoscopy, hydrocephalus, subarachnoid hemorrhage, and neuro-oncology is also being carried out. Residents are given the opportunity to work in the research laboratory during their third year in neurosurgery and have an option for additional research time if they wish. The institution is especially strong in neuroscience research with many outstanding scientists, including those in the Howard Hughes Medical Institute and the Huntsman Cancer Institute. Our faculty often collaborate with, and residents may do their research in, these affiliated laboratories. The Department had a steady growth under the direction of Dr. M. Peter Heilbrun who assumed the leadership of the Division of Neurosurgery in 1983 and became chairman of the Department of Neurosurgery in 1992 after a national search. The elevation of neurosurgery to departmental status in November of 1992 (becoming the first new department in the University of Utah Medical School in 11 years) reflects the value and contributions of the neurosurgical faculty to the teaching, research, and service mission of the School of Medicine. Dr. William T. 2

Couldwell assumed the chairmanship in 2002 and is taking the department to the next level. He has already successfully recruited three new faculty members, increased clinical and academic productivity, and strongly supports resident education. The University of Utah residency program in neurological surgery is accredited for resident education in neurosurgery by the Accreditation Council For Graduate Medical Education (ACGME). The program is intended to prepare individuals to become fully competent and compassionate neurological surgeons. Individuals completing this program will be well prepared to practice neurosurgery, possessing the knowledge base and technical skills required by this specialty. Clinical competence requires: a. b. c. d. e. f. A solid foundation of basic and clinical knowledge. The ability to perform a thorough neurological and basic physical examination on the patient. The ability to know which diagnostic studies to order and to interpret the results accurately. Advanced technical abilities refined to a high level. Diligence and compassion in dealing with patients and their families. An attitude conducive to the practice of medicine including appropriate interpersonal interaction with patients, professional colleagues and supervisory faculty, and paramedical personnel. An unyielding commitment to ethical behavior and personal integrity.

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The Department has endeavored to select residents who, by their prior performance, have demonstrated their intelligence, thirst for knowledge, commitment to neurosurgery, ethical integrity, and capacity and willingness to work hard. During training, each resident will be exposed to all aspects of neurosurgery. Residents are given graduated levels of responsibility throughout the training program. The rotation schedule is designed to facilitate a stepwise accrual of knowledge and expertise. Residents also will have the opportunity to engage in scientific research. This research experience teaches the scientific method and critical scientific reasoning, preparing our graduates to evaluate future advances in the specialty. For individuals desiring an academic career, the research experience offers the opportunity to acquire knowledge and techniques that they may use in the future and positions them for future leadership roles in neurosurgery.

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Rotations NS1 (PGY2) - Clinical Neurosurgery at the UUMC (6 months). During this year, the resident is a junior member of the housestaff participating in patient care on the Adult Neurosurgery Service. Here residents are introduced to the full spectrum of adult neurosurgical disorders. The other 6 months are focused on neuro-oncology (at Huntsman Cancer Hospital and UUMC) and peripheral nerve problems (outpatient clinics and outpatient surgery at the VA Medical Center). During this time, they begin their study of neuropathology. NS2 (PGY3) - Neurosurgical Intensive Care at the UUMC (6 month). During this time the resident is responsible for the care of the patients in the Neurosurgical Intensive Care Unit in conjunction with the other residents on the clinical service. During the Neurosurgery ICU time their primary responsibility is to the ICU but they may go to the operating room when on call and as the service allows. Clinical Pediatric Neurosurgery at PCMC (6 months). During this rotation the residents are involved in the care of children with neurosurgical disorders along with a senior resident and a pediatric neurosurgery fellow. They have a one-in-three call rotation from home and obtain inpatient and outpatient emergency department and surgical experience. NS3 (PGY4) - Research (12 months). Several options for laboratory and/or clinical research in neuro-oncology, spine, skull base, pediatric neurosurgery, and clinical trials are available during this year. Residents participate in relevant course work at the University of Utah School of Graduate Medicine, and several have earned graduate degrees. NS4 (PGY5) - Senior resident on Clinical Neurosurgery at the UUMC (6 months) and Clinical Pediatric Neurosurgery at PCMC (6 months). NS5 (PGY6) - Chief resident at the UUMC (12 months). During this year the resident functions as the Chief Resident in charge of the service and doing a high volume of surgical cases. Extra Research Year (optional) - We allow residents to do an additional year of research if they wish. This optional additional year has been chosen by two of our current residents. If they chose to do this, the residents NS1 NS2 (PGY2 PGY3) rotations are as above but the rest of their residency is as follows: NS3 (PGY4 and PGY5) - Research (24 months). The residents who choose to complete a second research year usually do so in order to conduct more involved research than can be accomplished in one year. The options are the same as those listed above but specific areas of interest have been accommodated. NS4 (PGY6) - Senior resident on Clinical Neurosurgery at the UUMC (6 months) and Clinical Pediatric Neurosurgery at PCMC (6 months). NS5 (PGY7) - Chief resident at the UUMC (12 months). During this year the resident functions as the Chief Resident in charge of the service and doing a high volume of surgical cases. 5

The residents therefore spend 36 months in clinical neurosurgery, 12 months in research, 6 months in neurocritical care, and 6 months in neuro-oncology/peripheral nerve. Neurology (3 months) is done during internship. Residents have the option of an additional research year. 3. The duties of the residents in each year NS-1 residents are responsible for evaluating all patients coming through the outpatient surgery department for admission prior to surgery, assisting in their surgery, and providing pre- and postoperative care in the neurosurgical intensive care unit and on the hospital floor. They are at all times supervised by more senior residents and the faculty. They learn the basics of neurological evaluation and increase their knowledge about diseases affecting the nervous system from exposure to a wide variety of problems, independent reading, daily rounds with the senior residents and the staff, and regular conferences. In the operating room, they learn how to "set up" a case and how to assist, progressing to "opening and closing" and then assuming more responsibility as their skills grow. Assisting in the OR is rotated among the junior residents so that patient care out of the OR is neither neglected nor de-emphasized. Junior residents also answer consultation requests from other services and the emergency room and present these patients to the appropriate staff person. There also is a resident clinic in which patients are evaluated by the resident and then discussed with the staff. The residents follow these patients postoperatively in their clinic as well. By the end of the NS 1 year the resident is expected to: Patient Care Perform and document comprehensive Neurosurgery history and physical examination Select and interpret appropriate investigations (laboratory studies and imaging) Perform selected surgical procedure under direct supervision (lumbar discectomies, opening and closing of simple craniotomies, place ICP monitors and EVDs). Assist in major surgical procedures and perform those portions of such procedures (under supervision) that are appropriate for level of training. Perform initial resuscitation of patients who are critically ill with neurosurgical problems (coma, raised intracranial pressure, intracranial hemorrhage, head injury, hydrocephalus). Medical Knowledge Localize lesions within the nervous system, based on the clinical findings. Generate an appropriate differential diagnosis. Demonstrate knowledge of the anatomy and physiology relevant to clinical neurosurgery. Describe common neurosurgical operations. Develop a solid foundation of knowledge of the commonly encountered neurosurgery disorders.

Practice-Based Learning and Improvement Attend M&M conference. Review personal involvement in M&M cases with faculty and describe the changes they will make in patient care. Demonstrate critical appraisal skills when using the medical literature. Interpersonal and Communication Skills Provide compassionate patient care as determined by patients, families, colleagues and ancillary health professionals. Develop excellent interpersonal and communication skills (verbal and written). Provide clear unambiguous information to other health care workers. Demonstrate the ability to accurately and concisely document and report findings and a plan of treatment. Professionalism Demonstrate a high level of professionalism at all times. System-Based Practice Demonstrate an awareness of the variety of systems within which health care is provided. The NS-2 residents in their six months at UUMC are responsible for running the neurosurgical intensive care unit. They supervise and teach the NS-1 residents in regard to neurointensive care. They in turn are supervised by the senior residents and faculty. This rotation allows the resident more time to read and study than in the NS-1 year but still provides intraoperative experience when on call and as the service allows. The other six months are spent as the junior resident at PCMC performing essentially the same duties as the NS-1 resident at the UUMC. Because of their increasing experience, they can be allowed more operative responsibility however. In addition to the goals/objectives of the previous years, the NS-2 resident is expected to: Patient Care Perform and document comprehensive pediatric neurosurgery history and physical examination. Select and interpret appropriate investigations (laboratory studies and imaging). Describe treatment options and their pros and cons. Perform selected surgical procedures under direct supervision (craniotomy for metastasis, ACDF approach, craniotomy for trauma, VP shunt insertion, lumbar laminectomy). Assist in major surgical procedures and perform those portions of such procedures (under supervision) that are appropriate for level of training. Manage patients who are critically ill with neurosurgical problems throughout their NCC stay (coma, raised intracranial pressure, intracranial hemorrhage, head injury, hydrocephalus, vasospasm, spinal cord injury, ventilator management, nutrition).

Medical Knowledge Demonstrate familiarity with current neurosurgical literature. Demonstrate a detailed knowledge of neurosurgical intensive care disorders and management. Demonstrate knowledge of common pediatric neurosurgical disorders. Practice-Based Learning and Improvement Attend M&M conference. Review personal involvement in M&M cases with faculty and describe the changes they will make in patient care. Demonstrate critical appraisal skills when using the medical literature. Interpersonal and Communication Skills Provide compassionate patient care as determined by patients, families, colleagues, and ancillary health professionals. Develop excellent interpersonal and communication skills (verbal and written). Provide clear unambiguous information to other health care workers. Demonstrate the ability to accurately and concisely document and report findings and a plan of treatment. Professionalism Demonstrate a high level of professionalism at all times. System-Based Practice Discuss the most cost efficient options for patient investigation and treatment. The NS-3 residents spend their year focused primarily on research. They are encouraged to work either in the departmental laboratories or in other research laboratories at our institution so that they can continue to participate in teaching conferences. The NS-3 residents also participate in the weekend call rotation at the UUMC. This is approximately every third or fourth weekend. They function as junior residents and are on call with/supervised by a senior resident and faculty member. During the NS-3 year the residents also gain further exposure to neuropathology. In addition to the goals/objectives of the previous years, the PGY4 resident is expected to: Patient Care Develop an appropriate plan for the research rotation. Learn the necessary techniques for the research. Complete research tasks on time. Medical Knowledge Acquire an in depth knowledge of the literature relevant to their research. Practice-Based Learning and Improvement Learn from previous research and research performed on this rotation, and based on that, plan/suggest future experiments.

Interpersonal and Communication Skills Present/describe the research so that other residents/faculty can understand it. Professionalism Work well independently. Adhere to ethical principles of research conduct. Adhere to ethical principles of animal care and experimentation (if appropriate). System-Based Practice Be aware of the clinical relevance of the research. Understand the cost of conducting the research. Understand the potential implications of the research on health care delivery. The NS-4 residents spend six months as senior resident at the UUMC. During this time the resident is a senior member of the Neurosurgical housestaff. They begin to direct patient care and supervise junior residents in preparation for the PGY6 (chief) year. They share weekend senior resident call at the UUMC every third or fourth weekend and take occasional junior resident call. The other six months are spent as senior resident at PCMC. There they supervise the junior resident and share the operative experience with the pediatric neurosurgery fellow. The volume of cases is such that each can either be first assistant or primary operating surgeon as appropriate on a large number of pediatric cases. They also participate in outpatient clinics with pediatric neurosurgery attendings. In addition to the goals/objectives of the previous years, the NS-4 resident is expected to: Patient Care Teach a comprehensive neurosurgery history and physical examination. Select and interpret appropriate investigations (laboratory studies and imaging). Describe treatment options and their pros and cons. Perform selected surgical procedures under direct supervision (for example, craniotomy for glioma, ACDF, craniotomy for trauma in an acutely ill patient, pterional craniotomy and exposure of ICA, split Sylvian fissure, closure of myelomeningocele, repair of sagittal synostosis, insertion of VNS, lumbar laminectomy, microdiscectomy, posterior cervical stabilization). Assist in major surgical procedures and perform those portions of such procedures (under supervision) that are appropriate for level of training. Begin to direct in/outpatient care. Teach residents/interns/students selected noncomplex surgical procedures appropriate to their level of training. Medical Knowledge Demonstrate detailed knowledge of the current neurosurgical literature. Demonstrate a detailed knowledge of complex neurosurgical disorders. Demonstrate detailed knowledge of complex neurosurgical procedures. Teach/mentor PGY2/3 residents.

Practice-Based Learning and Improvement Attend M&M conference. Review personal involvement in M&M cases with faculty and describe the changes they will make in patient care. Demonstrate critical appraisal skills when using the medical literature. Interpersonal and Communication Skills Provide compassionate patient care as determined by patients, families, colleagues and ancillary health professionals. Develop excellent interpersonal and communication skills (verbal and written). Provide clear unambiguous information to other health care workers. Demonstrate the ability to accurately and concisely document and report findings and a plan of treatment. Professionalism Demonstrate a high level of professionalism at all times. System-Based Practice Demonstrate an understanding of different types of neurosurgical practice and their pros and cons. Understand and consider the health care costs of their management decisions. The NS-5 year is spent as chief resident at the UUMC. The chief resident is responsible for the administration of the service and oversees the smooth functioning of the operating room schedule. The chief resident also supervises the junior residents and coordinates the entire service including teaching, work rounds, and conferences. The chief resident also has significantly expanded operative experience. In addition to the goals/objectives of the previous years, the NS-5 resident is expected to: Patient Care Demonstrate the ability to perform all general neurosurgical procedures. Demonstrate the highest level of patients care skills, problem solving skills and technical skills. Manage and administrate the complexities of a large clinical and academic service. Medical Knowledge Instruct and nurture junior residents in critical care related procedures, intensive care unit, call, etc. Demonstrate the ability to teach effectively. Manage and lead the patient care conference. Assist program director in overseeing personal, academic and clinical growth and development of junior residents. Participate actively and lead conferences in a manner that demonstrates a high level of global awareness regarding clinical neurosurgery, applied research, an understanding of the literature, neurosurgical education and program building.

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Practice-Based Learning and Improvement Manage and administrate the complexities of a large clinical and academic service. Develop skills as program builder and an administrator of the neurosurgical service. Interpersonal and Communication Skills Demonstrate a high level of interpersonal communication skills. Provide compassionate patient care as determined by patients, families, colleagues and ancillary health professionals. Develop excellent interpersonal and communication skills (verbal and written). Provide clear unambiguous information to other health care workers. Demonstrate the ability to accurately and concisely document and report findings and a plan of treatment. Professionalism Demonstrate a high level of professionalism at all times. System-Based Practice Demonstrate understanding of legal issues in neurosurgery. Demonstrate a high level of understanding regarding practice types, medical economics and medical politics. Incorporate evidenced-based methodologies on an ongoing basis to the clinical practice of neurosurgery. Develop and demonstrate a high level of knowledge and skill in each of the subspecialties of neurosurgery. Develop, nurture, and demonstrate high level leadership skills. 4. Outpatient and inpatient facilities a. University of Utah Medical Center (UUMC) UUMC was built in 1981 and is the major teaching hospital of the University of Utah. This is a level I trauma center with 434 acute care beds and an excellent aeromedical transfer service. All major medical and surgical specialties are represented with training programs in each. Collegiality and cooperation among services is the rule rather then the exception. The neurosurgical service at UUMC has its own 11-bed neurointensive care unit, which is shared with neurology, as well as a dedicated 28-bed ward adjacent to the ICU. When necessary, neurosurgery patients can and do overflow into the surgical, medical, burn, or cardiac intensive care units and to other surgical wards while remaining on our service. The outpatient clinic at UUMC is dedicated to neurosurgery five days per week. The neurosurgical staff see their private patients here and staff the resident's clinic as well. A new part of the UUMC is the Huntsman Cancer Hospital. This is a freestanding building connected to the main hospital by indoor walkways. It is also connected to the Huntsman Cancer Institute, which is a research facility. The Huntsman Cancer Hospital contains 50 inpatient beds and 4 operating rooms. A 11

portion of the UUMC brain tumor operations are done in the Huntsman Cancer Hospital and the neuro-oncology outpatient clinics are located there. b. Primary Childrens Medical Center (PCMC) Primary Children's Medical Center is a modern 232-bed pediatric hospital built in 1990. It is located adjacent to the UUMC and connected via a pedestrian bridge. It is the major pediatric referral center for the intermountain west. It is the pediatric training hospital for the University of Utah, and the chairman of pediatrics at the University is also the medical director of the hospital. There is a 32-bed ICU and 43-bed newborn ICU where neurosurgery patients treated under the joint direction of the neurosurgical service and full-time pediatric intensive care specialists. Patients are not on a specific ward but are taken care of on wards stratified by the patient's age. Outpatients are seen in the pediatric neurosurgical clinic located in the hospital. Patients can be seen every day at this facility. c. Salt Lake VA Hospital The Salt Lake VA Hospital is a 138-bed facility. It too is a major component of the University of Utah teaching system and staffed primarily by University faculty. The Department of Neurosurgery does not cover ORs, clinics, or the E.R. at the VA Hospital. Residents from our department participate in peripheral nerve clinics and surgery with Dr. D. Hutchinson (Orthopedic Hand Service) at the VA. d. Neuroscience Institute Our department has the support of the Dean of the University of Utah Medical School to develop a Neuroscience Institute in the next two years. An existing 80,000-square-foot building located adjacent to the UUMC has been dedicated for this purpose. It will house the departmental offices, research laboratories, outpatient clinics, and operating rooms. It is directly connected to the UUMC. We believe that this will further enhance the department by providing a concentrated focus of all activity and a more collaborative environment for resident education and research. The additional operating rooms and outpatient clinics will further increase the volume of neurosurgical cases treated in the department. The Institute will add to our visibility in the community and enhance our ability to move forward in our multiple areas of interest. 5. Research facilities The Department of Neurosurgery has 3000 square feet of research space occupying one half of the fifth floor of the Biopolymer Research Building located a few hundred yards south of the medical school. The building also has a vivarium with a full-time veterinarian and a small-animal support facility. Additional research equipment is available to our group in the Hughes and Eccles Research Institutes, which are located adjacent to the Biopolymer Building, and at the Center for Advanced Medical Imaging located one mile away in Research Park. 12

Research opportunities with faculty members are as follows: 1. 2. 3. 4. 5. Dr. Dan Fults lab investigating the molecular biology of brain tumors. Dr. Randy Jensens lab studying angiogenesis and the role of hypoxia inducible factor in malignant and benign brain tumors. Dr. Couldwells lab investigating meningiomas, pituitary tumors, and skull base anatomy and surgical approaches. The Orthopedic Lab, run by Orthopedic faculty, designed to evaluate spine biomechanics. Clinical Epidemiology and Clinical Trial Design (with the option to obtain a Masters in Public Health) with Dr. John Kestle.

To the east of the UUMC is the Huntsman Cancer Institute (HCI). It is connected via walkways to UUMC. The Huntsman Cancer Institute is a national cancer institute, with world-class laboratory research facilities. Dr Jensens lab is located in HCI. In addition, the Department has a full-time medical editor and a full-time media technician, both of whom support resident research activities. 6. Operating rooms and scheduled surgery days Three operating rooms are dedicated to neurosurgery on a daily basis at UUMC with additional rooms often available as needed. All are state-of-the-art operating rooms and are fully equipped for microneurosurgery and stereotaxis. Video monitors allow viewing of all procedures and facilitate training. Intraoperative fluoroscopy is routinely used and intraoperative angiography is available. Neurophysiologic monitoring is available at all times. Adequate instrumentation is in place to support multiple simultaneous cases. Chief residents can select from among the cases that are being operated each day and normally both of them spend a good part of each day in surgery. Junior residents work under the supervision of the chief resident or under the supervision of a faculty member, depending on the number of rooms that are in operation simultaneously. At PCMC, the neurosurgery ORs have all of the same facilities as those at UUMC, including advanced microsurgery, endoscopy, and stereotaxis equipment. Overflow to an additional OR is frequently accommodated with adequate equipment available to support such utilization. The resident, under faculty supervision, may assist or perform the major portion of the procedure, depending on their level of experience and faculty judgment.

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Chief resident's responsibilities As noted above, the residents assume increasing responsibility for the care of the neurosurgical patient and are allowed to perform more of the operative portions of the patient care as they progress. By the time they are at the senior and chief levels residents often are doing most or all of the procedure under staff supervision and in turn are supervising the junior residents in noncritical portions of the procedure as appropriate. The chief residents conduct twice-daily work and teaching rounds with the residents and nursing staff, supervise the junior residents, plan the resident call and vacation schedule, organize the resident assignments for conference, oversee the compilation of the morbidity and mortality data, and select cases for presentation at conference. Consultations from the emergency room or other hospital services are usually discussed with them before they are presented to the staff.

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Outpatient experience At the UUMC, residents staff an outpatient clinic each Wednesday. It is attended by an NS-4, two NS-3s, and one or two juniors (NS-1 or NS-2). Chief residents also attend if they are available. They perform pre-operative evaluations and post-operative care. This includes taking the history, conducting the examination, ordering appropriate diagnostic tests, arriving at an independent diagnosis, and formulating a plan of management. Neurosurgical attendings staff the clinic on a rotating basis. At PCMC the resident on call participates in the surgeons clinic. They evaluate the patient and review the findings and their management plan with the surgeon. Residents at all levels at both hospitals may be called upon to evaluate outpatients either pre- or post-operatively when their attending physician is unavailable (in the clinics or in the E.R.). They then staff these patients with an attending to arrive at an appropriate treatment decision.

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Critical Care Experience The Neurosurgical service at the UUMC has its own dedicated neurosurgical intensive care unit (NCC) with 11 beds (see section A(4) above). The residents assume primary care of all neurosurgical patients in the NCC with an NS-2 resident having the primary responsibility to these patients under the supervision of the chief resident, the patients neurosurgical attending, and a neuro-critical care neurologist, Dr. Elaine Skalabrin. Dr. Skalabrin is a neurologist with fellowship training in neuro-critical care. She makes daily teaching rounds on all NCC patients and works closely with the NCC resident. The medical director of the NCC is Dr. William Couldwell, who is the chairman of the neurosurgery department. Consultation is readily available with our neuro-anesthesiologist, pulmonologist, and surgical intensivist as needed to assist in the management of these complex patients.

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Neurology The three-month neurology rotation is part of the PGY-1 year prior to starting neurosurgery. It is divided between the UUMC and VA Hospital neurology services. For those residents interested in pediatric neurosurgery, a rotation on the neurology service at PCMC is available.

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Neuropathology Neuropathology training is a part of the NS-1 neuro-oncology/peripheral nerve rotation and the NS-3 research year. Each resident is required to complete a selfstudy course, designed by our neuropathology department (and available on CD). In addition, they review the content of Surgical Pathology of the Nervous System and its coverings (Burger, Scheithauer and Vogel, 4th edition). During the neurooncology/peripheral nerve rotation, they focus on tumor and peripheral nerve pathology and during the NS-3 year they cover other aspects of neuropathology. In addition, there is a weekly brain cutting conference (Wednesday a.m.) and neuropathology slide review conference with our new neuropathologist, Dr. S. Chin. Throughout their training, residents are encouraged to review the biopsy and specimen material sent on their cases with Dr. Chin. He also regularly participates in our weekly case conferences, at which time the relevant pathology findings are reviewed.

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Neuroanatomy The residents are responsible for their own review of neuroanatomy and this review is carried out annually in preparation for the primary written examination for the American Board of Neurological Surgery. Specific talks on cranial nerve anatomy are part of the Wednesday a.m. curriculum. In addition, the relevant surgical anatomy is discussed as appropriate to case presentations.

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Neurophysiology The same as noted above under neuroanatomy applies to neurophysiology. Residents are also exposed to clinical neurophysiology during cases involving physiological monitoring. These areas have been the subject of a number of Grand Round and resident conference presentations.

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Neuroradiology Neuroradiology is a constant component of the daily practice of neurosurgery. Studies on all patients are reviewed with the faculty and with the neuroradiology staff. Our neuroradiologists participate in our case conferences and often give didactic presentations to the residents on Wednesday evenings. The residents are encouraged to avail themselves with the many weekly neuroradiology teaching sessions.

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Electroencephalography No formal training in electroencephalography is provided. Except for those patients who are candidates for epilepsy surgery, EEG studies are rarely utilized by the neurosurgical faculty. Limited studies related to brain death and burst suppression analysis associated with barbiturates are learned as part of the junior resident's experience in the neurocritical care unit. Electrocorticography analysis during seizure surgery is taught by Dr. Matsuo (UUMC) and Dr. Van Orman (PCMC), our epileptologists in the neurology department, and by Dr. Couldwell and Dr. Kestle who perform the adult and pediatric epilepsy surgery.

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Teaching Daily bedside teaching rounds are made by the faculty on their respective patients. The structured teaching sessions are listed below. 1. Conferences with required attendance: a. A series of didactic lectures by attendings covering a core curriculum (one hour per week). The week-by-week curriculum is provided starting on page 18. Case-based teaching (one hour per week). Cases from both institutions are presented. General topics are rotated between spine, neurovascular, tumor, trauma, epilepsy, and pediatric cases. During this time, residents may present a current literature review centered about a specific case. The conference is attended by all the neurosurgery service, the neurosurgery residents, most of the neuroradiology faculty, some of the neurology faculty, as well as our neuropsychologists and neuropathologist. In addition, practicing neurosurgeons from Utah and Idaho often attend this conference and are invited to present interesting and problem cases. The conference serves as the most important teaching conference of the department and utilizes advanced audiovisual and computer aides to enhance the teaching. Journal Club (one hour per week). Topics vary and are chosen by the R3s (research residents). The following are common examples: i. Review of current articles from neurosurgical journals. ii. Critical appraisal. iii. Review of neuroradiology topics with neuroradiology attendings. iv. Hands-on session involving spinal instrumentation, skull plating, microsurgical technique. Pediatric Neurosurgical Case Management Conference (one hour per week), attended by neurosurgeons, neurologists, and neuroradiologists at PCMC. Saturday conference. Cases based management discussions with Dr Couldwell (Department Chair) (One hour per week). Morbidity/Mortality conference is held each month. Cases presented include unexpected neurologic deficit, infection, early reoperation, death, and any other case of unusual/adverse outcome. Attendance of all faculty and residents is required. 16

b.

c.

d.

e. f.

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Conferences with optional attendance: a. Combined Neurosurgery and Neurology Grand Rounds The combined Neurology/Neurosurgery Grand Rounds are conducted on a weekly basis from 9:00 to 10:00 AM on Wednesdays. The responsibility for the didactic presentation of these rounds is divided by neurosurgery and neurology. The presentations are made by the medical school faculty on a wide array of subjects of interest to the neurosurgical trainee and faculty. In addition, outside speakers participate in this program. Pediatric Neurosurgery Epilepsy Conference (two hours per month). Spine Conference. This is a combined conference with the Orthopedic Service. Once a month it is based on journal articles related to spinal disorders and once a month it is conducted at the Shriners Hospital with an emphasis on scoliosis and deformity surgery (two hours per week). Tumor Conference. A neuro-oncology (neurotumor board) conference is conducted on Wednesdays from 4:00 to 5:00 PM by the medical neurological and neurosurgical neuro-oncology faculty and residents, and our neuropathologist and neuroradiologist. A review of all patients referred with neuro-oncologic problems are conducted weekly. Management plans and assignment of treatment protocols are the most important function of the conference. Pediatric Brain Tumor Conference. This is a multi-disciplinary case management conference (one hour per month). Adult Epilepsy Surgery Conference. Multidisciplinary case management conference with Neurology and Neuropsychology (one hour per week). The conference is conducted by Drs. Matsuo and Constantino, our medical epileptologists. Their technical staff, epilepsy fellows, and neurosurgeons performing epilepsy surgery, as well as our neuropsychologists involved in the management and evaluation of epilepsy patients, all participate. Pituitary Conference. A multidisciplinary conference with Endocrinology, Neurosurgery, Neuroradiology, Neuropathology, and Radiotherapy (one hour per month). Neuropathology. A neuropathology conference is conducted on Wednesdays from 11:00 to 12:00 by the neuropathology faculty. This consists of brain cutting or a slide review of current cases.

b. c.

d.

e. f.

g.

h.

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Resident Core Curriculum Vascular Medical management of SAH R Schmidt Surgical management of supratentorial aneurysms J MacDonald Surgical management of infratentorial aneurysms I R Schmidt Surgical management of infratentorial aneurysms II R Schmidt Cavernous malformations R Jensen AVM surgery D Brockmeyer Spinal vascular disease M Schmidt Ischemic disease J MacDonald Dural AV fistulae R Schmidt Guidelines for surgical management of head injury J MacDonald Cardiogenic shock in neurosurgery E Skalabrin Critique of ISAT methods and results J Kestle Management of anterior circulation aneurysms Traumatic vascular injury Tumors Meningiomas Part 1 R Jensen Meningiomas Part 2 R Jensen Current management of spinal tumors M Schmidt Craniopharyngioma M Walker Intraventricular tumors D Brockmeyer Posterior fossa tumors J Kestle Hypothalamic/chiasmatic tumors M Walker Acoustic neuroma C Shelton Spinal cord tumors D Brockmeyer Brain mets R Jensen Pineal tumors J Kestle Dermoid/epidermoid/teratoma R Schmidt Glioma surgery D Fults Skull base approaches J MacDonald Pituitary tumors W Couldwell Neurofibromatosis A Osborn Anterior skull base reconstruction P Sharma Radiobiology/radiosurgery D Shrieve Chemotherapy of CNS tumors part I D Blumenthal Chemotherapy of CNS tumors part II D Blumenthal

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Functional Epilepsy Hemispherectomy and other Ped Epilepsy Surgery J Kestle Epilepsy surgery Temporal J MacDonald Epilepsy surgery Extratemporal P House Vagal Nerve Stimulation R Schmidt The history of movement disorder surgery W Couldwell Baclofen pump trouble shooting J Gooch, J Balbierz, C Lipscombe, RN DBS for Parkinsons P House Surgery for spasticity: Baclofen pumps J MacDonald Surgery for spasticity: rhizotomy M Walker Patient selection for epilepsy surgery T Constantino Neuropsych assessment of neurosurgical patients G Mooney Peds/Congenital Spinal dysraphism M Walker Congenital brain malformations D Brockmeyer Craniofacial disorders and craniosynostosis I - F Siddiqi Craniofacial disorders and craniosynostosis II - F Siddiqi Complicated hydrocephalus M Walker Slit ventricle syndrome M Walker Hydrocephalus management and Hx of 3rd ventric Kestle Neuroembryology for neurosurgeons G Schoenwolf Arachnoid cyst J Kestle Chiari malformations - Brockmeyer Spinal deformity J Smith Pediatric Vascular disease - Brockmeyer Peds topics already covered in other sessions: Pediatric C-spine injuries D Brockmeyer Craniopharyngioma M Walker Hypothalamic/chiasmatic tumors M Walker Surgery for spasticity: rhizotomy M Walker Pediatric Head Injury J Kestle Ped Epilepsy Surgery J Kestle Posterior fossa tumors J Kestle Trauma Guidelines for surgical management of head injury J MacDonald Physiology of spinal cord injury R Schmidt Brain death R Schmidt GSWs R Jensen Pediatric C-spine injuries D Brockmeyer Physiology of spinal cord injury R Schmidt Pediatric Head Injury J Kestle Evaluating the unstable spine Occ C1/2 R Apfelbaum The evolution of cervical plating R Apfelbaum Management of subaxial C-spine fractures M Schmidt 19

Anatomy Electrophysiology of the subthalamic nucleus M Hornyak Cranial nerve II Cranial nerves III,IV,VI Cranial nerves V, VII, VIII Cranial nerves IX,X,XI,XII Radiation safety training D Tripp Infections Complications of sinus disease R Orlandi Spine Infection M Schmidt Miscellaneous Planning your research project J Kestle Sir W Osler W Couldwell DVT prophylaxis study S Browd Medicolegal issues Dave Williams The anatomy game J MacDonald/J Kestle Suggestions incidental aneurysms primer on research methodology pathology billing and coding medical economics some practice management topics like contracting, reimbursement, etc... bone physiology peripheral nerve metastatic disease C. Research All residents are encouraged to carry out clinical research projects during their clinical rotations and are required to carry out a spectrum of basic and clinical research projects during the NS-3 year. They generally work under the supervision of one of the neurosurgical faculty participating in their laboratory projects. Most commonly, this has been in the department's laboratories under the direction of Dr. Dan Fults, Dr. Randy Jensen, or Dr. William Couldwell. Clinical research may be done in association with any of the faculty. Graduate training in clinical trial design and clinical research methods may be done with Dr. Kestle. Depending on their interests, they may also work in other departmental or institutional research laboratories. The residents are encouraged to submit their work for presentation and publications. The following is a list of publications in which a resident of the program was an author or joint author. 20

2003 Liu JK, Kan P, Schmidt MH. Diffuse large B-cell lymphoma presenting as a sacral tumor. Report of two cases. Neurosurg Focus. 2003 Aug 15;15(2):E10. Gottfried ON, Gluf W, Quinones-Hinojosa, Kan P, Schmidt M. Spinal meningiomas: surgical management and outcome. Neurosurg Focus. 2003 June 14(6): Article 2. Gottfried ON, Schmidt MH, Stevens EA. Embolization of sacral tumors. Neurosurg Focus. 2003 Aug 15;15(2):E4. Gottfried ON, Soleau SW, Couldwell WT. Suprasellar displacement of intracavernous internal carotid artery: case report. Neurosurgery. 2003 Dec;53(6):1433-4; discussion 1434-5. Gottfried ON, Fults DW, Townsend JJ, Couldwell WT. Spontaneous hemorrhage associated with a pilomyxoid astrocytoma. Case report. J Neurosurg. 2003 Aug;99(2):416-20. Review. Gottfried ON, Schmidt M. Management of spinal meningiomas. Contemp Neurosurg. 2003 Dec 1;25(24): 1-4. Soleau SW, Schmidt R, Stevens S, Osborn A, MacDonald JD. Extensive experience with dural sinus thrombosis. Neurosurgery. 2003 Mar;52(3):534-44; discussion 542-4. House P, Dunn J, Carroll K, MacDonald J. Seeding of a cavernous angioma with Mycoplasma hominis: case report. Neurosurgery. 2003 Sep;53(3):749-52; discussion 752-3 Klimo P Jr, Rao G, Schmidt RH, Schmidt MH. Nerve sheath tumors involving the sacrum. Case report and classification scheme. Neurosurg Focus. 2003 Aug 15;15(2):E12. Rao G, Apfelbaum RI. Symptomatic pneumocephalus occurring years after transphenoidal surgery and radiation therapy for an invasive pituitary tumor: a case report and review of the literature. Pituitary. 2003;6(1):49-52. Review. Rao G, Brodke DS, Rondina M, Bacchus K, Dailey AT. Inter- and intraobserver reliability of computed tomography in assessment of thoracic pedicle screw placement. Spine. 2003 Nov 15;28(22):2527-30. Rao G, Pedone CA, Coffin CM, Holland EC, Fults DW. c-Myc enhances sonic hedgehoginduced medulloblastoma formation from nestin-expressing neural progenitors in mice. Neoplasia. 2003 May-Jun;5(3):198-204. Rao G, Jensen RL. Coexistent cerebral metastasis and cavernous malformation. J Neurol Neurosurg Psychiatry. 2003 Jan;74(1):105. Klimo P Jr, Kestle JR, Schmidt MH. Treatment of metastatic spinal epidural disease: a review of the literature. Neurosurg Focus. 2003 Nov 15;15(5):E1. Klimo P Jr, Blumenthal DT, Couldwell WT. Congenital partial aplasia of the posterior arch of the atlas causing myelopathy: case report and review of the literature. Spine. 2003 Jun 15;28(12):E224-8. Ragel B, Jensen RL. New approaches for the treatment of refractory meningiomas. Cancer Control. 2003 Mar-Apr;10(2):148-58. Fassett DR, Schmidt MH. Lumbosacral ependymomas: a review of the management of intradural and extradural tumors. Neurosurg Focus. 2003 Nov 15;15(5):E13. Liu JK, Weiss MH, Couldwell WT. Surgical approaches to pituitary tumors. Neurosurg Clin N Am 14:93-107, 2003 Liu JK, Couldwell WT. Interpositional carotid bypass strategies for the surgical management of aneurysms and tumors of the skull base. Neurosurg Focus 14 (3):Article 2, 2003 Liu JK, Kan P, Karawande SV, Couldwell WT. Conduits for cerebrovascular bypass and lessons learned from the cardiovascular experience. Neurosurg Focus 14 (3):Article 3, 2003 21

Liu JK, Chiles BW III, Schmidt MH. Anterior reconstruction and stabilization techniques for cervical spinal metastasis. Contemp Neurosurg 25 (5):1-8, 2003 Liu JK, Forman S, Moorthy CR, Benzil DL. Update on treatment modalities for optic nerve sheath meningiomas. Neurosurg Focus 14 (5):Article 7, 2003 Liu JK, Schmidt MH, MacDonald JD, Jensen RL, Couldwell WT. Hypophysial transposition (hypophysopexy) for radiosurgery of pituitary tumors involving the cavernous sinus: technical note. Neurosurg Focus 14 (5):Article 11, 2003 Liu JK, Gottfried ON, Couldwell WT. Surgical management of posterior petrous meningiomas. Neurosurg Focus 14 (6):Article 7, 2003 Liu JK, Couldwell WT. Pituitary apoplexy: diagnosis and management. Contemp Neurosurg 25 (12):1-6, 2003 Liu JK, ONeill B, Orlandi RR, Moscatello AL, Jensen RL, Couldwell WT. Endoscopic-assisted craniofacial resection of esthesioneuroblastoma: minimizing facial incisions. Technical note and report of 3 cases. Minim Invasive Neurosurg 46:310-315, 2003 Liu JK, Decker D, Schaefer SD, Moscatello AL, Orlandi RR, Weiss MH, Couldwell WT. Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors. Neurosurgery 53:1126-1137, 2003 Liu JK, Apfelbaum RI, Chiles BW III, Schmidt MH. Cervical spinal metastasis: reconstruction and stabilization techniques after tumor resection. Neurosurg Focus 15 (5):Article 2, 2003 Liu JK, Brockmeyer DL, Dailey AT, Schmidt MH. Surgical management of aneurysmal bone cysts of the spine. Neurosurg Focus 15 (5):Article 4, 2003 Couldwell WT, Liu JK, Orlandi RR, Weiss MH. Zones of exposure in surgical approaches to the anterior cranial base and paranasal sinuses. Contemp Neurosurg 25 (25):1-12, 2003 Liu JK, Burger PC, Harnsberger HR, Couldwell WT. Primary intraosseous skull base cavernous hemangioma: case report. Skull Base 13:219-228, 2003 2004 Liu JK, Orlandi RR, Apfelbaum RI, Couldwell WT. New closure technique for the endonasal transsphenoidal approach: technical note. J Neurosurg 100:161-164, 2004 York JE, Klimo Jr P, Apfelbaum RI. Treatment of axis fractures. In Youman's Neurological Surgery, 5th Ed., Vol. 4 (Winn HR, Youmans GR, eds.), pp. 4939-4949. Elsevier, Philadelphia, 2004. Liu JK, Decker D, Tenner MS, Couldwell WT, Chiles BW 3rd. Traumatic arteriovenous fistula of the posterior inferior cerebellar artery treated with endovascular coil embolization. Surg Neurol 61(3):255-260, 2004 Klimo Jr P, Kestle JR, MacDonald JD, Schmidt R. Marked reduction of cerebral vasospasm with lumbar CSF drainage following subarachnoid hemorrhage. J Neurosurg 100(2):215224; editorial response, 209, 2004 Schmidt MH, Gottfried ON, von Koch CS, Chang SM, McDermott MW. Central neurocytoma: A review. J Neuro-oncol 66(3):377-384, 2004 Couldwell WT, Gottfried ON, Weiss MH, Popp AJ. Trends in the neurosurgical workforce. AANS Bull 12(4):7-9, 2004 Liu JK, Tenner MS, Stevens EA, Gottfried ON, Rosenow JM, Madan N, MacDonald JD, Kestle JR, Couldwell WT. Efficacy of multiple intraarterial papavarine infusions on cerebral 22

circulation time in patients with recurrent cerebral vasospasm. J Neurosurg 100(3):414421, 2004 Liu JK, Gottfried ON, Cole CD, Dougherty WR, Couldwell WT. Porous polyethylene implant for cranioplasty and skull base reconstruction. Neurosurg Focus 16(3):Clinical Pearl 1, 2004 Klimo Jr P, Schmidt MH. Surgical management of spinal metastases. Oncologist 9: 188-196, 2004 Liu JK, Brockmeyer DL, Schmidt MH. Aneurysmal bone cysts of the spine. Contemp Neurosurg 26:1-8, 2004 Kan P, Gottfried O, Blumenthal DT, Townsend JJ, Drozd-Borysiuk E, Brothman AR, Jensen RL. Oligodendroglioma and juvenile pilocytic astrocytoma presenting as synchronous primary brain tumors: Case report and review of the literature. J Neurosurg 100(4):700705, 2004 Cole CD, Gottfried ON, Liu JK, Couldwell WT. Hyponatremia in the neurosurgical patient: Diagnosis and management. Neurosurg Focus 16 (4):Article 9, 2004. Liu JK, Couldwell WT. Contemporary management of prolactinoma. Neurosurg Focus 16 (4):Article 2, 2004. Ragel B, Couldwell WT. Pituitary carcinoma: A review of the literature. Neurosurg Focus 16 (4):Article 7, 2004. Fassett DR, Couldwell WT. Metastases to the pituitary gland. Neurosurg Focus 16 (4):Article 8, 2004 Fassett DR, Schmidt MH. Spinal epidural lipomatosis: A review of the etiology and treatment recommendations. Neurosurg Focus 16 (4):Article 11, 2004. Amini A, Schmidt MH. SIADH and hyponatremia after spinal surgery. Neurosurg Focus 16 (4):Article 10, 2004. Fassett DR, Brodke DS. Antibiotics in the management of spinal postoperative wound infections. Semin Spine Surg 16:174-181, 2004 Liu JK, Schaefer SD, Moscatello AL, Couldwell WT. Neurosurgical implications of allergic fungal sinusits. J Neurosurg 100(5):883-890, 2004 Ragel B, Jensen RL. Pathophysiology of meningiomas. Semin Neurosurg 14(3): 169-185, 2004 Rao G, Pedone CA, Valle LD, Reiss K, Holland EC, Fults DW. Sonic hedgehog and insulin-like growth factor signaling synergize to induce medulloblastoma formation from nestinexpressing neural progenitors in mice. Oncogene 23(36): 6156-62, 2004 Liu JK , Apfelbaum RI. Treatment options for trigeminal neuralgia. Neurosurg Clinics N Amer 15(3):319-334, 2004 Schmidt R, Klimo Jr P, MacDonald JD. Marked reduction of cerebral vasospasm with lumbar CSF drainage following subarachnoid hemorrhage: Letter to the Editor. J Neurosurg 101: 357, 2004 Walker ML, Browd S. Craniopagus twins: embryology, classification, surgical anatomy, and separation. Childs Nerv Syst 20(8-9):554-566, 2004 (cover article) Anderson R, Kan P, Klimo Jr P, Brockmeyer DL, Walker ML, Kestle JR. Complications of ICP monitoring in children with head trauma. J Neurosurg (Pediatrics 2) 101:53-58, 2004 Gottfried ON, Liu JK, Couldwell WT. Comparison of radiosurgery and surgery for treatment of glomus jugulare tumors. Neurosurg Focus 17(2): E4, 2004 Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches: Surgical experience in 105 cases. Neurosurgery 55:539-550, 2004 Liu JK, Kan P, Smith ME, Apfelbaum RI. Soft tissue complications of anterior cervical surgery: dysphagia, dysphona, and injuries to the vital nonneural structures of the neck. In Complications of pediatric and adult spinal surgery (Vaccaro A, ed), p. 217-234. Marcel Dekker, New York, 2004 23

Klimo Jr P, Schmidt MH, Fessler RG. Nerve sheath tumors of the spine. In Cancer of the Nervous System, 2nd ed. (Loeffler J and Black PM, eds). Lippincott Williams & Wilkins, Philadelphia, 2004 Gottfried ON, Schloesser PA, Schmidt MH, Stevens E. Embolization of metastatic spinal tumors. Neurosurg Clinics N Amer 15(4): 391-399, 2004 Liu JK, Schmidt MH, Apfelbaum RI. Surgical management of cervical spinal metastasis: anterior reconstruction and stabilization techniques. Neurosurg Clinics N Amer 15(4):413-424, 2004 Klimo Jr P, Dailey AT, Fessler RG. Posterior surgical approaches and outcomes in metastatic spine disease. Neurosurg Clinics N Amer 15(4):425-435, 2004 Binning M, Gottfried ON, Klimo Jr P, Schmidt MH. Minimally invasive treatments for metastatic tumors of the spine. Neurosurg Clinics N Amer 15(4):459-465, 2004 Klimo Jr P, Kestle JR, Schmidt MH. Clinical trials and evidence-based medicine for metastatic spine disease. Neurosurg Clinics N Amer 15(4):549-564, 2004 Rao G, Kestle JR. Pleomorphic xanthoastrocytoma (Part 2: Tumor-specific principles). In Berger MS and Brown eds: Textbook of Neuro-Oncology (ed. MS Berger MS and MD Prados), W. B. Saunders, Philadelphia, 2004 Gluf W, Gottfried ON, Schmidt MH. Cavernous hemangioma of the skull with subdural hematoma. Neurosurg Focus 17(4): Clinical Pearl 1, 2004 Browd SR, Ragel BT, Davis GE, Scott AM, Skalabrin EJ, Couldwell WT. Prophylaxis for deep vein thrombosis in neurosurgery: A review of the literature. Neurosurg Focus 17(4):E1, 2004 Fassett DR, Schloesser P, Couldwell WT. Hemorrhage from Moya-Moya vessels associated with a cerebral arteriovenous malformation. J Neurosurg 101:869871, 2004 Klimo Jr P, Thompson CJ, Drake JM, Kestle JR. Assessing the validity of the Endoscopic Shunt Insertion Trial Did surgical experience affect the results? J Neurosurg (Pediatrics 2) 101:130133, 2004 Rao G, Apfelbaum RI. Dens fractures. In Clark C (ed): The Cervical Spine, 4th Edition. Chapter 45, pp. 614-628. Lippincott Williams & Wilkins, Philadelphia, 2004. Klimo Jr P, Apfelbaum RI. Surgical management of cervical radiculopathy: Part B. Posterior laminoforamintomy. In Clark C (ed): The Cervical Spine, 4th Edition. Chapter 75, pp. 1031-1042. Lippincott Williams & Wilkins, Philadelphia, 2004. Liu JK, Gottfried ON, Amini A, Couldwell WT. Aneurysms of the petrous internal carotid artery: Anatomy, etiology and treatment. Neurosurg Focus 17 (5):E13, 2004 (cover photo) Liu JK, Brockmeyer DL, Schmidt MH. Aneurysmal bone cysts of the spine. Contemp Spine Surg 5(11), 2004 (reprint from Contemp Neurosurg)

2005 Schmidt R, Klimo Jr P. Cerebral vasospasm is markedly reduced by lumbar cerebrospinal fluid drainage. In Cerebral Vasospasm: Advances in Research and Treatment, R.L. Macdonald, ed. pp. 259-262. Thieme Medical Publishers, New York, 2005. Klimo Jr P, Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery compared with conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neurooncology 7(1):64-76, 2005 Gottfried ON, Couldwell WT. Review of Yadav JS, Wholey MH, Kuntz RE, et al: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:1493-1501, 2004. Neurosurg Focus 18 (1):EJC1, 2005 Journal Club, 2005 Couldwell WT, Liu JK, Stevens E, Tenner MS. Response to a Letter to the Editor. J Neurosurg 102:181-182, 2005 24

Fassett DR, Pingree J, Kestle JR. High incidence of tumor dissemination in myxopapillary ependymoma in children. J Neurosurg (Pediatrics 1) 102:5964, 2005 Liu JK, Walker ML. Posterior cervical approach for intrathecal baclofen pump insertion in children with previous spinal fusions: Technical note. J Neurosurg (Pediatrics 1) 102:119122, 2005 Liu JK, Rosenberg WS, Schmidt MH. Titanium cage-assisted polymethylmethacrylate reconstruction for cervical spinal metastasis. Neurosurgery 56 (suppl 1): E207, 2005. Ragel B, Arthur A, Townsend JT, Couldwell WT. Intraventricular tanycytic ependymoma: case report. J Neurooncol 71(2):189-193, 2005 Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Simon AS, Couldwell WT. Trends in the neurosurgical workforce in the United States. J Neurosurg 102:202-208, 2005 Gottfried ON, Binning ML, Schmidt MH. Surgical approaches to spinal schwannomas. Contemp Neurosurg 27(4):1-8, 2005 Couldwell WT, Rao G, House P. Contemporary applications of functional and stereotactic techniques for molecular neurosurgery. In Progress in Neurological Surgery, vol. 18 (ed. Freese A, Simeone FA, Leone P, Janson C). pp. 124-145. Karger, New York, 2005. Gottfried ON, Binning M, Couldwell WT. Distal ventriculoperitoneal shunt failure secondary to Clostridium difficile colitis. Acta Neurochir (Wien) 147(3): 335-338, 2005 Liu JK, Gottfried ON, Couldwell WT. Thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus. Acta Neurochir (Wien) 147(4): 413-417, 2005 Young AL, Ragel B, Su E, Mann CN, Frank EH. Assessing automobile head restraint positioning in Portland, Oregon. Inj Prev 11:97-101, 2005 Rao G, Anderson RCE, Feldstein NA, Brockmeyer DL. Expansion of arachnoid cysts in children: Two cases and review of the literature. J Neurosurg (Pediatrics 3) 102:314 317, 2005 Liu JK, Apfelbaum RI, Schmidt MH. Anterior surgical anatomy and approaches to the cervical spine. In Spinal Instrumentation: surgical techniques (Kim, Vaccaro, Fessler, eds), pp. 59-69. Thieme, New York, 2005 Fassett DR, Apfelbaum RI. Posterior C1-C2 transarticular screw fixation. In Spinal Instrumentation: surgical techniques (Kim, Vaccaro, Regan, eds), pp. 307-314.: Thieme, New York, 2005 Klimo Jr P, Apfelbaum RI. Odontoid screw fixation. In Spinal Instrumentation: surgical techniques (Kim, Vaccaro, Regan, eds), pp. 70-80. Thieme, New York, 2005 Cole CD, Liu JK, Apfelbaum RI. Historical perspectives on the diagnosis and treatment of trigeminal neuralgia. Neurosurg Focus 18 (5):E4, 2005 Liu JK, Couldwell WT. Intraarterial papaverine infusions for the treatment of cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurocrit Care 2(2):124132, 2005 Gottfried ON, Rao G, Anderson R, Hedlund GO, Brockmeyer DL. Diffusion restriction of a spinal arachnoid cyst. J Neurosurg (Pediatrics 4) 102:439, 2005 Liu JK, Cole CD, Kestle JRW, Brockmeyer DL, Walker ML. Cranial base strategies for resection of craniopharyngioma in children. Neurosurg Focus 18 (6a):E9, 2005 Browd S, MacDonald JD. Percutaneous dilational tracheostomy in neurosurgical patients. Neurocrit Care 2(3): 268-273, 2005 Liu JK, Couldwell WT. Far-lateral transcondylar approach: surgical technique and its application in neurenteric cysts of the cervicomedullary junction. Report of two cases. Neurosurg Focus 19 (2):E9, 2005 Gottfried ON, Opitz JM, Hedlund GL, Walker ML. Chiari 1 malformation in patients with FG syndrome. J Neurosurg (Pediatrics 2) 103:148155, 2005 Ragel B, Jensen RL, Gillespie D, Prescott SM, Couldwell WT. Ubiquitous expression of cyclooxygenase-2 in meningiomas and decrease in cell growth following in vitro 25

treatment with the inhibitor celecoxib: potential therapeutic application. J Neurosurg 103(3):508-517, 2005 Klimo Jr P, Kestle JR. Potentially useful outcome measures for clinical research in pediatric neurosurgery. J Neurosurg (Pediatrics 3) 103:207212, 2005 Liu JK, Cole CD, Sherr GT, Kestle JRW, Walker ML. Non-communicating spinal extradural arachnoid cyst causing spinal cord compression in a child. J Neurosurg (Pediatrics 3) 103:266269, 2005 (cover article) Cohen-Gadol AA, Liu JK, Laws Jr ER. Cushings first case of transsphenoidal surgery: the launch of the pituitary surgery era. J Neurosurg 103:570574, 2005 Ragel BT, Couldwell WT. Response to Letter to the Editor about Nonfunctioning Pituitary Carcinomas. Neurosurg Focus 19 (3): E11, 2005 Fassett DR, Apfelbaum RI. Microsurgical C1/2 stabilization. In Min. Invasive Spin. Surgery (ed. H.M. Mayer), Springer, New York, 2005 Klimo Jr P, Rao G, Apfelbaum RI. Microsurgical treatment odontoid fractures. In Min. Invasive Spin. Surgery (ed. H.M. Mayer), Springer, New York, 2005 Klimo Jr P, Schmidt MH, Vrionis FD. Metastatic spinal cord compression. J Natl Comprehensive Cancer Network 3(5):711-720, 2005 Fassett DR, Apfelbaum RI. Vocal cord paralysis after anterior cervical spine surgery. In Spine Surgery Complications (ed. H. An and L. Jenis), Chapter 4, pp. 23-29. Lippincott Williams & Wilkins, Philadelphia, 2005 Binning M, Gottfried O, Osborn A, Couldwell WT. Rathkes cleft cyst intracystic nodule: A characteristic MRI finding. J Neurosurg 103:837840, 2005 Browd S, Kestle JR. Peri-insular hemispherotomy. In Silbergeld D and Miller J (ed): Epilepsy Surgery: Principles and Controversies; Chapter XI-33, pp. 585-588. CRC Press, New York, 2005. Fassett DR, Apfelbaum RI, Clark R, Bachus KN, Brodke DS. Biomechanical Analysis of a New Concept: An Add-on Dynamic Extension Plate for Adjacent-Level Anterior Cervical Fusion (Presented at the 2004 CSRS Meeting). Spine 30:2523-2529, 2005 Ragel BT, Jensen RL. Molecular genetics of meningiomas. Neurosurg Focus 19 (5):E9, 2005 Couldwell WT. Bulletin momentum continues: New editor considers peer review, practice survey impact. AANS Bulletin, 2005 Krieger MD, Couldwell WT, Amar AP, Liu JK, Weiss MH. Surgical management of growth hormone-secreting and prolactin-secreting pituitary adenomas. Operative Neurosurgical Techniques: Indications, Methods, and Results, 5th ed. (Schmidek H and Roberts DW, eds). W.B. Saunders, Philadelphia, 2006. Liu JK, Cohen-Gadol AA, Cole CD, Kan P, Couldwell WT. Harvey Cushing and Oskar Hirsch: Early forefathers of modern transsphenoidal surgery. J Neurosurg 103:1096-1104, 2005 (cover article) Amini A, Beisse R, Schmidt MH. Thoracoscopic spine surgery in instrumentation and stabilization of the anterior thoracic and lumbar spine. Neurosurg Focus 19 (6):E4, 2005 Amini A, Schmidt RH. Endoscopic third ventriculostomy in adult patients: A series of 36 patients. Neurosurg Focus 19 (6):E9, 2005 Klimo Jr P, Kestle JR, MacDonald JD, Schmidt R. Marked reduction of cerebral vasospasm with lumbar CSF drainage following subarachnoid hemorrhage. J Neurosurg 2004 Feb; 100(2):215-224. In Gibbs SR and Verma A: Year Book of Neurology and Neurosurgery 2005; pages 250-251. Elsevier, Philadelphia, 2005. Liu JK, Tenner MS, Stevens EA, Gottfried ON, Rosenow JM, Madan N, MacDonald JD, Kestle JR, Couldwell WT. Efficacy of multiple intraarterial papavarine infusions on cerebral circulation time in patients with recurrent cerebral vasospasm. J Neurosurg March 2004; 100(3):414-421. In Gibbs SR and Verma A: Year Book of Neurology and Neurosurgery 2005; pages 222-223. Elsevier, Philadelphia, 2005. 26

Liu JK, Orlandi RR, Apfelbaum RI, Couldwell WT. New closure technique for the endonasal transsphenoidal approach: technical note. J Neurosurg 2004 January; 100:161-164. In Gibbs SR and Verma A: Year Book of Neurology and Neurosurgery 2005; pages 335336. Elsevier, Philadelphia, 2005. Liu JK, Decker D, Schaefer SD, Moscatello AL, Orlandi RR, Weiss MH, Couldwell WT. Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors. Neurosurgery. 2003 Nov;53(5):1126-37. In Gibbs SR and Verma A: Year Book of Neurology and Neurosurgery 2005; pages 334335. Elsevier, Philadelphia, 2005. 2006 Gottfried ON, Viskochil D, Fults DW, Couldwell WT. Molecular, genetic, and cellular pathogenesis of neurofibromas and surgical implications. Neurosurgery 58(1):1-16, 2006 McCall T, Chin SS, Salzman KL, Fults DW. Tuberous Sclerosis a Syndrome of Incomplete Tumor Suppression. Neurosurg Focus 20(1): E3, 2006 Kan P, Cusimano M. Validation of a quality-of-life questionnaire for patients with pituitary adenoma. Can. J. Neurol. Sci. 33: 80-85, 2006 Rao G, Ragel BT, Amirlak B, Couldwell WT. Apoptosis in glioma cells: review of the literature. In Cell Cycle in the Central Nervous System (ed. D. Janigro). Chapter 12. Humana Press, Totowa, NJ, 2006. Browd SR, Ragel BT, Gottfried ON, Kestle JRW. Failure of cerebrospinal fluid shunts: Part I: Obstruction and MECHANICAL FAIlure. Pediatr Neurol 34(2): 83-92, 2006 Fassett DR, McCall T, Brockmeyer DL. Cervical spine deformity associated with resection of spinal cord tumors. Neurosurg Focus 20 (2):E2, 2006 Anderson RCE, Kan P, Hanson K, Brockmeyer DL. Cervical spine clearance after trauma in children. Neurosurg Focus 20 (2):E3, 2006 McCall T, Fassett DR, Brockmeyer DL. Subaxial cervical spine trauma in children: a review. Neurosurg Focus 20 (2):E5, 2006 Fassett DR, Clark R, Schmidt MH. Odontoid synchondrosis fractures in children. Neurosurg Focus 20 (2):E7, 2006

27

D.

Faculty

William T. Couldwell M.D., Ph.D. Professor and Chairman of Neurosurgery

Medical School: McGill University 1979-1984 Post Graduate: McGill University 1989-1991 Ph.D. Neuroimmunology and Molecular Biology Neurosurgery Residency: University of Southern California 1985-1989 Clinical Fellowship: McGill University 1989-1991

Surgical Management of Epilepsy

Clinical Interests:

Surgical Managment of Epilepsy Neuro-oncology Pituitary Tumors Skull base Cerebrovascular neurosurgery

28

John R.W. Kestle, M.D., M.Sc. Residency Program Director Director of Pediatric Neurosurgery Professor of Neurosurgery Primary Childrens Medical Center

Medical School: University of Western Ontario 1980-1984 Residency: University of Toronto 1985-1990 Post Graduate: McMaster University 1987-1989 MSc Epidemiology and Biostatistics Clinical Fellowships: University of Toronto 1991 Peripheral Nerve The Hospital for Sick Children, University of Toronto 1991-1992 Pediatric Neurosurgery Clinical Interests:

Pediatric Neurosurgery Pediatric Epilepsy Surgery

29

Ronald I. Apfelbaum, M.D. Spine Fellowship Director Professor of Neurosurgery

Medical School: Hahnemann Medical College Residency: Albert Einstein College of Medicine Clinical Interests:

Cervical Spine Instrumentation Pituitary Disorders Management of Trigeminal Neuralgia

30

Daniel W. Fults, III, M.D. Professor of Neurosurgery

Medical School: University of Texas Southwestern Medical School Residency: Bowman Gray School of Medicine, Wake Forest University Research Fellowship: University of North Carolina Clinical and Research Interests:

Neuro-oncology Molecular Biology of Nervous System Tumors General Neurosurgery

31

Marion L. Walker, M.D. Professor of Neurosurgery Primary Childrens Medical Center

Medical School: University of Tennessee Residency: Barrow Neurological Institute Clinical Fellowship: The Hospital for Sick Children, University of Toronto Pediatric Neurosurgery Clinical Interests:

General Pediatric Neurosurgery Management of Hydrocephalus

32

Douglas L. Brockmeyer, M.D. Professor of Neurosurgery Primary Childrens Medical Center

Medical School: Case Western Reserve University Residency: University of Utah Clinical Fellowship: University of Utah

Pediatric Neurosurgery

Clinical Interests:

Pediatric Spine Surgery Pediatric Cerebrovascular Neurosurgery General Pediatric Neurosurgery

33

Randy L. Jensen, M.D., Ph.D. Associate Professor of Neurosurgery

Medical School: University of Utah 1987-1991 Post Graduate: Loyola University 1993-1998 Ph.D Neuroscience Neurosurgery Residency: Loyola University 1993-1998 Clinical Interests:

Neuro-oncology Intraoperative navigation and cortical mapping of lesions in eloquent brain General Neurosurgery

34

Joel D. MacDonald, M.D. Associate Professor of Neurosurgery

Medical School: University of North Carolina, Chapel Hill Residency: University of Utah Clinical Fellowship: University of Florida

Cerebrovascular Neurosurgery

Clinical Interests:

Cerebrovascular Neurosurgery Functional Neurosurgery o Epilepsy, Movement Disorder, etc. General Neurosurgery Organized Neurosurgery Computer-based applications in neurosurgery Complex Spine o Cervical, Thoracic and Lumbar Trauma o Degenerative Disease

35

Richard H. Schmidt, M.D., Ph.D. Associate Professor of Neurosurgery

Medical School: University of Iowa Post Graduate: University of Iowa

PhD Pharmacology

Residency: University of Washington Clinical Interests:

Cerebrovascular Neurosurgery Skull base General Neurosurgery Neurosurgical Intensive Care Neurotrauma

36

Meic H. Schmidt, M.D. Director, Spinal Oncology Service Huntsman Cancer Institute Assistant Professor of Neurosurgery Adjunct Assistant Professor of Orthopedic Surgery

Medical School: Medical College of Wisconsin 1990 to 1994 Neurosurgery Residency: Medical College of Wisconsin 1994 to 2000 Clinical Fellowships:

University of California, San Francisco Neuro-Oncology 2000 to 2001 Spinal Surgery 2001 to 2002

Clinical Interests:

Minimally invasive spine surgery Endoscopic Spinal Surgery Primary and metastatic spine tumors Spinal cord neoplasms Kyphoplasty/Vertebroplasty Radiosurgery Neuro-oncology Complex Brain tumors

37

Paul A. House, MD Assistant Professor Neurosurgery

Medical School: Washington University School of Medicine 1994-1998 Neurosurgery Residency: Neurosurgery, University of Utah 1998-2004 Clinical Fellowship: University of California San Francisco 2004-2005

Surgical Management of Movement Disorders Surgical Management of Epilepsy

Clinical Interests:

Epilepsy Movement Disorders (Tremor, Parkinsons Disease, Dystonia)

38

L. Eric Huang, M.D., Ph.D. Associate Professor of Neurosurgery

Medical School: Fudan University Shanghai Medical College Doctorate: Rutgers University (cell and developmental biology) Postdoctoral Training: Brigham and Women's Hospital-Harvard Medical School Clinical and Research Interests:

Molecular mechanisms of hypoxic response Cancer biology Brain tumors Molecular targets

39

Jay Riva-Cambrin, M.D. Assistant Professor of Neurosurgery Primary Childrens Medical Center

Medical School: University of Alberta, Edmonton, Alberta Canada-1998 Residency: University of Toronto, Toronto, Ontario, Canada 1999-2005 Post Graduate: University of Toronto, Toronto, Ontario, Canada M.Sc., Clinical Epidemiology, 2002-2006 Clinical Fellowships: Pediatric Neurosurgery - The Hospital for Sick Children, University of Toronto 2005-2006

Clinical Interests:

Pediatric Neurosurgery Hydrocephalus Clinical Trials

40

Ken S. Yonemura, MD Assistant Professor Neurosurgery

Medical School: Jefferson Medical College Neurosurgery Residency: University of California, Irvine Medical Center Clinical Fellowship: Barrow Neurological Institute

Spinal Surgery

Clinical Interests:

Interbody fusion techniques Minimally invasive surgical techniques for both the cervical and lumbar spine Peripheral nerve disorders

41

Rudolf W.Beisse, M.D. Adjunct Professor of Neurosurgery

Dr. Beisse is a leading internationally recognized pioneer in thoracolumbar endoscopic spine

stabilization and the developer of the MACS-TL plating system. He is the associate director and head trauma surgeon at the Trauma Center of the Berufsgenossenschaftliche Unfallklinik in Murnau, Germany. This is one of the major regional trauma centers in Germany. We are honored to have him join our faculty as Adjunct Professor of Neurosurgery. Dr. Beisse is an excellent surgeon and superb teacher.

Dr. Beisse will be visiting us periodically from Germany to teach his techniques to our faculty
and residents and to other US spine surgeons. When licensure is granted, he also will be available to assist with surgery and consult with colleagues on difficult cases. Medical School: University of Erlangen, Germany Residency: Trauma Center Murnau, Germany Clinical Interests:

Spine Trauma Minimally Invasive Spine Surgery Endoscopic Spinal Surgery Spinal Cord Injury Surgical Intensive Care

42

E.

Departmental Policies DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH RESIDENT SELECTION AND REPLACEMENT POLICY Reviewed 2/22/06

RESIDENT SELECTION Eligibility 1. Applicant must be a graduate of a US or Canadian medical school accredited by the Liaison Committee on Medical Education (LCME) OR2. Be a graduate of a college of osteopathic medicine in the US accredited by the American Osteopathic Association (AOA) OR3. Be a graduate of a medical school outside of the US who meets one or more of the following qualifications: Has a currently valid ECFMG certificate, OR Has a full and unrestricted license to practice medicine in a US licensing jurisdiction, OR Is a graduate of a medical school outside the US who has completed a Fifth Pathway Program provided by an LCME-accredited medical school. 4. Applicant must have passed Parts I and II of USMLE prior to the time they begin training. 5. Applicant must be willing to comply with the Health Sciences Center Drug Testing Policy if selected. Application Process The neurosurgery training program at the University of Utah participates in the National Neurosurgery Matching Program. They provide a Central Application Service (CAS) for neurosurgery residencies, which standardizes and distributes all application materials. This allows applicants to complete only one application to apply to as many of the participating programs as they select. The neurosurgery training program at the University of Utah does not accept applications from any source except CAS. All applicants to our program must contact the Neurological Surgery Matching Program directly. For candidates inquiring about our program via telephone, mail or email, a packet is sent which contains the GME brochure and a letter from Dr. Kestle, the program director, outlining the application and interview process as well as information about the Neurosurgery faculty and program in general. They are also informed that additional information can be obtained from the departmental website at http://uuhsc.utah.edu/neurosurgery/ as well as the Graduate Medical Education (GME) website at http://uuhsc.utah.edu/som/education/gme/. Required materials for application include the completed CAS application, which includes a personal statement, college and medical school transcripts, USMLE scores and three letters of recommendation.

43

Interview Process From the completed applications, a group of outstanding applicants are selected to be interviewed by a committee made up of the program director and additional faculty members. Applicants are notified whether or not they have been invited for interviews via email. If they are invited for an interview, the interview dates and an overview of the interview process is included in the email. When possible, an informal gathering for the applicants and residents is held at a local restaurant the evening before or after the interview day. Applicants are provided with information and directions related to this prior to their interview visit. The interviews are held on two or three designated days, interviewing between 10-15 candidates each day. By grouping the interviews on a dedicated day we can assure all Resident interviewees have the opportunity to meet most of our faculty and residents and to see our institution in an efficient manner. This also allows us to evaluate, discuss and rate the applicants in as fair and objective manner as possible. On the interview day applicants receive an information folder. The following are included in this folder: The days itinerary A synopsis of each resident and faculty member Faculty and resident publication list An excerpt from our standards of performance Program Description Work hours policy Supervision Policy Moonlighting Policy Leave Policy This Resident Selection Policy Liability coverage policy Stipend memo (previous year's) A copy of the contract they would be expected to sign (previous year's) J1 Visa Acknowledgement form for International Medical Graduates

Applicants interview with all faculty and residents available that day. After interviews are complete, they all meet for lunch and the applicants are then taken on a tour of the clinical and research facilities by two or three of the current residents. The remaining faculty and residents meet to discuss the match ranking. At the conclusion of the interview process, match-ranking lists are completed by the applicants as well as the residency programs. The match results are available in late January. The Neurological Surgery Matching Program match occurs approximately two months prior to the general NRMP match. The University of Utah School of Medicine dos not discriminate on the basis of sex, race, age, religion, color, national origin, disability, or veteran's status. 44

Resident Replacement Despite the rigorous application and resident selection process, it is possible that an active resident will change career plans and leave the program. If that is the case, the Department will assess the current number of residents, the work load and work hours and the impact of having one less resident in the Department. Based on these factors, a decision will be made as to whether to attempt to hire a resident in the middle of the academic year or to wait until the next application process. Should an attempt be made to hire a resident during the academic year, an interview process would be set up with as many faculty available as possible. This may not be on a dedicated Saturday, as occurs prior to the CAS Neurosurgery Match. The other criteria for eligibility and required materials for application are the same as for the resident selection process.

45

DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH SUPERVISION POLICY Reviewed 5-24-06 INTRODUCTION All residents at all levels of the training program are supervised by a faculty neurosurgeon. Faculty schedules are structured to provide residents with continuous supervision and consultation. Faculty and residents are educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects. A. On inpatient units All patients that are admitted through the emergency room or are direct admissions from outside institutions or physicians are assigned to a specific faculty neurosurgeon, generally the neurosurgeon on-call. To assure that the full spectrum of specialized neurosurgical services can be offered to the patient, the senior resident and the faculty person on-call will contact the appropriate neurosurgeon within the group best prepared to handle this problem and arrange for such care. For example, neurovascular problems, specifically acute subarachnoid hemorrhage, and thoracolumbar fractures are managed on both an emergent and elective basis by members of the faculty with specific expertise in these areas. A specific call schedule is published to indicate who is available at any time for these cases. All elective cases are generally admitted to the inpatient service by the neurosurgical faculty. The activities of the residents are supervised by the neurosurgical attendings. Rounds are made daily on inpatients and major diagnostic and treatment decisions are discussed with faculty. Junior residents often discuss patient care issues with chief residents prior to going to the attending. All inpatients are assigned an attending physician who is clearly identified in the patients record. The attending neurosurgeon directs the care of the patient and provides the appropriate level of supervision based on the patients condition, complexity of care and experience of the resident being supervised. Documentation of the supervision is by progress notes entered into the record by the attending neurosurgeon or the resident. The attending may choose to countersign or append the residents note. The attending physician meets all inpatients for whom he or she is responsible early in the course of care and documents this in the chart. In addition, the attending insures the discharge or transfer of patients is appropriate. Attending physicians make daily rounds on inpatients. In between rounds, major decisions regarding diagnosis and/or care are discussed with the attending.

46

B.

On outpatient services At the UUMC, attending neurosurgeons see all of the patients in their own clinics. Residents are invited to participate if they are available and in those situations they are under direct supervision of the faculty member. There is also a resident clinic on Wednesdays. In this clinic the residents perform the initial evaluation and investigation of patients. They are then discussed with faculty. The neurosurgeons supervise the resident clinic on a rotating basis. At PCMC, the outpatients are seen in neurosurgical attending clinics. Again, the residents are encouraged to participate and do so under the direct supervision of the neurosurgeon. Documentation from both clinics, whether dictated by the resident or the attending, reflects the attending with whom the case was reviewed.

C.

In the operating room The specific institution requirements of all the hospitals in our complex require the presence of the surgeon within the institution during all operative procedures. In most cases, the neurosurgical faculty is present within the operating room, and in the majority of cases is scrubbed as either the primary surgeon or first assistant. These requirements assure adequate supervision yet graded responsibility throughout the training period.

Attached (pages 48-58) is the GME Resident Supervision Policy (Section 7, No. 10, Rev. 2, Reviewed April 2006, Revised January 2006). This provides further details. The Department of Neurosurgery complies with this policy.

47

UNIVERSITY OF UTAH HOSPITALS AND CLINICS

GRADUATE MEDICAL EDUCATION

HOUSESTAFF POLICIES AND PROCEDURES _________________________________________________________ RESIDENT SUPERVISION Section 7 No. 10 Rev.2 Review Date: April 2006 Revision Date: January 2006 I. PURPOSE: To outline guidelines for supervision for postgraduate trainees in the University of Utah Affiliated Training Programs. II. POLICY: Each discipline will be responsible for the development of a policy for its program, which includes the principles stated in this document and outlines specific supervision issues distinctive to their training program. All supervision situations will be specialty specific. Programs are free to adopt these guidelines as appropriate to their specialties. III. PROCEDURE: Resident Supervision Policy - Summary of Main Points Key principles 1. An attending physician must be identified for each episode of patient care involving a resident. 2. The attending physician is responsible for the care provided to these assigned patients. 3. The attending physician is responsible for determining the level of supervision required to provide appropriate training and to assure quality of patient care. 4. Resident supervision must be documented. 5. Program directors direct and supervise the program. Key supervision issues 1. Attending physician/staff practitioner responsibilities a. Inpatient i. Attending physician is identified in the chart. ii. Meet with the patient within 24 hours of admission iii. Document supervision with progress note by the end of the day following admission. iv. Follow local admission guidelines for attending notification. v. Ensures discharge is appropriate. vi. Ensures transfer from one inpatient service to another inpatient service is appropriate. b. Outpatient i. Attending physician is identified in the chart ii. Discuss patient with resident during initial visit - Document attending involvement by either an attending note or documentation of attending supervision in the resident progress note. iii. Countersign note c. Emergency Room 48

d.

e.

f. 2.

i. An attending physician must always be physically present. Consultation i. Discuss with resident doing consultation within 24 hours ii. Document supervision of consultation by the end of the next working day. Surgery/Procedures i. Attending physician is identified ii. Attending meets with the patient before procedure/surgery iii. Documents agreement with surgery/procedures iv. Countersign procedure note Sign initial DNR orders and document compliance with local DNR policies

Program director/program coordinator a. Establish and write program specific supervision policy b. Orientation for residents c. Education of attending physicians d. Implementation and follow-up of policy

49

POLICY FOR SUPERVISION OF POSTGRADUATE TRAINEES AT THE UNIVERSITY OF UTAH AFFILIATED HOSPITALS Salt Lake City, Utah
I. DEFINITIONS: a. Graduate Medical Education. Postgraduate medical education is the process by which clinical and didactic experiences are provided to residents to enable them to acquire those skills, knowledge, and attitudes, which are important in the care of patients. The purpose of graduate medical education is to provide an organized and integrated educational program providing guidance and supervision of the resident, facilitate the residents professional and personal development, and ensure safe and appropriate care for patients. Graduate medical education programs focus on the development of clinical skills, attitudes, professional competencies, and an acquisition of detailed factual knowledge in a clinical specialty. c. Program Director. The Program Director is responsible for the quality of the overall affiliated education and training program in a given discipline (i.e., medicine, surgery, psychiatry, pediatrics etc.) and for ensuring the program is in compliance with the policies of the respective accrediting and/or certifying body(ies). d. Residents. The term "residents" refers to individuals who are engaged in a postgraduate training program in medicine (which includes all specialties such as internal medicine, surgery, psychiatry, pediatrics, etc.) The term "resident" for the purposes of this policy includes individuals in their first year of training typically referred to as "interns" and individuals in advanced postgraduate education programs who are typically referred to as "fellows." e. Attending Physician. Attending physician refers to licensed, independent physicians, who have been formally credentialed and privileged at the training site, in accordance with applicable requirements. The Attending physician may provide care and supervision only for those clinical activities for which they are privileged. This term is synonymous with the Attending Physician in medicine. f. Supervision. Supervision refers to the dual responsibility that an attending physician has to enhance the knowledge of the resident and to ensure the quality of care delivered to each patient by any resident. Such control is exercised by observation, consultation and direction. It includes the imparting of the practitioners knowledge, skills, and attitudes by the practitioner to the resident and assuring that the care is delivered in an appropriate, timely, and effective manner. g. Documentation. Documentation is the written or computer-generated medical record evidence of a patient encounter. In terms of resident supervision, documentation is the written or computer-generated medical record evidence of the interaction between a supervising practitioner and a resident concerning a patient encounter. h. Supervising Practitioner. Supervising Practitioner must provide an appropriate level of supervision. Determination of this level of supervision is a function of the experience and demonstrated competence of the resident and of the complexity of the patients health care needs.

50

II. POLICY: a. In a health care system where patient care and the training of health care professionals occur together, there must be clear delineation of responsibilities to ensure that qualified practitioners provide patient care, whether they are trainees or full-time staff. It is recognized that as resident trainees acquire the knowledge and judgment that accrue with experience, they will be allowed the privilege of increased authority for patient care. The hospital must comply with the institutional requirements and accreditation standards of the Joint Commission of Accreditation of Healthcare organizations (JCAHO) and other health care accreditation bodies. Qualified health care professionals with appropriate credentials and privileges provide patient care and provide supervision of residents. The intent of this policy is to ensure that patients will be cared for by clinicians who are qualified to deliver that care and that this care will be documented appropriately and accurately in the patient record. This is fundamental, both for the provision of excellent patient care and for the provision of excellent education and training for future health care professionals The quality of patient care, patient safety, and the success of the educational experience are inexorably linked and mutually enhancing. Incumbent on the clinician educator is the appropriate supervision of the residents as they acquire the skills to practice independently. The principles of good training and educational supervision are not likely to change radically over time. Rules governing billing and documentation, however, will inevitably evolve. This policy focuses on resident supervision from the educational perspective. Institutional Requirements of ACGME state that [medical] residents must be supervised by teaching staff in such a way that the residents assume progressively increasing responsibility according to their level of education, ability and experience. This process is the underlying educational principal for all graduate medical education, regardless of specialty or discipline. Clinician educators involved in this process must understand the implications of this principle and its impact on the patient and the resident. All programs which include residents within the University of Utah Affiliated Hospital System must be approved by the appropriate the ACGME (Accreditation Council for Graduate Medical Education) or have special approval by the Graduate Medical Education (GME) committee.

b.

c.

d.

e.

f.

g.

51

RESPONSIBILITIES: a. Associate Dean for Graduate Medical Education. The Associate Dean for Graduate medical education is responsible for establishing local policy to fulfill the requirements of this policy and the applicable accrediting and certifying body requirements. Residency Program Director. The Residency Program Director is responsible for the quality of the overall education and training program in a given discipline (i.e., medicine, surgery, psychiatry, pediatrics, etc.) and for ensuring that the program is in compliance with the policies of the respective accrediting or certifying bodies. The Residency Program Director defines the levels of responsibilities for each year of training by preparing a description of the types of clinical activities residents may perform and those for which residents may act in a teaching capacity. i. Assess the attending physicians discharge of supervisory responsibilities. At a minimum, this includes written evaluations by the residents and interviews with residents, other practitioners and other members of the health care team. ii. Structure training programs consistent with the requirements of the accrediting and certifying bodies (as identified above) and the affiliated sponsoring entity. iii. Arrange for all residents entering their first rotation to participate in an orientation to policies, procedures, and the role of residents within the affiliated training program iv. Ensure that residents are provided the opportunity to contribute to discussions in committees where decisions being made may affect their activities. c. Attending physician. The attending physician is responsible for and must be personally involved in the care provided to individual patients in inpatient and outpatient settings as well as long-term care and community settings. When a resident is involved in the care of the patient, the responsible attending physician must continue to maintain a personal involvement in the care of the patient. The attending must provide an appropriate level of supervision. Determination of this level of supervision is a function of the experience and demonstrated competence of the resident and of the complexity of the patients health care needs. The procedures through which the attending physician provides and document appropriate supervision is outlined below in section 5. d. Resident. The residents, as individuals, must be aware of their limitations and not attempt to provide clinical services or do procedures for which they are not trained. They must know the graduated level of responsibility described for their level of training and not practice outside of that scope of service. Each resident is responsible for communicating significant patient care issues to the attending physician. Such communication must be documented in the record. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the resident from patient care activities. 52

b.

III. PROCEDURES: a. Resident Supervision by the attending physician. Attending physicians are responsible for the care provided to each patient, and they must be familiar with each patient for whom they are responsible. Fulfillment of such responsibility requires personal involvement with each patient and each resident who is providing care as part of the training experience. Each patient will be assigned an attending physician whose name will be clearly identified in the patient's record. It is recognized that other attending physicians may, at times, be delegated responsibility for the care of a patient and provide supervision instead of, or in addition to, the assigned practitioner. It is the responsibility of the attending physician to be sure the residents involved in the care of the patient are informed of such delegation and can readily access an attending physician at all times. Such a delegation will be documented in the patient's record. The attending physician is expected to fulfill this responsibility, at a minimum, in the following manner: i. The attending physician will direct the care of the patient and provide the appropriate level of supervision based on the nature of the patients condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment of the resident being supervised. Medical, surgical or mental health services must be rendered under the supervision of the attending physician or be personally furnished by the attending physician. Documentation of this supervision will be by progress notes entered into the record by the attending physician or reflected within the residents progress note at a frequency appropriate to the patients condition. The medical record must reflect the degree of involvement of the attending physician, either by staff physician progress note, or the residents description of attending involvement. . The resident note shall include the name of the attending physician with whom the case was discussed as well as a summary of that discussion. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement and supervision. Pathology and radiology reports must be verified by an attending physician. Attending physicians will be responsible for following the admitting procedures required by the institutions at which they are admitting patients is association with resident physicians. ii. For patients admitted to an inpatient team, the attending physician must meet the patient early in the course of care (within 24 hours of admission including weekends and holidays). This supervision must be personally documented in a progress note no later than the day after admission. The attending physicians progress note will include findings and concurrence with the residents initial diagnosis and treatment plan as well as any modifications or additions. The progress note must be properly signed, dated, and timed. Attending physicians are expected to be personally involved in the ongoing care of the patients assigned to them in a manner consistent with the clinical needs of the patient and the graduated level of responsibility of the trainee. iii. Discharge from Inpatient Status. The attending physician, in consultation with the resident, ensures that the discharge of the patient from an inpatient service is appropriate and based on the specific circumstances of the patients 53

diagnoses and therapeutic regimen; this may include physical activity, medications, diet, functional status and follow-up plans. Evidence of this assurance must be documented by the attending physician countersignature of the discharge summary. iv. Transfer from One Inpatient Service to Another, or Transfer to a Different Level of Care. The attending physician, in consultation with the resident, ensures that the transfer of the patient from one inpatient service to another or transfer to a different level of care is appropriate and based on the specific circumstances of the patients diagnoses and condition. The attending physician from the transferring service must be involved in the decision to transfer the patient. The attending physician from the receiving service must treat the patient as a new admission and write an independent note or an addendum to the residents transfer acceptance note. v. Intensive Care Units (ICU), including Medical, Cardiac and Surgical ICUs. For patients admitted to, or transferred into an ICU the attending physician must physically meet, examine, and evaluate the patient as soon as possible, but no later than2 4 hours after admission or transfer, including weekends and holidays. vi. Night Float Admissions. For patients admitted to an inpatient service of the medical center, a night float resident occasionally provides care before the patient is transferred to an inpatient ward team. In these cases, the supervising practitioner must physically meet and examine the patient within 24 hours of admission by the night float to the inpatient service, irrespective of the time the ward team assumes responsibility for the patient. In addition, the supervising practitioner for the night float must be clearly designated by local policy. vii. Out Patient clinic. An attending physician must be physically present in the clinic area during clinic hours. All patients to the clinic for which the attending physician is responsible should be supervised by the attending physician. This supervision must be documented in the chart via a progress note by the attending physician or the residents note and include the name of the attending physician and the nature of the discussion. New patients should be supervised as dictated by graduated level of responsibility outlined for each discipline. The supervision for new patients should be documented by either independent attending physician note or an addendum to the resident note. Unless otherwise specified in the graduated levels of responsibility, new patients must be seen by and evaluated by the attending physician at the time of the patient visit. Return patients should be seen by or discussed with the attending physician at such a frequency as to ensure that the course of treatment is effective and appropriate. This supervision must be documented in the record via a note by the attending physician or the residents note that indicates the nature of the discussion with the attending physician. The medical record should reflect the degree of involvement of the attending physician, either by staff physician progress note or the residents description of attending involvement. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement. All notes must be signed, dated, and timed by the resident. The Attendings co-signature 54

of the residents note is an acceptable method for the attending physician to document resident supervision. viii. The attending physician is responsible for official consultations on each specialty team. When trainees are involved in consultation services, the attending physician will be responsible for supervision of these residents. The supervision of residents performing consultation will be determined by the graduated levels of responsibility for the resident. Unless otherwise stated in the graduated levels of responsibility, the attending physician must meet with each patient who received consultation by a resident and perform this personal evaluation in a timely manner based on the patients condition. The patients seen in consultation by residents must be discussed and/or reviewed with the attending physician supervising the consultation within 24 hours of initial consultation by the resident. The attending physician must document this official consultation supervision by writing a personal progress note or by writing his/her concurrence with the resident consultation note by the close next working day. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement. ix. Emergency Department. An emergency department attending physician must be physically present in the emergency department. Each new patient to the emergency department must be seen by or discussed with an attending physician. The attending physician, in consultation with the resident, ensures that the discharge of the patient from the emergency department is appropriate. x. Emergency room consultations. Emergency room consultations by residents may be supervised by a specialty attending physician or the emergency room attending physician. All emergency room consultations by residents should involve the attending physician supervising the residents discipline specific specialty consultation activities for which the consultation was requested. After discussion of the case with the discipline specific attending physician, the resident may receive direct supervision in the emergency room from the emergency room attending physician. In such cases where the emergency room attending physician is the principal provider of care for the patients emergency room visit, the specialty specific attending physician does not need to meet directly with the patient. However, the specialty specific attending physicians supervision of the consultation should be documented in the medical record by co-signature of the consultation note or be reflected in the resident physician consultation note. xi. Assure all Do Not Resuscitate (DNR) orders are appropriate and assure the supportive documentation for DNR orders are in the patient's medical record. All DNR orders must be signed or countersigned by the attending physician. b. Assignment and Availability of Attending physicians. i. Within the scope of the training program, all residents, without exception, will function under the supervision of attending physicians. A responsible attending physician must be immediately available to the resident in person or by telephone and able to be present within a reasonable period 55

of time (generally considered to be within 30 minutes of contact), if needed. Each discipline will publish, and make available "call schedules" indicating the responsible attending physician(s) to be contacted. ii. In order to ensure patient safety and quality patient care while providing the opportunity for maximizing the educational experience of the resident in the ambulatory setting, it is expected that an appropriately privileged attending physician will be available for supervision during clinic hours. Patients followed in more than one clinic will have an identifiable attending physician for each clinic. Attending physicians are responsible for ensuring the coordination of care that is provided to patients. iii. Facilities must ensure that their training programs provide appropriate supervision for all residents as well as a duty hour schedule and a work environment that are consistent with proper patient care, the educational needs of residents, and all applicable program requirements. c. Graduated Levels of Responsibility. i. Each training program will be structured to encourage and permit residents to assume increasing levels of responsibility commensurate with their individual progress in experience, skill, knowledge, and judgment. ii. As part of their training program, residents should be given progressive responsibility for the care of the patient. The determination of a resident's ability to provide care to patients without a supervisor present or to act in a teaching capacity will be based on documented evaluation of the resident's clinical experience, judgment, knowledge, and technical skill. Ultimately, it is the decision of the attending physician as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. In general, however, residents are allowed to order laboratory studies, radiology studies, pharmaceuticals, and therapeutic procedures as part of their assigned levels of responsibility. In addition, residents are allowed to certify and re-certify certain treatment plans (e.g., Physical Therapy, Speech Therapy) as part of their assigned levels of responsibility. These activities are considered part of the normal course of patient care and require no additional documentation on the part of the supervising practitioner over and above standard setting-specific documentation requirements. The overriding consideration must be the safe and effective care of the patient that is the personal responsibility of the attending physician. iii. The Residency Program Director will define the levels of responsibilities for each year of training by preparing a description of the types of clinical activities residents may perform and those for which residents may act in a teaching capacity. The documentation of the assignment of graduated levels of responsibility will be made available to other staff as appropriate. These guidelines will include the knowledge, attitudes, and skills which will be evaluated and must be present for a resident to advance in the training program, assume increased responsibilities (such as supervision of lower level trainees), and be promoted at the time of the annual review. 56

d. Supervision of Procedures. i. Diagnostic or therapeutic procedures require a high level of expertise in their performance and interpretation. Although gaining experience in performing such procedures is an integral part of the education of the resident, such procedures may be performed only by residents with the required knowledge, skill, and judgment and under an appropriate level of supervision by attending physicians. Examples include operative procedures performed in the operating suite, angiograms, endoscopy, bronchoscopy, and any other procedures where there is the need for informed consent. Attending physicians will be responsible for authorizing the performance of such procedures, and such procedures should only be performed with the explicit approval of the attending physician. NOTE: Excluded from the requirements of this section are procedures that, although invasive by nature, are considered elements of routine and standard patient care. Examples are the placing of intravenous and arterial lines, thoracentesis, paracentesis, lumbar puncture, routine radiologic studies, wound debridement, and drainage of superficial abscesses. ii. Attending physicians will provide appropriate supervision for the patients evaluation, management decisions and procedures. For elective or scheduled procedures, the attending physician must evaluate the patient and write a pre-procedural note or addendum to the residents preprocedure note describing the findings, diagnosis, plan for treatment, and/or choice of specific procedure to be performed. This pre-procedural evaluation and note may be done up to 30 days in advance of the surgical procedure. All applicable JCAHO standards concerning documentation must be done. A pre-procedure note may also serve as the admission note if it is written within 1 calendar day of admission by the attending physician with responsibility for continuing care of the inpatient, and if the notes meet criteria for both admission and pre-operatives notes. Other services involved in the patients operative care (e.g., Anesthesiology) must write their own pre-procedure notes (such as for the administration of anesthesia) as required by JCAHO, but such documentation does not replace the pre-operative documentation required by the surgery attending physician. iii. During the performance of such procedures, an attending physician will provide an appropriate level of supervision. Determination of this level of supervision is generally left to the discretion of the attending physician within the context of the previously described levels of responsibility assigned to the individual resident involved. This determination is a function of the experience and competence of the resident and of the complexity of the specific case. e. Emergency Situation. An "emergency" is defined as a situation where immediate care is necessary to preserve the life of, or to prevent serious impairment of the health of a patient. In such situations, any resident, assisted by other clinical personnel as available, shall be permitted to do everything possible to save the life of a patient or to save a patient from serious harm. The 57

appropriate attending physician will be contacted and apprized of the situation as soon as possible. The resident will document the nature of that discussion in the patient's record. f. Evaluation of Residents and Supervisors. i. Each resident will be evaluated according to accrediting and certifying body requirements on the basis of clinical judgment, knowledge, technical skills, humanistic qualities, professional attitudes, behavior, and overall ability to manage the care of a patient. Evaluations will occur as indicated by the accrediting or certifying body at the end of the resident's rotation or every six months, whichever is more frequent. Written evaluations will be discussed with the resident. ii. If a resident's performance or conduct is judged to be detrimental to the care of a patient(s) at any time, action will be taken immediately to ensure the safety of the patient(s). iii. At least annually, each resident rotating through the will be given the opportunity to complete a confidential written evaluation of attending physicians and of the quality of the residents training. Such evaluations will include the adequacy of clinical supervision by the attending physician. The evaluations will be reviewed by the program director. iv. All written evaluations of residents and attending physicians will be kept on file by the Residency Program Director in an appropriate location and for the required time frame according to the guidelines established by the respective ACGME Residency Review Committee or other accrediting and certifying agencies. g. Monitoring Procedures. i. The goal of monitoring resident supervision is to foster a system-wide environment of peer learning and collaboration among managers, attending physicians and residents. The monitoring process involves the use of existing information, the production of a series of evaluative reports, the accompanying process of public review of key findings, and discussion of policy implications. Monitoring will of the compliance with these procedures will be performed by the program director and as part of the scheduled internal program reviews. ii. The basic foundation for resident supervision ultimately resides in the integrity and good judgment of professionals (attending physicians and residents) working collaboratively in well-designed health care delivery systems. Approval body: Graduate Medical Education Committee Approval date: April 2002 Policy Owner: Graduate Medical Education Historical Information: Review dates: 2/06 Revision dates 1/06 Approval dates: 58

DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH WORK HOURS POLICY Revised 4/13/05

Work hours will be established to conform to the ACGME work hours regulations for all core and subspecialty programs as of July 1, 2003. These regulations are reproduced below: Resident Duty Hours and the Working Environment Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. 1. Duty Hours a. Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. c. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. d. Adequate time for rest and personal activities must be provided. This should consist of a 10 hour time period provided between all daily duty periods and after in-house call. 2. On-Call Activities The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution. a. In-house call must occur no more frequently than every third night, averaged over a fourweek period. b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements. c. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty.

59

d. At-home call (pager call) is defined as call taken from outside the assigned institution. 1. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. 2. When residents are called into the hospital from home, the hours residents spend inhouse are counted toward the 80-hour limit. 3. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. 3. Oversight a. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the residents and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service. b. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care. 4. Duty Hours Exception An RRC may grant exceptions for up to 10% of the 80-hour limit, to individual programs based on a sound educational rationale. However, prior permission of the institution's GMEC is required. 5. University of Utah Department of Neurosurgery Work Hours Policy The definitions of duty hours and on-call activities as described by the ACGME have been adopted. Compliance with these regulations is monitored on an ongoing basis. Resident work hours are entered into commercially available software and reported every four weeks at the Wednesday Departmental Conference by the Program Director. The Program Director also monitors call schedules to ensure compliance. Particular attention is paid to the at-home call, which is not subject to the one in three restriction. All Department members (faculty and residents) have completed the SAFER Training Program so that they are familiar with the signs and symptoms of fatigue. Should these arise, back up support for clinical care and call responsibilities has been available as needed from residents on research rotations. The Department applied for and was granted a 10% exemption to the 80 hour limit and has therefore been working with an 88 hour work week.

60

140

120

100

80

60

40

20

0 May June July Aug Sept PGY 6 Oct PGY 5 Nov PGY 3 Dec Jan PGY 2 Feb ACGME Mar Apr May June

61

DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH VACATION, CONFERENCES AND LEAVE Revised 7/26/06 The service will try to be flexible to try to accommodate individual's vacation requests as long as it does not interfere with the proper functioning of the service. The following general rules should be adhered to: 1) All vacation and travel request forms need to be signed by Dr. Kestle. This applies to any and all time away from the service. This includes going to meetings that are funded by sources other than the Department. Vacation/conference leave requests should be submitted well prior to the date of departure. The last date that they will be accepted is one month prior to the date of the meeting, but earlier notification would be best. There will be no vacation the last two weeks of June and the first two weeks of July. In addition, residents should not plan vacation during times of meetings, since that will reduce the ability of other residents to attend these meetings. Specifically, no vacation should be planned during the time of the Lende Winter Neurosurgery Conference which is held the first week of February every year. In addition, other meetings that should be respected are the Rocky Mountain Neurosurgical Society, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons annual meetings. Only one resident may be gone from a service at a time. We traditionally try to provide additional time off during the Christmas/New Years holiday season. To provide for adequate service coverage vacations should not generally be planned at this time. Residents involved in the National Guard or any other organized reserve branch of the United States Armed Services are entitled to leave of absence not exceeding 15 calendar days or 11 working days per year. This is leave time and is in addition to annual paid vacation. The usual vacation will be seven days. The maximum consecutive vacation time that can be taken is two weeks but if this is done it should be organized to minimize the impact on the service. For example PGY-2 residents should overlap months. In case of conflicting requests, vacations will be awarded by seniority, however seniority preference only exists at the time of the initial request. A senior resident may not change his vacation time to a time already scheduled by a junior resident.

2)

3)

4)

5)

6)

D.

Meeting Policies Residents are encouraged to submit papers for presentation at both regional and national neurosurgical meetings. A submitted presentation should be coordinated with one of the faculty staff and a copy of any abstract submitted should be forwarded to the program director. If a resident has a talk or poster accepted for the meeting, the travel request form should be sent to the program director as soon as they have been informed that their work has been accepted. The same applies to talking at courses. Requests will be considered in light of the number of people who want to travel, the relevance of the meeting, the academic work that the resident is doing at the meeting and the cost. Academic work will be considered in the following hierarchy: Residents receiving awards will have priority over residents giving platform presentations, who will have 62

priority over oral posters, who will have priority over regular posters. Residents (including Chiefs) will not necessarily be reimbursed for attendance at meetings where they are not presenting academic work. Additional time taken either before or after the meeting however will be at the individual's expense and taken as vacation time. It is anticipated that any resident attending a meeting at departmental expense will participate fully in the meeting. Submission of abstracts to meetings outside the Continental United States can only be done with prior approval of the program director and will usually only be considered under exceptional circumstances. Each resident will have a maximum of five weeks off per academic year: three weeks of vacation and a maximum of two weeks time off for attendance at meetings, etc. E. Leave Policy The Neurosurgery Residency Review Committee has no specific policy regarding leave of any kind. Heretofore, leave has been determined by the department chairman. The Family Leave Act mandates that employees be granted leave from work for various personal and medical reasons. Resident staff at the University of Utah are contractually guaranteed 21 days of vacation per year of training. An additional 4 weeks of leave, for whatever reason, will be allowed during a given year for a total of 7 weeks of missed training time in a 12-month period (14%). During a period of leave the resident will continue to receive pay and benefits, including insurance, at the rate specified by hospital policy. Because of the intense nature of neurosurgical training and the major responsibilities every resident has to the patients and the service, use of leave time must be restricted to significant personal or family needs and for the minimum amount of time needed for these events. Residents will be readmitted to the program at the end of the family leave at the same status as when leave commenced. Any resident who takes an extended leave must meet with the program director about his or her return to determine if they will have to make up time to make up the minimum requirements required by the program and the American Board of Neurological Surgery. Abuse of leave time may serve as grounds for probation or termination. 1) Definition Leave is defined as time spent away from clinical or research responsibility on the neurosurgery service during the duration of the residency training program (6 years). Activities such as educational symposiums or professional meetings related to neurosurgical education are not considered leave if they are approved by the program director. Vacation is independent of leave. Leave cannot be accumulated from year to year. 2) Types of Leave Leave will be classified as one of the following: maternity, paternity, adoption, major illness, military service, personal or family need, or bereavement. a) Maternity: The Department of Neurosurgery feels that maternity leave is important for full recovery of the resident and to assure her ability to work 63

b)

c)

d)

e)

f)

g)

h)

a complete schedule upon her return. Maternity leave of 4 weeks paid leave and vacation time may be taken in conjunction. Per the FMLA, additional unpaid leave is available, and residents should discuss this matter with the Program Director. Maternity leave may have to be made up from elective time or at the end of the residency to meet the requirements of the American Board of Neurological Surgery. No scheduling concessions, i.e., "light duty" can be accommodated. The resident is responsible for arranging for coverage of her normal call assignments during maternity leave. It is strongly suggested that individual arrangements be made during the prenatal period to make up this time. Paternity: A resident is allowed to attend the birth of his children and an additional 2 days paid leave. Vacation time may be taken in conjunction with paternity leave. Per the FMLA, additional unpaid leave is available, and residents should discuss this matter with the Program Director. Adoption: A resident, either male or female, is entitled to 2 days paid leave for the purpose of adoption. Vacation time may be taken in conjunction with adoption leave. Per the FMLA, additional unpaid leave is available, and residents should discuss this matter with the Program Director. Major Illness: Since residents are considered "temporary employees by the University Hospital, they do not accrue sick leave. Leave will be granted for the duration of a major medical or psychological illness at the discretion of the program director. The resident may be required to make up the missed training time at the end of the training period without pay. Sick pay and insurance benefits will continue for the duration specified by hospital policy. Military Service: A resident involved in the National Guard or other organized reserve branches of the U.S. Armed Forces are entitled to 15 work days of leave per year. This is paid leave and is in addition to vacation time. Personal or Family Need: A resident may be granted a 1-week period of leave with the prior approval of the program director. An example of acceptable reasons for approval might include a family member with a major illness. Bereavement: A resident may take up to three working days, to extent Program Director deems reasonable and necessary. This leave is available in the event of death of a parent, spouse, child, sibling, parent-in-law, brother-in-law, sister-in-law, grandparent or grandchild. Unusual Circumstances: Under "unusual circumstances, a resident may be granted leave for an unspecified amount of time with the prior approval of the program director. This leave may or may not be paid and make up time may be required.

As specified above, a resident may receive up to 7 weeks of paid leave per year, including vacation, without penalty, with additional unpaid time if circumstances dictate. Individuals with prolonged absences or with repetitive annual absences may require additional make up time at the end of the residency to meet the requirements of board eligibility or if, in the judgment of the program director, it is needed for the individual to be fully trained. Such additional make up time at the end of the residency will be without pay. 64

DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH MOONLIGHTING POLICY Revised 9/17/04

Moonlighting Policy Neurosurgery residency training is a rigorous full-time educational experience. It is important that residents have time for adequate rest and personal pursuits. The ACGME has instituted work hour regulations, which require residents to work no more than 88 hours per week when averaged over a four week period. The University of Utah Neurosurgery program received approval from the Residency Review Committee for a 10% extension of the work hour limit. We therefore have an 88 hour per week maximum. The ACGME requires that hours spent moonlighting be counted towards the 88 hours. Residents should not be diverted from their primary responsibilities of patient care and learning by engaging in extramural professional activities. Because the Neurosurgery Training Program is time intensive and it is difficult to meet all the requirements in only 88 hours per week, moonlighting is not allowed. Military service is not considered moonlighting.

65

DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH PREGNANCY GUIDELINES FOR NEUROSURGERY TRAINEES Revised 9/17/04 The residency program can anticipate that female trainees may have children during training. The AAWR (American Association of Women in Radiology) suggests that reasonable policies regarding pregnancy be established and presented to all trainees. By outlining expectations of the pregnant neurosurgery resident, potential misunderstanding, apprehensions, and even discrimination may be averted. 1. The planned pregnancy, pre-conception Any changes in fluoroscopy schedules to accommodate a resident attempting to become pregnant should not be anticipated. The trainee should take it upon herself to provide extra radiation protection during the critical weeks by: (a) wearing a maternity lead apron, (b) normal precautions of decreasing fluoroscopy time and exposure, (c) wearing a belly badge under the lead apron during fluoroscopy. The maternity lead apron will be kept in the Radiology Chairs Office and can be checked out upon request. The trainee is responsible for the safe return of the lead to the Chairs Office. 2. Antenatal guidelines The greatest radiation risk for the fetus occurs during the first trimester, the period of organogenesis. The NRC allows a fetal dose of up to 500 mR over the nine month gestation period. Studies suggest an expected nine month fetal dose of only 50 mR for the average radiologist. Such a dose increases the theoretical risk for fetal malformation or tumor development by 0.005% (from the normal population rate of 4.100% to 4.105%). Data suggest that fluoroscopy and angiography are safe to the fetus when normal radiation safety precautions are taken. The 1994 occupational dose analysis for the residents in our department also suggests that elimination of fluoroscopy at any time during pregnancy cannot be justified on scientific grounds. At the request of the pregnant trainee, her first trimester schedule can be adjusted so that it does not include angiography or fluoroscopy (to be made up at a later date). For services using extensive under-table fluoroscopy, such adjustments will be considered upon request. The department has available a maternity lead apron (reinforced ventrally, wrap-around style). This apron will be kept in the Administrative Office and may be checked out upon request. The trainee will be responsible for the safe return of the apron to the Administrative Office. The Department Medical Physicist has special belly badges that should be worn beneath the apron. These are inexpensive, re-usable, and can be read weekly or on very short notice. Fetal exposure can and should be closely monitored.

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In the healthy radiologist, prenatal sickness morbidity, is generally minimal and does not impact work attendance. Serious illness requiring prolonged bed rest will be treated as a recognized leave of absence (leave with pay; time to be made up without pay). The pregnant trainee should recognize the potential disruption in scheduling that her maternity leave will cause. Every effort should be made to complete expected service duties during the pre-natal period.

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DEPARTMENT OF NEUROSURGERY UNIVERSITY OF UTAH RESIDENT EVALUATION, STANDARDS OF PERFORMANCE AND DUE PROCESS POLICY Revised 2-22-06 INTRODUCTION Resident performance is evaluated through the residency and advancement to the next level is dependent on satisfactory performance. Residents are evaluated by attending neurosurgeons, often with the input of colleagues, chief residents, nurses and other allied health professionals. In addition, input received by the Department from any source relevant to a residents performance is considered in their progression through and graduation from the program. RESIDENT EVALUATION PROCESS The following methods are used to formulate resident evaluations: a. There is a continuous process of resident evaluation through the residency. This consists of discussion of resident performance at weekly faculty meetings and at faculty retreats. Issues arising from such discussions are brought to the residents attention when appropriate or incorporated into their structured evaluations. The residents are continuously observed during conferences and on the ward and in the operating room. In these situations, immediate feedback is usually given to the residents regarding their decision making process, their skills and their teaching presentations. Structured Evaluations Each resident is formally evaluated by the faculty every three months or at the end of each rotation. This is done on line at https://www.e-value.net/ using the evaluation forms (pages 71-73), which are based on the six competencies as outlined by the ACGME/Neurosurgery RRC. An assessment of their strengths and weaknesses and recommendations for improvement is developed. These evaluation forms are reviewed by the Program Director and Chairman. The Program Director then meets with each resident individually to review and sign the evaluation. The resident receives a copy of the evaluation and may discuss it further at any time. c. Notable Incidents Exceptional resident performance (good and/or bad) is brought to the attention of the Program Director in writing and added to the residents file. These incidents are usually discussed with the resident on an individual basis as they occur. They may be received from Neurosurgical faculty, other disciplines, nurses, families or other allied health workers.

b.

68

d.

American Board of Neurological Surgery Written Examination This examination is taken by the residents during or after the PGY-3 year. The Department pays for the examination. On the first attempt, the residents may choose to take it for practice or for credit. All residents are required by the American Board of Neurological Surgery to satisfactorily pass this examination for credit. The Department goal is to have residents achieve a score of 70th percentile or higher. If this is achieved on the first attempt, a second attempt is not necessary.

STANDARDS OF PERFORMANCE The Department has developed PGY specific standards of performance, which were established by consensus among Department members. These are used as the basis for evaluation and for advancement through the residency training program. They are described in Section A.3. Duties of the residents in each year, pages 6-11. UNSATISFACTORY PERFORMANCE Any resident who receives an unsatisfactory rating on a rotation or who otherwise is not performing in a satisfactory fashion as determined by the faculty and program director will be reviewed for corrective action. Specific recommendations from these reviews might include: 1) 2) 3) 4) 5) Suggesting specific corrective actions Requiring repeating some time Requiring special programs such as counseling Placing an individual on academic probation Terminating the individual if prior corrective action and probation have not been successful or immediately if behavior is especially egregious

The resident will be given an opportunity to remediate unsatisfactory performance. They will be advised as to the length of the probationary period and what must be accomplished in order to be removed from probation. The policies in Section 7, No. 1 (page 76) of the University of Utah Housestaff Policies and Procedures Manual entitled "Academic Probation" will be followed. DUE PROCESS The University of Utah School of Medicine Housestaff Due Process Policy detailed in Section 7 No. 5 of The Housestaff Manual will be followed (pages 78-82). This has been adopted to assure that all actions regarding resident disciplinary action or probation are enacted fairly. Please note that the departmental due process checklist on page 82 is not quite correct in item 7. The policy which is to be applied is stated in Section 7, No. 5, Rev. 2, Section IIA of the Housestaff Manual: "No resident will be dismissed for academic problems without a probationary period, unless extraordinary circumstances exist" (emphasis added). Such extraordinary circumstances are beyond the normal professional behavior expected of all physicians. They may include, but are not limited to, abusive behavior to patients, the public or other health professionals, theft or abuse of property, substance abuse, dishonesty or insubordination.

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PROBATION AND DISMISSAL See Housestaff Manual Resident Evaluation Policy Section 7 No. 1 (page 76). RESIDENT GRIEVANCE POLICY See Housestaff Manual Grievance Policy Section 7 No. 6 (page 83).

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EVALUATION FORM FOR NEUROSURGERY RESIDENTS ON CLINICAL ROTATIONS

Name:

PGY Level:

Evaluator:

Dates of Rotation:

PATIENT CARE: Delivers appropriate and effective patient care Demonstrates compassion toward patients and their families. Is technically competent in the performance of surgical procedures

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5

Not assessed

COMMENTS: _________________________________________________________________

MEDICAL KNOWLEDGE: Knowledge of clinical neurosurgery. Decision making ability.

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 2 2 3 3 4 4 5 5

Not assessed

COMMENTS: _________________________________________________________________

PRACTICE-BASED LEARNING AND IMPROVEMENT: Willingness to learn from errors in order to improve patient care. Uses current literature to support patient care.

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 2 2 3 3 4 4 5 5

Not assessed

COMMENTS: _________________________________________________________________

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INTERPERSONAL AND COMMUNICATION SKILLS: With patients and families. With residents/attendings. With clerical and nursing staff. Maintains comprehensive, timely, appropriate and legible medical records.

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5

Not assessed

COMMENTS: _________________________________________________________________

PROFESSIONALISM: Commitment to professional responsibilities. Adheres to ethical principles. Sensitive to a diverse patient population.

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5

Not assessed

COMMENTS: _________________________________________________________________

SYSTEM BASED PRACTICE: Demonstrates knowledge of different practice and delivery systems. Practices cost effective care.

Rating 1-5 (1=Poor, 5=Outstanding) 1 1 2 2 3 3 4 4 5 5

Not assessed

COMMENTS: _________________________________________________________________

Academic initiative/activity for their level of training

COMMENTS: _________________________________________________________________

Resident________________________________

Program Director_______________________________

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EVALUATION FORM FOR NEUROSURGERY RESIDENTS ON RESEARCH Name:__________________________________________ PGY Level:_____________________________________________ Evaluator:_______________________________________ Dates of Rotation:_______________________________________ 1 Poor 2 3 Expected Level 4 5 Outstanding

Research Performance During the research rotation, the resident developed an appropriate plan for the research rotation. 1

Rating 1-5 (see scale above) 2 3 4 5

Not assessed

learned the necessary techniques for the research.

completed research tasks on time.

acquired an in depth knowledge of the literature relevant to the research.

was able to present/describe the research so that other residents/faculty can understand it.

was aware of the clinical relevance of the research.

was able to suggest/plan future experiments which will build on the work (s)he is doing.

was able to work well independently.

List of presentations: Title

Authors

Conference

List of publications: Title

Authors

Status

List of funding applications: Source

Amount

Status

Program Directors Signature________________________________ Date _________________ Residents Signature_______________________________________

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UNIVERSITY OF UTAH HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION HOUSESTAFF POLICIES AND PROCEDURES ______________________________________________________________________ RESIDENT EVALUATION POLICY Section 7 No. 1 Rev. 2 Review Date: February 2005 Revision Date: February 2005 _____________________________________________________________________ I. PURPOSE: The Graduate Medical Education Committee of the University of Utah School of Medicine has responsibility for the overall academic quality of each of the graduate medical training programs. A part of that quality can be measured by the performance of the residents (a term used to identify interns, residents, and clinical fellows in ACGME accredited training programs). Each program expects a progression of knowledge in the specialty area from beginning to end of training, and such progress needs to be monitored. It is further expected that residents will be eligible for the specialty board examination (if applicable) upon completion of the training program, with an overall goal that all residents will pass the examination and become board certified. In addition to achieving board certification, the training of effective and competent physicians is the goal of each training program, and all evaluations will be directed at that ultimate objective. II. POLICY: STANDARDS OF PERFORMANCE Each program will have a written set of standards of performance for residents. These standards should include, where applicable: 1) A definition of clinical competence, including at least: a) appropriate behavior by the resident, towards patients, colleagues and staff b) ability to perform an adequate history and physical c) fund of basic and clinical knowledge to perform adequately at the assigned level in the training specialty. 2) The conditions for promotion to the next year of training, and 3) Conditions which warrant academic probation or other remedial action. A written copy of these standards will be given to each resident on or before the first day of training in that program, and a copy will also be filed with the Office of Graduate Medical Education. The policy shall spell out the method and frequency of evaluation for residents in the training program. If an In-Service examination is given, the purpose will be spelled out. If it is used as a performance measure, that will be clearly stated to the residents. RENEWAL OF HOUSEOFFICER AGREEMENTS Residents performing satisfactorily may have the resident agreement renewed for the subsequent year. The resident agreement is renewable annually as agreed among the resident, the program director, and the School of Medicine. Issuance of an agreement for one year does not imply the resident will complete the training program. Agreements for succeeding years of training will be issued only after specified conditions have been met. 74

ACADEMIC EVALUATION 1. In addition to regular contact with supervisors, each resident will be evaluated in writing at least monthly, or at the end of each rotation. Rotations longer than one month should have an interim evaluation, if resident progress is not satisfactory. The written evaluations will be placed in the resident's file, and will be available for review by the resident upon request. Residents new to a training program need special monitoring during the first six months of the program. Supervisors are responsible for early detection of problems, and remedial programs must be established by each program. For any evaluation of less than satisfactory performance, for whatever reason, the program director must: a. b. Discuss the evaluation with the resident immediately. Outline in written form and in the discussion any corrective action to be taken to remedy the deficiency, and how the resident will be evaluated to determine if the problem has been corrected. Notify the program evaluation committee of the unsatisfactory evaluation.

2.

3.

4.

c. 5.

The resident will be allowed to refute in writing any evaluation, which will be placed in the resident's file along with the evaluation. Each residency program will designate an evaluation committee, with resident representation, responsible for resident evaluation. That committee must meet at least quarterly to review performance of all residents not progressing satisfactorily. Residents having performance difficulty may need to be placed on a special program immediately, so the problem can be resolved before it is time to renew the agreement for the coming year. The evaluation committee may make recommendations on corrective action as described below. The resident will meet with the program director at the end of each agreement year to review the accumulated written evaluations of the year's performance. A final written evaluation will be done for each resident who completes a program, or changes to another program, whether at the University of Utah School of Medicine or another institution. That evaluation must include a review of the resident's performance during the final period of training and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. This final written evaluation will state whether a resident has successfully completed requirements for board eligibility, or list areas of deficiency for board eligibility. This final evaluation should be part of the resident's permanent record maintained by the Office of Graduate Medical Education.

6.

7.

8.

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ACADEMIC PROBATION Any resident who receives an unsatisfactory rating on any rotation or who is otherwise not performing in a satisfactory fashion, in the opinion of the program or as defined by the program standards of performance, should be reviewed for corrective action. Such corrective actions can include repeating a rotation(s), repeating a year, a special program, which might include special supervision, or termination, if previous corrective action has not been successful, or academic probation in addition to any of the above. Each program will designate who has authority for instigating corrective action, i.e., the evaluation committee, the program director, or the department chair. The Director of Graduate Medical Education should be notified at this time. The resident should have an opportunity to remediate unsatisfactory performance. The program will determine the length of the probationary period, and what must be accomplished in order for the resident to be removed from probation. In general, the probationary period will not extend past the end of the current agreement year, unless the agreement year ends within three months, in which case the program has the option of extending the probationary period into the next agreement year, but that extension shall not exceed three months. Any houseofficer agreement which may have been issued by a program for a subsequent year, will be considered invalid until the resident has fulfilled the probationary requirements and been removed from probation. At the time the houseofficer is removed from probation, the program has the option to: 1) Allow the resident to complete the remainder of the training year, 2) Offer a houseofficer agreement for the next agreement year. 3) Not offer an agreement for the coming year. Houseofficer agreements offered for a subsequent year may contain a written clause stating conditions under which the agreement may be terminated immediately. Usually that clause will refer to continuing problems of the kind that resulted in the first probationary period. If the resident and the program director cannot agree on the terms of remediation, the resident can request review of his case by the program evaluation committee. The decision of a program not to renew an agreement shall be made by the chair after consultation with the program director. Any decision to not renew shall be made and communicated in writing to the houseofficer no later than four months prior to the end of the agreement year, when possible. Virtually all actions of a houseofficer in connection with the performance of duties relate to the suitability of the houseofficer as a medical practitioner. Therefore issues of integrity; abusive behavior to patients, the public, or other health professionals; tardiness or unexcused absences; theft or abuse of property, substance abuse, or insubordination, will be considered as part of the comprehensive academic evaluation. Approval body: Graduate Medical Education Committee Approval date: February 2005 Policy Owner: Graduate Medical Education Historical Information: Review dates: February 2005 Revision dates February 2005 Approval dates: January 6, 1992 76

EVALUATION POLICY CHECKLIST 1. Write departmental standards of performance. Send a copy to the Office of Graduate Medical Education. Set up a procedure whereby all housestaff receive these standards at the start of their training, and updates if revisions are made. Do a written evaluation of each houseofficer at least monthly and put in resident's file. Do interim evaluations if rotation is longer than one month and performance is not satisfactory. Set up a program evaluation committee to meet quarterly to review performance. Monitor housestaff new to the program very carefully for at least six months. If performance is unsatisfactory: a. b. c. 7. Discuss immediately with resident. Outline in discussion and in writing any corrective action to be taken, and what will determine if the problem has been corrected. Notify program evaluation committee of unsatisfactory evaluation.

2.

3.

4. 5. 6.

Do not renew a resident agreement for a subsequent training year without a satisfactory performance review. Resident must be given four months notice of contract nonrenewal. Meet with the resident at least once a year to review performance. Upon completion of training, send a final written evaluation of the resident's performance to the Office of Graduate Medical Education.

8. 9.

77

__________________________________________________________________________________________ SCHOOL OF MEDICINE HOUSESTAFF DUE PROCESS POLICY Section 7 No. 5 Rev. 2 Review Date: February 1, 1992 Revision Date: February 1, 1992 I. PURPOSE

To assure fairness in all evaluations the Graduate Medical Education Committee has adopted Standards of Review for actions that may affect the status of the resident. All residents will receive a copy in the orientation packet of the institution's Standards of Review at the start of training, as well as in the Housestaff Manual. Any resident being disciplined or put on probation, or otherwise affected by the policy will receive a second copy of the policy in the mail, from the Director of Graduate Medical Education (DGME). The policy will be sent with a cover letter as soon as the DGME is notified of the problem by the program director. II. POLICY A. All programs will follow the University of Utah School of Medicine Resident Evaluation Policy. Standards (as spelled out by the institution and each individual program) not met will be considered to be academic problems. No resident will be dismissed for academic problems without a probationary period, unless extraordinary circumstances exist. No resident will be dismissed without consultation with the Director of Graduate Medical Education to make sure that appropriate evaluation, documentation, and probationary procedures have been followed. B. A resident's pay will stop at the time of termination by the program. If the decision is later reversed by the appeals process, back pay may be awarded as part of that decision. An appeal of any decision in this process must be made in writing to the DGME within one week of receipt of the written decision, unless other arrangements have been made.

C.

III.

THE RESIDENT: A. Will be notified in writing by the program director of any negative evaluations which may affect his or her standing or progress in the training program. Has a right to appeal the evaluation if the resident feels he/she has been evaluated unfairly. The resident is allowed to appropriately address the questions of performance before various committees within the department or School of Medicine as specified by the policy below. Academic evaluations during a rotation and the assignment of a rating at the conclusion of a rotation are provided by the course director(s) and will be sustained unless found to be arbitrary, capricious, or not based on established criteria. The unsatisfactory rating may result in interruption of the normal sequence of rotations.

B.

78

C. Has a right to provide additional or explanatory information to the body considering an appeal, as that body is receiving information. If the appeals body has requested the resident to provide or expand upon that information in person, he/she will be excused from committee deliberations after presenting his/her information. D. Has a right to be accompanied by a faculty member or another resident to act as advocate during any personal appearance at an appeal procedure. A summary of proceedings will be made available to the resident. The resident may take notes at the meeting. The resident will be informed, by the program director or the DGME: 1. of the decision of each committee or appeals body. This will be followed by written notification of the decision, at which time the time starts for the next level of appeal. Notification should contain information on the next level of appeal, if the resident is so inclined. The department will be sent a copy of the decision of each committee as well. that at each level of appeal, the party making the appeal, whether it be the resident, program director, or hospital, is responsible for providing evidence to convince the committee or appeals body to reverse the decision being appealed.

E.

2.

IV.

THE PROGRAM: May appeal any decision made by any body subsequent to the decision of the program Grievance Committee, by filing a written appeal with the DGME, as per the above resident procedures, substituting the word "program" for "resident".

79

INSTITUTIONAL DUE PROCESS PROCEDURES I. Informal

The Office of Graduate Medical Education will try to facilitate informal discussions to resolve differences. II. Formal

Any houseofficer, or any party dissatisfied with a decision of the program evaluation committee, may appeal for: A. review by the Program Grievance Committee, comprised equally of housestaff and faculty. Members of the committee should be broadly representative of the program faculty and residents. Appeals may be for any action considered to be arbitrary, capricious, or not in keeping with previously announced criteria. The resident may appear before this committee to testify on his/her behalf, with an advocate, as previously specified. This committee will take into consideration the resident's overall performance when arriving at a decision. This committee will reach a decision no longer than 30 days after receiving an appeal. Any party dissatisfied with the decision of this committee may appeal for: B. review by the School of Medicine Housestaff Grievance Committee, which shall be made up of a program director, two faculty members, and one resident. No member of the committee shall be a member of the resident's department, and if that is the case, that individual shall be replaced for purposes of this particular appeal. They may ratify, reverse, or make a new decision. This committee will reach a decision no longer than 30 days after receiving an appeal. Any party dissatisfied with the decision of this committee may appeal for: C. review by the Dean, School of Medicine, who will review to be sure procedures have been followed. Usually, he/she will not rule on a case but merely pass it on to the Vice President after review. However, the Dean may ratify, reverse, or make a new decision. The Dean will make a decision no longer than 14 days after receiving an appeal. Any party dissatisfied with the decision of the Dean may appeal for: D. review by the Vice President of Health Sciences who may ratify, reverse, or make a new decision. The Vice President will make a decision no longer than 14 days after receiving an appeal. This will be the final step in the appeal process.

III.

Time limits as established above may be extended by mutual agreement between the DGME and the aggrieved party. Time limits refer to working days.

IV. Appeals at every level may result in hearings where the parties will be afforded ample opportunity to present their case and to introduce relevant information. V. Violations of law and other such behavior which do not bear directly on performance or suitability as a physician are considered disciplinary problems, and will be referred to the civil authorities where appropriate.

80

Approved by: Graduate Medical Education Committee January 6, 1992

81

DEPARTMENTAL DUE PROCESS CHECKLIST FOR HOUSESTAFF 1. Establish program criteria pursuant to the University of Utah School of Medicine Resident Evaluation Policy. Set up a Program Grievance Committee, comprised equally of housestaff and faculty and broadly representative of faculty and residents. Notify a resident in writing of any negative evaluations which might affect his or her standing or progress in the program. The resident has a right to appeal any evaluation on the basis that it is arbitrary, capricious, or not based on an established criteria. The resident has a right to provide additional or explanatory information to the Program Grievance Committee. The resident has a right to be accompanied by a faculty member or another resident to act as advocate during any appeal procedure. The resident may take notes at the meeting. No resident may be dismissed without a period of corrective action, or probation. The resident will be informed by the program director, or Director of Graduate Medical Education, of the decision of each committee or appeals body. All the above steps must be followed, as outlined in the School of Medicine Housestaff Due Process Policy (Section 7, No. 5, Rev. 2) before the resident may appeal to the School of Medicine Housestaff Grievance Committee.

2.

3.

4.

5.

6.

7. 8.

9.

REPORTING POLICY All residents dismissed from a training program, or whose contracts are not renewed as expected, or for cause, will be reported to the Utah Physician Licensing Board. A letter will be written by the Dean stating "_____________________________________, M.D., was dismissed (did not have his/her contract renewed) from (name of training program) at the University of Utah School of Medicine on (date)." Approved by: Graduate Medical Education Committee January 6, 1992

82

______________________________________________________________ SCHOOL OF MEDICINE HOUSESTAFF GRIEVANCE COMMITTEE HEARING GUIDELINES Section 7 No. 6 Rev. 1 Review Date: February 1, 1992 Revision Date: February 1, 1992 _______________________________________________________________ If the due process procedure results in a hearing, these guidelines are to be followed: 1. 2. 3. Hearings are in the nature of informal, adjudicative proceedings; they are not formal trials. Formal rules of evidence are not applicable. Hearings will be open to all parties, but may be closed to the public at any time if the evidence reasonably requires or involves a discussion of the character, professional competence, or physical or mental health of an individual. Hearings will be held only after timely notice to all parties. Each of the parties will be permitted to testify and comment on the issues at the hearing, or present written evidence or testimony. When invited to a hearing, each of the parties will be permitted to examine all documents introduced at the hearing, together with any other documents relied upon by the Committee in reaching its decision. Each of the parties will be permitted to bring a representative to the hearing who shall function in an advisory capacity only. Unless called as a witness, the advisor shall not address the Committee or question witnesses. If the resident's advocate is an attorney, a University attorney will also be invited. Cross-examination of one side by the other will not be permitted. Each of the parties will be allowed to submit questions to the Chair, however, to be put to the other if determined to be significant and helpful in the Chair's sole discretion. The presentation of information by either party may be limited by the Chair if it is determined to be irrelevant, inappropriate, repetitious, or generally of little use in contributing to a fair and expeditious resolution of the issues. Any questions about committee rules or procedures should be directed to the Chair. Committee deliberations after a hearing will be private.

4. 5.

6.

7.

8.

9.

10. 11.

Approved by: Graduate Medical Education Committee, January 6, 1992 83

Other rules and guidelines A. General 1. 2. Residents are at all times expected to exhibit appropriate and professional behavior towards patients, staff and fellow residents. Residents are required to follow the procedures and meet the standards and requirements detailed in the University of Utah Housestaff Policies and Procedures Manual unless otherwise specified in this document. Residents are expected to answer all pages promptly.

3. B.

Medical Records 1. Residents are expected to adhere to the medical record policy of the institution. This includes the timely preparation of both discharge summaries and operative dictations as well as timely correction of any oversights that have occurred. Every patient admitted to the hospital will have a history and physical recorded on the medical record. If this is done by the intern or medical student it will be reviewed by the appropriate neurosurgery resident and any additions that are necessary appended to it. Every patient going to surgery will have their history reviewed and be examined by the most senior resident who is scrubbing on the procedure. The resident assigned to the case will be responsible for entering the appropriate data in the Op Coder computer program in the operating room and generating an operative note for the chart from that program. Hospital policy requires orders to be rewritten after any procedure done in the operating room regardless of the anesthetic. For small procedures done outside the operating room under local anesthesia only, a "resume all previous orders" order can be written. Residents with an excessive number of incomplete charts will not be allowed to scrub in surgery until these charts are completed. Accumulation of undictated reports or summaries will result in suspension, with the need to make up suspended time to complete the residency.

2.

3. 4.

5.

6.

C.

Attire Neurosurgery has adopted the Graduate Medical Education Professional Attire Guidelines UNIVERSITY OF UTAH HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION HOUSESTAFF POLICIES AND PROCEDURES PROFESSIONAL ATTIRE GUIDELINES Section 07 No. 12 Rev. 0 Review Date: August 2, 2004 Revision Date:

84

Purpose To present a professional appearance to patients, staff, and the public at all training sites, and comply with JCAHO standards where applicable. Policy Resident appearance and conduct should at all times reflect the dignity and standards of the medical profession. Dress guidelines for residents assist in achieving this goal while also acknowledging individual desires for diversity and self-expression. Following are guidelines for professional attire. It is recognized that each department or specialty may have requirements which are more specific or less rigorous than the guidelines outlined herein. It is the purpose of this policy to provide general guidelines to assist each department or specialty in developing its own dress code policy to meet its specific needs. These guidelines apply to each work day, including days with no patient care responsibilities. Maternity clothes are not exempt from these guidelines. Specific Standards: Name Tags: Proper identification as required by each training site must be worn and clearly displayed at all times while on duty. White coats: White coats are recommended, and must be clean and neat. If wearing scrubs outside the operating area, it is recommended that a clean white coat be worn over the scrubs. Scrubs: Scrubs should not be worn outside of the hospital premises. Scrubs are expected to be clean and pressed. Scrubs may be worn in the operating room, delivery areas, or on the following rotations only unless otherwise delineated by departmental policy: Emergency room, AO, and all ICUs. In patient care areas, it is recommended that a coat with name tag be worn over the scrubs. Shoes: Footwear must be clean, in good condition, and appropriate. Open-toed shoes and sandals are not recommended in patient care areas for safety reasons. Style: No tank or halter tops, midriffs or tube tops. No sweatshirts or shirts with messages, lettering or logos (except UUMC, LDS or VAMC). No shorts. Jeans are discouraged. A tie is recommended for men on weekdays and recommended on weekends unless described as optional in the specific department policy. Fragrance: No strong colognes or perfumes as patients may be sensitive to strong fragrances. Hands: Fingernails must be clean and short to allow for proper hand hygiene, use of instruments, prevent glove puncture and injury to the patient. Artificial nails do not allow for proper hand hygiene. Hair: Mustaches, hair longer than chin length, and beards must be clean and well trimmed. Residents with long hair who render patient care should wear hair tied back to avoid interfering with performance of procedures or coming into contact with the patient. Jewelry: Should not be functionally restrictive or excessive.

85

Piercings/ Tatoos: There should be no visible body piercings, with the exception of ears. Nose piercings which have religious significance are acceptable. There should be no visible tattoos. Violation: If a resident is in violation of his/her departments guidelines, he/she may be asked to return home to change into more appropriate attire. Repeat violations will result in a letter being placed in the residents permanent file, addressing deficiencies in the professionalism competency portion of training. Departments should write a department-specific policy which may deviate from this policy as long as it adheres to these basic guidelines, as well as those found in the University Hospital Professional Image Standard 1-6. D. Special Consideration for Pregnant Residents Regarding Radiologic Exposure The Department of Radiology has very reasonable guidelines based on the American Association of Women in Radiology (AAWR) recommendations. These guidelines will be the official policy of this department as well (pages 66-67). E. Resident/Staff Communications The attending neurosurgeon should be notified as expeditiously as possible of any significant worsening in the patient's condition. Any major treatment decisions should be coordinated with the attending staff as well. All patients at University Hospital and Primary Children's Medical Center are private patients and have an attending surgeon. The attending staff should be notified of any patient of theirs who is admitted to the hospital or transferred to or from the service. No patient will be taken to surgery unless the attending surgeon is either in house or immediately available except in the case of a life-threatening situation in which the most senior resident available may proceed while the support staff attempts to notify the attending surgeon or, if unable to contact him, contact any other staff surgeon. F. Drug Testing 1. 2. Random drug testing will be carried out at the VA Hospital as part of the federal mandate to maintain drug-free government work places. A positive drug test will adversely affect an individual's ability to remain in the neurosurgical residency program.

G.

Additional Items 1. Residents should notify the program director or department chair if at any time they feel they are not getting regularly scheduled time off or feel that their educational experience is suffering from a service load that has been given to them. The University of Utah Housestaff well-being program is available to provide assistance and appropriate professional referral to assist housestaff in dealing with depression, anxiety, substance abuse, or marital and family conflicts. Leonard Haas, Ph.D. is in charge of student counseling and can be reached at 581-7914, pager 339-7113 or email at lhaas@dfpm.utah.edu. This service is confidential. See Section 7 No. 4.5 of The Housestaff Manual for detail. 86

2.

3.

In view of the ADVAMED regulations recently introduced, a Department policy regarding interactions between the residents and industry has been discussed and developed by the Education Committee. Residents are, on occasion, invited to attend conferences, receive books, surgical loupes, or other such items at the expense of industry. These arrangements were sometimes made on an individual basis between a resident and industry and in the past there was little oversight of the process from the Department. Since the Department is responsible for the education of the residents and since some of these items are related to the educational process, the Department now evaluates the appropriateness of these items in light of the rest of the educational process. Therefore, any offers of industry support for residents should go through the Program Director and should be in the form of an unrestricted educational grant to the Department. The funds generated will be distributed in a fashion that best meets the educational needs of all of the residents. Industry support will be welcomed and encouraged in this form.

F.

Resident Support At UUMC, there is a nurse specialist assigned for every two attending surgeons. They provide assistance in the care and management of inpatients and outpatients. They provide an especially valuable interface with patients and families. They take care of scheduling of imaging and follow-up appointments and answer patient and family questions. They are also involved in clinical research studies for the appropriate attending. UUMC has all of the usual support services including phlebotomists. The location of imaging studies for surgical procedures is facilitated by a digital imaging system. This is available in NCC as well. Hospital dictation is easily available from any telephone in the hospital. Outpatient clinical personnel are provided by both the hospital and department. In addition, the department provides full secretarial and administrative support to the residents. At PCMC, the same hospital, secretarial, and administrative support is available. There is a nurse practitioner and a clinical nurse specialist. The nurse practitioner assists with the care and management of inpatients and functions similar to an intern or junior resident. The clinical nurse specialist is in charge of the clinics and deals with calls from outside physicians and patients. She also performs surgical scheduling. Both hospitals have an on-call room available adjacent to the clinical areas. Both hospitals provide a food allowance for residents on call and both hospitals have a medical library on site. In addition, there is a neurosurgery library in the office area of the adult division at UUMC and in the office area at PCMC. The Department has two support staff that are instrumental in resident academic productivity: a) a medical editor who assists the residents with manuscript development and submission, and (b) a media technician who develops and catalogues their slide/video presentations for meetings and conferences.

87

G.

Evaluation 1. Evaluation of Residents Described in Department Policies (page 68). 2. Evaluation of Faculty The residents are asked to evaluate the faculty using a standard on-line questionnaire (page 89) at the end of each rotation. The evaluations are completed anonymously by residents, reviewed by the program director and department chair, and discussed with the individual faculty members. Correction of any serious problem is monitored by the program director and chairman.

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EVALUATION FORM (to be completed by neurosurgical residents) Name of Faculty Member Dates Rate from 1 to 5 (1 is outstanding and 5 is poor) A) Teaching ability 12345 COMMENTS:

B) Clinical ability and respect as a role model 12345 COMMENTS:

C)

Interest in the residents' educational experience 12345 COMMENTS:

D) Operating room technical ability 12345 COMMENTS:

E)

Willingness to teach in the OR through supervising residents surgery 12345 COMMENTS:

F)

Encourages residents to be involved in research projects 12345 COMMENTS:

G) Ability to get along with peers, residents, students, nurses, patients 12345 COMMENTS: H) Please rate the faculty member as a speaker using the rating scale as follows: 1=Outstanding 2=Very Good 3=Satisfactory 4=Fair 5=Poor 1. Organization and preparation 2. Were objectives clearly defined 3. Clarity of presentation/explanations 4. Was relevance of the material to medicine made clear 5. Degree to which conference enhanced your understanding of subject 6. Was material covered appropriate for your needs 7. Speaker's enthusiasm; ability to make material interesting 8. Quality of handout or syllabus material for these conferences 9. Quality of audiovisual material 10. Pace of presentation COMMENTS: GENERAL COMMENTS: GREATEST STRENGTH OF FACULTY MEMBER: GREATEST WEAKNESS OF FACULTY MEMBER:

89

3.

Evaluation of the Program The following methods are used to evaluate the residency program: A. Review of residency. At the end of each academic year, in addition to evaluating the faculty, the residents conduct a review of the residency (which focuses on the preceding year). There are no faculty present at the meeting. The chief residents summarize the evaluation and submit it in writing to the department it is distributed to all faculty members and discussed at the weekly faculty meeting. Informal feedback. During the year, informal feedback is received from the residents on a regular basis. Because of the small number of residents (and the almost one-to-one ratio of faculty to residents) and the close working relationship among the group, this is probably our best method of feedback. Problems are identified quickly and addressed as they arise. Meetings with the program director. The program director (Dr. Kestle) meets with every resident to review their progress but also to get their feedback on the program, including clinical rotations, research, faculty, teaching sessions, call, and anything else that they felt was a concern. In addition, feedback is solicited from the residents during their quarterly meeting with the program director Resident surveys. The program director administers confidential surveys to all the residents. One asks general questions about the program. The other asks them to rate the conferences (attached). Each year the ACGME asks that 70% or more of our residents complete an online survey. Our compliance is usually very high and the results are provided to us in a summary format. Resident retreats. Once or twice each academic year the Chair, Program Director and Associate Program Director have a retreat with all the residents and interns. An open discussion of issues related to the residency is held.

B.

C.

D.

E.

As a result of the above evaluation processes, a number of changes have been made over the past few years: 1. 2. A nurse practitioner and physician assistant were hired to help with the inpatient service at the UUMC. Feedback to residents from faculty has increased in frequency and the results of the evaluations are available at any time on line at https://www.e-value.net/. The PGY-specific expectations have been developed and distributed to all of the residents. Attendance at Grand Rounds and PCMC Trauma Conference have been made optional.

3. 4.

90

Strongly disagree 1 Hospital support services are sufficient to help me care for my inpatients The caseload on the wards is about right The average number of work-ups on call days is reasonable There is enough clerical/administrative support provided by the program The workload is generally excessive on the wards I get timely and appropriate feedback from faculty I receive sufficient counseling from faculty to help with career planning Full time faculty contribute to a great extent to the teaching Ive received I have enough personal support from faculty I receive enough instruction on what is expected of me in each level of training I have far too little leisure time There are too many difficult patient management problems on the service I often feel stressed out or depressed I often feel tired and overworked I rarely have time to read

Strongly agree 5

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Please evaluate the following conferences. If you have not attended a particular one enough to have an opinion pls check cant evaluate. Pls add comments on back especially constructive ones if you think a conference has low value.

Waste of time 1 Wed am first hour Wed am 2nd hour Grand Rounds (Wed am third hour) M+M Wed evening journal club PCMC Fri am radiology case conference (0800-0900) PCMC epilepsy conference (Fri 0700) PCMC trauma conference (Fri 0700) PCMC tumor board Sat am case conference UU Spine conference (Tues 5:30) UU tumor board (Wed 3 pm) UU epilepsy UU pituitary conference

Extremely valuable 5

Cant evaluate

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H.

Fellowships A. Pediatric Neurosurgery Fellow The Pediatric Neurosurgery Fellow is appointed for one year and is based exclusively at Primary Childrens Medical Center. One fellow is accepted per academic year and he or she works closely with the two Neurosurgery residents rotating at PCMC. The Pediatric Fellow has completed neurosurgical residency training prior to the fellowship. The fellowship is primarily clinical, with the fellow being a full-time member of the housestaff on the Pediatric Service. Call and clinical duties are shared equally by the fellow and the two residents (one-in-three call from home). Because of the large surgical volume of pediatric cases, the fellow is able to obtain training in pediatric neurosurgery without interfering with the resident training experience. The division of operative cases on the service is primarily based on the call schedule. The person on call each day (whether it is the resident or the fellow) stays out of the operating room to cover the emergency department, inpatient service, and outpatient clinics. On rare occasions, when there is a complex or unique pediatric case, the senior resident and/or fellow may be in the operating room even though, according to the call schedule, they would be scheduled out of the operating room that day. In the OR, all cases are directly supervised by attending pediatric neurosurgeons with graded responsibility to the fellow, senior resident, and junior resident according to the complexity of the case and their surgical ability. The operative data for the 2003-2004 academic year indicate that there were 1,041 major procedures performed at PCMC. One hundred sixty-two of these did not have the resident in a significant role. This means the case was done primarily by the attending and fellow, or by the attending and residents with the resident having a minor role (i.e., involved in opening and/or closing only). The remaining 879 cases were performed with significant resident participation. Based on these numbers, we believe there is adequate clinical work at various levels of complexity for resident training and that the fellow does not interfere with the resident experience. B. Spine Fellow The Spine Fellowship Program at the University of Utah is a joint fellowship sponsored by the Spine Sections of both the Neurosurgery and Orthopaedic Departments. One fellow is accepted from the orthopaedic discipline and one from the neurosurgery discipline annually. Fellows are selected by the appropriate department and should have completed residency training. The fellow will spend one half year on each service. In addition they are encouraged to engage in scholarly activity and have an opportunity to participate in research projects in both departments and in the Orthopaedic Biomechanics Laboratory under the direction of Kent Backus, Ph.D. Regular joint conferences are held involving spine surgeons from both departments. The neurosurgery portion of our program is a resident-centric one and fellows are advised of this prior to their accepting a position. The chief residents have their choices of cases on which to scrub. However, with the volume of material on our services, there are often three or four ORs running simultaneously. The chief residents will usually pick the cases that interest or challenge them the most when there is the opportunity to do so. Our two 93

chiefs in 2003-2004 for example, Dr. Paul House and Dr. Adam Arthur, were planning careers in functional and epileptic surgery and cerebrovascular surgery, respectively, but had the opportunity to scrub on all types of cases during their chief year. The operative statistics support the fact that the fellow is not impinging on the training opportunities for the resident. In 2003-2004, 480 spine cases were done. Two hundred three of these were done by one of the two chief residents and 198 by the two spine fellows. For 79 cases, neither was available. Our junior residents scrubbed on 176 spine cases, sometimes as first assistant and other times as second. During the orthopaedic portion of the year there are not always senior orthopaedic residents, so the fellows have the opportunity to scrub on most cases. This helps round out the experience. With this balance, there has been a good acceptance of the casesharing concept necessary to preserve resident experience.

C. Skull-Base Fellow The Skull-Base Fellow is appointed for one to two years. The fellow will participate in the clinical diagnosis, pre-operative assessment, intraoperative participation, and postoperative management of patients with skull base lesions including complex tumors at the base of the skull, complex aneurysms located at the cranial base, and head and neck cancer (along with the ENT Division). Involvement of the fellow will not interfere with neurosurgical resident training. The material in the Department of Neurosurgery exceeds the ability of senior resident involvement in all cases. The fellow will also be involved with teaching of residents at all levels and he/she will participate in the skull base conference where cases are presented for discussion and management with ENT and Neuroradiology. The fellow is also expected to do be involved in a retrospective analysis and also a prospective study in the various disease processes that involve the cranial base. In addition, the anatomical skull base laboratory provided by the Department of Neurosurgery is available for correlative anatomical studies and the developments and refinements in skull base approaches. The fellow is expected to present papers at national and international meetings, as well as prepare publications in the peer-reviewed journals, as well as textbooks.

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I.

Operative data for one of the chief residents, 2003-2004

95

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY OPERATIVE EXPERIENCE FOR RESIDENTS
Supply the number of cases for the most recently graduating resident representing his/her entire neurosurgery experience. This information is to be reported separately: by senior clinical year, and by all other clinical years. Combined surgical statistics from ALL institutions in which the resident served are to be included on this one form and not broken down into separate institutions. Count only those cases in which the resident had a significant decision making role (including pre- and post-operative care). "Surgeon" refers to primary responsibility; "Assistant" refers to surgeon acting as an assistant. Patients up to 16 years of age inclusive are considered pediatric cases. Procedures listed as "Other", should be explained in the "Other" section found on page 7 of this log. Attach additional pages as necessary. Resident's Name: ___________________ ______ Log Covering Period from: __________ to__________ Resident Signature ________________________________________ Major Procedures Adult (17+ Years) 1. Craniotomy Other than Trauma Abscess Aneurysm AVM Epilepsy (diagnostic/ therapeutic) Hematoma Metastatic Tumor Primary Tumor Other Subtotal 2. Head Trauma Nonsurgical Management Decompressive Craniotomy Depressed Skull Fracture Gunshot/ Penetrating Wound Hematoma, Epidural Hematoma, Intracerebral Hematoma, Subdural Other Subtotal 29 4 8 1 0 2 16 13 73 24 2 7 1 0 1 16 10 61 53 6 15 2 0 3 32 23 134 6 0 0 55 65 168 5 17 8 12 6 0 0 61 68 167 3 17 6 6 12 0 0 116 133 335 8 34 14 18

SENIOR CLINICAL YEAR

Surgeon Assistant

OTHER CLINICAL YEARS

Surgeon Assistant

TOTAL EXPERIENCE ALL YEARS

Surgeon Assistant

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RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY OPERATIVE EXPERIENCE FOR RESIDENTS
Major Procedures Adult (17+ Years) 3. Transphenoidal Procedures Pituitary Tumor Other 13 0 13 10 0 10 23 0 23

SENIOR CLINICAL YEAR

Surgeon Assistant

OTHER CLINICAL YEARS

Surgeon Assistant

TOTAL EXPERIENCE ALL YEARS

Surgeon Assistant

Subtotal 4. Occlusive Vascular Surgery Bypass Endarterectomy Other

1 1 0 2

1 1 0 2

2 2 0 4

Subtotal 5. Spinal Surgery Cervical Disc & Spondylosis with: Bone Graft Instrumentation Both Neither Metastatic Tumor with: Bone Graft Instrumentation Both

0 0 47 6

0 0 80 13

0 0 127 19

0 0 0 0

0 0 0 0

0 0 0 0

Neither

97

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY OPERATIVE EXPERIENCE FOR RESIDENTS

Major Procedures Adult (17+ Years) Spinal Surgery (Continued) Primary Tumor with: Bone Graft Instrumentation Both Neither Trauma with: Bone Graft Instrumentation Both Neither Other Subtotal 6. Peripheral Nerve Entrapment Release Neurolysis Neurorrhaphy Sympathectomy Transposition Tumor Other Subtotal

SENIOR CLINICAL YEAR

Surgeon Assistant

OTHER CLINICAL YEARS

Surgeon Assistant

TOTAL EXPERIENCE ALL YEARS

Surgeon Assistant

0 0 0 6

0 0 0 9

0 0 0 15

0 0 9 0 37 105

1 2 6 0 93 204

1 2 15 0 130 309

1 0 1 0 0 2 0 4

7 1 0 3 0 1 0 12

8 1 1 3 0 3 0 16

98

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY OPERATIVE EXPERIENCE FOR RESIDENTS
Major Procedures Adult (17+ Years) 7. Stereotaxic Surgery Cardotomy Thalamotomy/ Pallidotomy 0 18 9 4 31 0 0 0 42 2 2 46 0 0 0 60 11 6 77 0 0

SENIOR CLINICAL YEAR

Surgeon Assistant

OTHER CLINICAL YEARS

Surgeon Assistant

TOTAL EXPERIENCE ALL YEARS

Surgeon Assistant

Trigeminal Tumor Biopsy Other Subtotal 8. CSF Shunting Procedures 9

Initial/ Revision Other Subtotal 9. Miscellaneous Other

23 3 35

24 2 61

35

33 5 96

58

11 11

35 35

46 46

Subtotal

99

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY OPERATIVE EXPERIENCE FOR RESIDENTS

SENIOR CLINICAL YEAR Major Procedures-Pediatric (Through 16 yrs) 1. 2. 3. 4. 5. 6. 7. 8. Brain Trauma Brain Tumor Craniofacial Reconstruction Craniosynostosis Peripheral Nerve Shunt Procedure (Initial / Revision) Spinal Dysraphism Spinal Trauma with: Bone Graft Instrumentation Both Neither 9. Spinal tumor with: Bone Graft Instrumentation Both Neither 10. Other Subtotal 0 0 0 0 1 5 0 0 0 0 1 0 SURGEON 1 1 0 0 0 1 49 ASSISTANT

OTHER CLINICAL YEARS SURGEON 19 33 4 16 0 74 4 ASSISTANT

TOTAL EXPERIENCE ALL YEARS SURGEON 20 34 4 16 0 50 4 75 ASSISTANT

0 0 0 0

0 0 0 0

0 0 0 5 60 264

0 0 0 5 61 269

GRAND TOTAL: MAJOR PROCEDURES ADULT PEDIATRIC 442 5 598 264 1,040 269

100

ABNS*

*American Board of Neurological Surgeons

101

I. Training in Neurological Surgery A. Fundamental Clinical Skills Internship Year - 12 months B. Neurological Surgery Residency - 60 months minimum C. Special Considerations D. Program Director's Endorsement II. The Primary Examination III. ABNS Board Certification A. Application requirements B. Oral examination

I. Training in Neurological Surgery To be eligible for certification by the American Board of Neurological Surgery (ABNS), each applicant must be a graduate of a medical school acceptable to the Board. A candidate must then have successfully completed an internship and neurosurgical residency training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). An exception applies for residents from Canadian neurosurgical programs who began training before July 16, l997. Qualified individuals interested in ABNS certification should contact the Board office. Neurosurgical training programs in the United States are reviewed and accredited by the Residency Review Committee for Neurological Surgery (RRC) under authority delegated to it by the ACGME. The ACGME is sponsored by the American Board of Medical Specialists (ABMS), the American Hospital Association (AHA), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies (CMSS). The RRC consists of six neurosurgeon members, two representatives each from the ABNS, the AMA, and the American College of Surgeons (ACS). The ABNS does not accredit training programs. A. Fundamental Clinical Skills Internship Year - 12 months Twelve months must be devoted to acquiring adequate knowledge in fundamental clinical skills. This year of training is preferably taken prior to beginning neurosurgical residency and must be completed prior to beginning the third year of residency training. This requirement may be satisfied by training for one or more years in an ACGME accredited general surgery program in the United States. The training may likewise be acquired during the course of training in an ACGME accredited neurosurgical residency program. Such training must include at least 6 months in surgical disciplines other than neurosurgery. The remaining 6 months should include other fundamental clinical skills considered appropriate by the neurosurgical training program director. This portion of the year may not include more that 6 weeks of neurosurgery. Up to 3 months of neurology may be included, thereby satisfying the ABNS requirement for neurology training.

102

B. Neurological Surgery Residency - 60 months minimum Each resident must complete a minimum of 60 months of training as a full-time resident in an ACGME accredited neurosurgical training program. (1) At least 36 months must be devoted to core clinical neurosurgery with progressive responsibility culminating in 12 months as senior-most resident. As senior resident, the trainee shall have major or primary responsibility for patient management, as well as administrative responsibilities, as designated and deemed appropriate by the program director. Training in clinical neurosurgery must be progressive and not obtained during repeated short periods in a number of institutions. At least 24 months of training in core clinical neurosurgery must be obtained in one institution. Trainees are required to record the operative procedures performed during their residency. The ABNS prefers that this record be provided to the via the web-based NeuroLog database logging system available to all residents and Program Directors. The ABNS furnishes passwords and ID numbers to gain access to this program, or residents may get started through communications with their program director. (2) A minimum of 3 months must be devoted to clinical neurology. This period must be taken as a full-time assigned resident in a neurology residency program accredited by the ACGME. Six months are recommended, but 3 months are required. Up to 3 months of this training may be acquired during the 12 months of training in fundamental clinical skills; however, doing neurology during the internship year does not shorten the requirement for 60 months of residency training thereafter. (3) The remaining 21 to 24 months (see 2 above) must be devoted to aspects of the basic or clinical neurological sciences, which may include neuropathology, neuroradiology, and research. Trainees are expected to acquire basic knowledge and skills in each of these disciplines. Some of the time might be dedicated to additional neurology or subspecialty neurosurgical training, for instance pediatric neurosurgery, or spine or endovascular surgery, and/or other disciplines related to the nervous system. (4) An individuals training is not complete and a Program Directors endorsement cannot be provided until the Primary Examination has been passed for credit toward certification. C. Special Considerations Modification of the above requirements to fulfill specific training goals may be formulated for an individual resident. Program Directors must request credit and receive approval in writing from the ABNS in advance if training is to be undertaken outside the parent program. Such training shall not count toward fulfilling the requirements for certification unless credit is specifically requested by the resident's program director in writing and approved by the Board in advance. Training other than as an appointed resident in an ACGME accredited neurosurgical training program shall not be considered as fulfilling the ABNS requirements unless specifically requested by the Program Director and approved by the Board in advance of such training.

103

On a Program Directors recommendation, the ABNS may at its discretion consider and give retroactive credit to a trainee who, before entering an accredited neurosurgical residency program, has had substantially more than the prerequisite training in general surgery, medical neurology, or basic neurological sciences in institutions acceptable to the Board. Should a resident transfer from one accredited neurosurgical training program to another, the ABNS must receive the written consent from the Program Directors of both programs, along with notification of the type and amount of training to be allowed in the transfer. The Program Director receiving the resident is responsible for ascertaining that any prior training may count toward completion of residency. D. Program Director's Endorsement Prior to acceptance of a candidate for oral examination, the ABNS requires a statement from his or her program director to the effect that the candidate: (1) Has fulfilled the professional training requirements of the Board. (2) Has performance satisfactorily in the program has been satisfactory. (3) Has passing of the Primary Examination for credit. (4) Is recommended by his or her program director as being professionally competent for the independent practice of neurological surgery and suitable for consideration by the Board for certification. II. The Primary Examination Each applicant for certification must first successfully pass the Primary Examination for credit toward certification. This examination is prepared by the ABNS and includes material on fundamental clinical skills, critical care, neuroanatomy, neurobiology, neurology, neuropathology, neuropharmacology, neuroradiology, neurosurgery, and other relevant disciplines deemed suitable and appropriate by the Board. The Primary Examination is open to all residents in ACGME-accredited neurosurgical training programs and to neurosurgeons who have successfully completed such training. Residents may take it either for credit toward certification or self-assessment, as determined by his or her Program Director. An individuals training is not complete and a Program Directors endorsement cannot be provided until the Examination has been passed for credit. The Primary Examination is given once each year, usually the last Saturday in March, at most ACGME accredited neurosurgical training programs. Applications must be filed with the ABNS by mid-December.

104

III. ABNS Board Certification A. Application Requirements As neurosurgical residents complete training, the ABNS sends application packets outlining the requirements for continuing the process to become a certified Diplomate. Candidates for certification must complete and file accurate applications with the Board, together with the required supporting documents. The ABNS will not schedule a candidate for oral examination until all requirements have been fulfilled and approved by the Directors. Each candidate must be scheduled for oral examination within five years of completing training; otherwise, he or she will no longer be considered actively involved in the certification process. Post-graduate fellowships do not extend this window of opportunity but are counted within the interval to complete the process. In order to comply with this five-year rule, applications should be filled out and sent to the ABNS office as soon as possible after completion of residency and logging of twelve months of practice data. Six to twelve months may be required for the entire application to be reviewed and approved by the various ABNS Committees and full Board. A completed application includes the application form, business agreement, hospital release, copies of licenses, appropriate fee, and at least one year of practice data, with oldest case not more than two years old at the time of review. Letters of recommendation and hospital privileges will be requested. (1) Application Form Application forms are available from the ABNS office or may be printed from this website. A candidate who fails to apply to the ABNS in time to be scheduled for oral examination within 5-years of completion of training is no longer considered to be within the certification process. To re-enter the process, the candidate must re-take and pass the Primary Examination. After re-passing, the candidate has 3 years to submit an application as outlined above, have it reviewed and approved, and take the oral examination. (2) Practice Data Requirements Each applicant for ABNS Certification must submit a list of all operative and nonoperative in-patients for whom he or she was the responsible physician or surgeon during a period of 12 consecutive months, with at least 3 months of follow-up. The list does not include out-patients or consultations in which the applicant did not assume primary responsibility for patients care. If the case log includes less than 100 operative cases, it must continue until 100 cases have been collected for analysis. Data collection should begin shortly after the applicant begins practice and sent to the Board as soon as 12 months have been accumulated. This process should ideally be completed within 3 years of completing residency training. Again, the oldest case cannot be more than two years old at the time of review.

105

The list of cases shall include all information as determined by the Board. The ABNS expects applicants to record their data in the web-based NeuroLog database system; however, forms and an example can be requested from the Board office or printed from this website. (3) Letters of Recommendation The applicant shall supply names and addresses of 3 or more physicians with whom he or she has had professional contact to attest to the quality of his or her professional conduct. At least 2 of these must be neurosurgeons who practice in the applicant's community, and at least one must be an ABNS Diplomate. (4) Licensure A currently valid license to practice medicine in the state, province or country where the applicant practices is a requirement for oral examination and issuance of an ABNS Certificate. Such license must be unrestricted and unencumbered by proceedings which threaten its continuance. (5) Hospital Privileges Each applicant must have unencumbered and unrestricted hospital staff privileges for neurosurgical practice in all hospitals in which he or she cares for patients, as well as in all hospitals where the applicant has practiced since the completion of neurosurgical training. Privileges must be unrestricted in respect to the hospital's usual requirements for a neurosurgeon and be unencumbered by any official hospital proceeding that threatens the continuation of such privileges. B. Oral Examination Once an application has been reviewed and approved by the Credentials Committee and received a favorable review by the full Board at a regularly scheduled meeting, the candidate will be scheduled for the oral examination. If the application is not completed within 5-years of the candidates completion of training, he or she shall no longer be considered to be actively involved in the certification process. An applicant who fails to apply to the ABNS in time to be scheduled for oral examination within the 5-year time frame will not be scheduled for oral examination until he or she has again passed the Primary Examination for credit and thereby returned to the certification process. Such candidates must then submit a request for oral examination accompanied by the then applicable fee. The new request, along with an updated application, must be approved by the ABNS and the applicant scheduled for oral examination within 3-years after passing the Primary Examination. The oral examination lasts 3-hours and covers the diagnosis, management, and outcome of surgical and medical diseases of the nervous system. Notwithstanding the growing tendency toward subspecialization, the examination covers all of neurosurgery; questions from all aspects of the discipline must be answered. The primary thrust relates to clinical practice via a case history format, including symptoms, findings, and results of diagnostic tests. Work up,

106

differential diagnosis, and management are evaluated with attention given to relevant anatomy, pathology, and physiological mechanisms, as well as descriptions of how operations should be performed, if indicated. The examination is structured to focus on problems which neurosurgeons may expect to encounter and manage in general practice. If an individual fails to obtain a passing score on the oral examination the first time, he or she may apply for re-examination. The candidate has 3-years in which to take the oral examination a second time. In the event that the individual fails again or the 3-year time frame lapses, he or she must re-pass the Primary Examination for credit, thereby returning to the certification process. Such candidates must then submit new information and the applicable fee as requested by the Board. The applicant will again have 3-years to be complete the certification process, including passing the oral examination.

Additional Information Detailed information about all aspects of the American Board of Neurological Surgery and the certification process is available in the Booklet of Information and the Bylaws, Rules and Regulations, and Code of Ethics; both available from the ABNS office. The Office address is: 6550 Fannin Street, Suite 2139 Houston, TX 77303 (713) 441-6015 FAX: (713) 794-0207
abns@tmh.tmc.edu

Ms. Sanderson and her staff are available in the office from 9am to 5pm, Monday through Friday.

107

ACGME* Neurosurgery Program Requirements

*Accreditation Council for Graduate Medical Education

108

ACGME COMMON PROGRAM REQUIREMENTS APPEAR IN BOLD

7/07/05
Program Requirements for Residency Education in Neurological Surgery Preface The program requirements set forth here are to be considered common to all specialties, and are complete only when supplemented, where indicated and individually, by each specialty. I. Introduction A. Definition of Discipline Neurological surgery is a discipline of medicine and that specialty of surgery which provides the operative and nonoperative management (ie, prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply; the evaluation and treatment of pathological processes that modify the function or activity of the nervous system, including the hypophysis: and the operative and nonoperative management of pain. As such, neurological surgery encompasses the surgical, nonsurgical and stereotactic radiosurgical treatment of adult and pediatric patients with disorders of the nervous system: disorders of the brain, meninges, skull, including skull base, and their blood supply, including the surgical and endovascular treatment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral column, including those that may require treatment by fusion, instrumentation, or endovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution. B. Duration and Scope of Education 1. The training program in neurological surgery must include a minimum of 1 year of training in Accreditation Council for Graduate Medical Education (ACGME) accredited program in general surgery or at least 1 year of a program accredited for the acquisition of fundamental clinical skills as defined below. This training should be completed prior to the third year of neurological surgery training.

109

2.

The neurosurgery program director is responsible for the design, implementation, and oversight of a PGY-1 year that will prepare residents for education in neurological surgery. a. This year must include resident participation in clinical and didactic activities that will give them the opportunity to: (1) Develop the knowledge, attitudes and skills needed to formulate principles and assess, plan, and initiate treatment of patients with surgical and medical problems. Be involved in the care of patients with surgical and medical emergencies, multiple organ system trauma, and nervous system injuries and diseases. Gain experience in the care of critically ill surgical and medical patients Participate in the pre-, intra-, and post-operative care of surgical patients Develop basic surgical skills

(2)

(3)

(4)

(5) b.

In order to meet the goals of the PGY-1 Year there must be: (1) At least 6 months of structured educational experience in surgery, as approved by the neurosurgery program director. The program director should consider training in adult and pediatric operative surgery, surgical critical care, and emergency/multisystem trauma care. (2) 3 months of training in an ACGME accredited neurology training program preferably included in the PGY1-year. (3) No more than 3 months of neurological surgery.

3.

The neurological surgery training program is 60 months in duration, in addition to the year of acquisition of fundamental clinical skills, and must provide 36 months of clinical neurological surgery at the sponsoring institution or one of its approved participating institutions. The remaining period of time, not devoted to clinical neurology and neurosurgery, should be spent in the study of the basic sciences, neuroradiology, neuropathology, or other appropriate subject matter related to the neurosciences as agreed on by individual residents and the

4.

110

program director. [Note: The program director should consult the American Board of Neurological Surgery for certification requirements concerning any training conducted outside the approved institutions of the program.] 5. A block of training of 3 months minimum in an ACGME-accredited neurology training program must be arranged for all residents, unless they have previously had a minimum of 1 year of formal residency training in an accredited neurology training program. This training may be taken during the year of fundamental clinical skills. The program must provide the residents with experience in direct and progressively responsible patient management as they advance through training. There must be a 12-month period of time as chief resident on the clinical service of neurological surgery in the sponsoring institution or its approved participating institutions. a. The chief resident must have major or primary responsibility for patient management with faculty supervision. The chief resident should also have administrative responsibility as designated by the program director.

6.

7.

b.

The specific portion of the clinical training that constitutes the 12 months of chief residency must be specifically designated as the chief residency experience and must be identified at the time of program review. 8. Prior to entry into the program, each resident must be notified in writing of the length of training. The prescribed length of training for a particular resident may not be changed without mutual agreement during his or her program unless there is a break in his or her training or the resident requires remedial training. Any training added to the accredited residency must be based on a clear educational rationale and must not interfere with the education and training of the residents enrolled in the program.

C.

Accreditation Guidelines 1. Training programs in neurological surgery are accredited by the Residency Review Committee (RRC) by authority of the ACGME. A list of accredited training programs in neurological surgery is published annually in the Graduate Medical Education Directory. To be accredited by the ACGME, an educational program in neurological surgery must be in substantial compliance with both the Program

2.

111

Requirements for Residency Education in Neurological Surgery and the Institutional Requirements of the Essentials of Accredited Residencies in Graduate Medical Education. Programs must be able to demonstrate their compliance with these requirements at the time of their site visit and subsequent review by the RRC.

II.

Institutions
A. Sponsoring Institution One sponsoring institution must assume ultimate responsibility for the program, as described in the Institutional Requirements, and this responsibility extends to resident assignments at all participating institutions. The sponsoring institution for an educational program in neurological surgery must be in a single geographic location. Appropriate institutions include medical schools, and hospitals. The institution must demonstrate commitment to the program in terms of financial and academic support, including timely appointment of a permanent department or division chairperson of Neurological Surgery. a. specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document; specify the duration and content of the educational experience; and state the policies and procedures that will govern resident education during the assignment.

b. c.

3.

An integrated institution must function as a single neurological surgery service with the sponsoring institution. The program director must demonstrate to the RRC that the clinical service operates as a single unit in the assignment of residents and their faculty supervisors, the formulation of call schedules, and the convening of teaching conferences and related educational activities. a. A participating institution functions as a separate neurological surgical service with a local training director under the direction of the program director and should be sufficiently close to the sponsoring institution to ensure peer interaction and regular attendance at joint conferences and other activities. Appropriate exceptions may be considered for special resource hospitals (eg, pediatrics, trauma).

112

III. Program Personnel and Resources

A. 1. When a change in chairmanship occurs within an accredited neurological surgery training program, the program must be site-visited within 2 years. B. Program Director 1. There must be a single program director responsible for the program. The person designated with this authority is accountable for the operation of the program. In the event of a change of either program director or department chair, the program director should promptly notify the executive director of the Residency Review Committee (RRC) through the Web Accreditation Data System of the Accreditation Council for Graduate Medical Education (ACGME). The program director, together with the faculty is responsible for the general administration of the program, including those activities related to the recruitment, selection, instruction, supervision, counseling, evaluation, and advancement of residents (in accordance with institutional and departmental policies and procedures) and the maintenance of records related to program accreditation, and for the establishment and maintenance of a stable educational environment. Adequate lengths of appointment for both the program director and faculty are essential to maintaining such an appropriate continuity of leadership.

2.

3. Qualifications of the program director are as follows: a. The program director must possess the requisite specialty expertise, as well as documented educational and administrative abilities, and experience to conduct the program. The program director must be certified in the specialty by the American Board of Neurological Surgery, or possess qualifications judged to be acceptable by the RRC. The program director must be appointed in good standing and based at the primary teaching site. The program director shall be licensed to practice medicine in the state where the institution that sponsors the program is located. (Certain federal programs are exempted.)

b.

c.

d.

113

4.

Responsibilities of the program director are as follows: a. The program director must oversee and organize the activities of the educational program in all institutions that participate in the program. This includes selecting and supervising the faculty and other program personnel at each participating institution, appointing a local site director, and monitoring appropriate resident supervision at all participating institutions. The program director is responsible for preparing an accurate statistical and narrative description of the program as requested by the RRC, as well as updating annually both program and resident records through the ACGMEs Accreditation Data System. The program director must ensure the implementation of fair policies, grievance procedures, and due process, as established by the sponsoring institution and in compliance with the Institutional Requirements. The program director must seek the prior approval of the RRC for any changes in the program that may significantly alter the educational experience of the residents. Such changes, for example, include: 1) the addition or deletion of a participating institution to which residents rotate a change in the format of the educational program (including fellowships within the program) a change in the approved resident complement of the program for those specialties that approve resident complement. the addition or deletion of any institutional rotation

b.

c.

d.

2)

3)

4)

On review of a proposal for any such major change in a program, the RRC may determine that a site visit is necessary.

e.

The program director is responsible for the annual collection, compilation, and retention of the number and types of neurological

114

surgery operative procedures performed in all institutions and facilities utilized in the clinical education of residents. This information must be provided in the format and form specified by the RRC. f. Annually, the program director must ensure the compilation of a comprehensive record of the number and type of operative procedures performed by each resident completing the program. This record must include all of the procedures in which the neurological surgery resident was either resident surgeon or assistant and must be signed by both the resident and the program director as a statement of its accuracy. This information must be provided in the format specified by the RRC. These records must be accurately maintained by the program director. The program director must monitor resident stress, including mental or emotional conditions inhibiting performance or learning and drug- or alcohol-related dysfunction. Program directors and teaching staff should be sensitive to the need for timely provision of confidential counseling and psychological support services to residents. Training situations that consistently produce undesirable stress on residents must be evaluated and modified.

g.

C.

Faculty 1. At each participating institution, there must be a sufficient number of faculty with documented qualifications to instruct and supervise adequately all residents in the program. The faculty, furthermore, must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities. They must demonstrate a strong interest in the education of residents, a commitment to their own continuing medical education, participation in scholarly activities, and must support the goals and objectives of the educational program of which they are a member. a. Neurological surgery faculty participation in undergraduate medical education is desirable. There should be a minimum faculty of three neurological surgeons

2.

b. 3.

Qualifications of the physician faculty are as follows:

115

a.

The physician faculty must possess the requisite specialty expertise and competence in clinical care and teaching abilities, as well as documented educational and administrative abilities and experience in their field, and an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice. The physician faculty who are neurological surgeons must be certified in the specialty by, or be in the certification process of, the American Board of Neurological Surgery or possess qualifications judged to be acceptable by the RRC. The physician faculty must be appointed in good standing to the staff of an institution participating in the program.

b.

c.

4.

The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty, and an active research component must be included in each program. While not all members of a teaching staff must be investigators, the staff as a whole must demonstrate broad involvement in scholarly activity. Scholarship is defined as the following: a. the scholarship of discovery, as evidenced by peer-reviewed funding or by publication of original research in a peerreviewed journal; the scholarship of dissemination, as evidenced by review articles or chapters in textbooks; the scholarship of application, as evidenced by the publication or presentation of, for example, case reports or clinical series at local, regional, or national professional and scientific society meetings.

b.

c.

Complementary to the above scholarship is the regular participation of the teaching staff in clinical discussions, rounds, journal clubs, and research conferences in a manner that promotes a spirit of inquiry and scholarship (e.g., the offering of guidance and technical support for residents involved in research such as research design and statistical analysis; and the provision of support for residents participation, as appropriate, in scholarly activities. 5. Qualifications of the nonphysician faculty are as follows: a. Nonphysician faculty must be appropriately qualified in their field.

116

b.

Nonphysician faculty must possess appropriate institutional appointments.

D.

Other Program Personnel Additional necessary professional, technical, and clerical personnel must be provided to support the program.

E.

Facilities and Resources The program must ensure that adequate resources (e.g., sufficient laboratory space and equipment, computer and statistical consultation services) are available. 1. Inpatient facilities a. Inpatient facilities available for training programs in neurological surgery should be geographically identifiable and have an adequate number of beds, support personnel, and proper equipment to ensure quality education and excellence in patient care. The presence of a neurological surgery operating room with microsurgical capabilities and an intensive care unit specifically for the care of neurological surgery patients is desirable to a training program, as are other units for specialized neurological surgery care. Similarly, neurological surgery beds should be on a unit designated for the care of neurosurgery patients.

b.

c.

2.

Outpatient Facilities Residents must have available appropriate outpatient facilities, clinic, and office space for training purposes in the regular preoperative evaluation and postoperative follow-up for cases for which the resident has responsibility.

3.

Research Facilities a. There should be space and support personnel for research identifiable in the neurological surgery division or department, and some activity should be ongoing in this area. Clinical and/or basic research opportunities should be available to the neurological surgery resident with appropriate faculty supervision.

b.

117

4.

Library a. b. Residents must have ready access to a major medical library. Library services should include the electronic retrieval of information from medical databases. There must be access to an on-site library or to a collection of appropriate texts and journals in each institution participating in a residency program. On-site libraries and/or collections of texts and journals must be readily available during nights and weekends. Training Directors at Participating Institutions a. The training director shall be a qualified neurological surgeon appointed by and responsible to the program director in each geographically separate institution. This individual must be responsible for the education of the residents and also will supervise the educational activities of other neurological surgeons relating to resident education in that institution. Appropriate exceptions may be considered for special resource hospitals. b. These appointments will generally be for a 1-year period and can be renewable to ensure continuity of leadership. c. The training director in neurological surgery at each participating institution must have major clinical responsibilities at that institution.

c.

ci.

IV.

Resident Appointments A. Eligibility Criteria The program must comply with the criteria for resident eligibility as specified in the Institutional Requirements. B. Number and Quality of Residents The RRC will approve the number of residents based upon established written criteria that include the adequacy of resources for resident education (e.g., the quality and volume of patients and related clinical material available for education), faculty-resident ratio, institutional funding, and the quality of faculty teaching.

118

1.

One of the measures of a training program is the quality of residents chosen and the ability of the program to ensure a steady increase in the resident's knowledge and skills.

2.

The RRC will review the selection process of residents and seek evidence that the program evaluates the progression of the residents during training. Where there is demonstrated excellence in providing educational experience for the residents, as determined by the RRC, a program may be authorized to enroll more than one resident per year. The ability to do so does not depend on any multiplication of the minimum requirements as established by the Program Requirements for Residency Education in Neurological Surgery. In determining the size of a resident complement, the RRC will consider the following: a. b. c. d. e. f. Presence of a faculty of national stature in neurological surgery Quality of the educational program Quality of clinical care Total number and distribution of cases Quality of clinical and basic research Quality of residents trained by the program, including numbers of residents starting and finishing the program, number of graduates who take written and oral examinations of the American Board of Neurological Surgery, and the number of graduates passing these written and oral examinations Facilities

3.

g. 4.

The number of residents at each year of training in a given program, except as provided below, shall not exceed the number approved by the most recent accreditation review of that program. A new resident may be appointed to fill a vacancy providing there is no adverse impact on the existing resident staff. The program must provide the RRC with an explanation for the excess complement and its plan for resolution to normal complement.

B.

Resident Transfers To determine the appropriate level of education for residents who are transferring from another residency program, the program director must receive written verification of previous educational experiences and a statement regarding the performance evaluation of the transferring resident prior to their acceptance into the program. A program director is required 119

to provide verification of residency education for residents who may leave the program prior to completion of their education. C. Appointment of Fellows and Other Students 1. The appointment of fellows and other specialty residents or students must not dilute or detract from the educational opportunities available to regularly appointed residents. Programs must notify the RRC when they sponsor or participate in any clinical fellowship taking place within institutions participating in the program. This notification must occur before the commencement of such training and at each subsequent review of the program. Documentation must be provided describing the fellowship's relationship to and impact on the residency. If fellows so appointed will, in the judgment of the RRC, detract from the education of the regularly appointed residents, the accreditation status of the program may be adversely affected.

2.

3.

V.

Program Curriculum
A. Program Design 1. Format The program design and sequencing of educational experiences will be approved by the RRC as part of the review process. 2. Goals and Objectives The program must possess a written statement that outlines its educational goals with respect to the knowledge, skills, and other attributes of residents for each major assignment and for each level of the program. This statement must be distributed to residents and faculty, and must be reviewed with residents prior to their assignments. All educational components of a residency program should be related to program goals. 3. Educational experience in neuroradiology, including surgical endovascular neuroradiology, and neuropathology must be an integral part of the training program designed for the education of the neurological surgery residents. Such experience should be under the direction of qualified neuroradiologists and preferably endovascular neurosurgeons, and neuropathologists.

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4.

The program must provide opportunities for experience and instruction in the basic neurosciences Resident participation in undergraduate medical education is desirable. Related Disciplines a. Recognizing the nature of the specialty of neurological surgery, it is unlikely that a program can mount an adequate educational experience for neurological surgery residents without approved training programs in related fields. Clinically oriented training programs in the sponsoring institution of the neurological surgery program should include accredited training programs in neurology, general surgery, internal medicine, pediatrics, and radiology. There should be clinical resources for the education of neurological surgery residents in anesthesiology, critical care, emergency medicine, endocrinology, ophthalmology, orthopedics, otolaryngology, pathology, and psychiatry. A lack of such resources will adversely affect the accreditation status of the neurological surgery program.

5. 6.

b.

B.

Specialty Curriculum The program must possess a well-organized and effective curriculum, both didactic and clinical. The curriculum must also provide residents with progressive responsibility for patient management.

C.

Residents Scholarly Activities Each program must provide an opportunity for residents to participate in research or other scholarly activities, and residents must participate actively in such scholarly activities.

D.

ACGME Competencies

The residency program must require its residents to obtain competence in the six areas listed below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, behaviors, and attitudes required, and provide educational experiences as needed in order for their residents to demonstrate the following:

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1.

patient care that is compassionate, appropriate, and effective for the treatment of health programs and the promotion of health with specific reference to neurosurgical conditions. At a minimum residents are expected to:

a.

Gather and understand essential patient information in a timely manner.

b.

Generate an appropriate differential diagnosis.

c.

Implement an effective plan of management.

d.

Prioritize and stabilize multiple patients simultaneously.

e.

Competently perform neurosurgical operative procedures.

f.

Manage Complications

g.

Analyze Outcomes

h.

Counsel and educate patients and families.

i.

Provide health care services aimed at preventing health problems and maintaining health.

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j.

Work with health care professionals to provide patientfocused care.

2.

Medical Knowledge: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences, with specific reference to basic and clinical neurosciences, as well as the application of this knowledge to patience care. Among other things, residents are expected to:

a. Generate a differential diagnosis and properly sequence critical actions for patient care, including management complications, morbidity and mortality.

b. Synthesize and properly utilize acquired patient data.

c. Identify neurosurgical emergencies.

d. Know how to access current medical information.

e. Understand how to treat neurosurgical conditions.

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f.

Incorporate evidence-based principles

3.

Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in patient care. At a minimum, residents are expected to:

a.

Analyze and assess their practice experience and perform practice-based improvement.

b.

Locate, appraise and utilize scientific evidence related to their patients health problems.

c.

Apply knowledge of study design and statistical methods to critically appraise the medical literature.

d.

Utilize information technology to enhance their education and improve patient care.

e.

Facilitate the learning of students and other health care professionals.

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4.

Residents must be able to demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals. At a minimum, residents are expected to:

a.

Develop an effective therapeutic relationship with patients and their families, with respect for diversity and cultural, ethnic, spiritual, emotional, and age-specific differences.

b.

Demonstrate effective participation in and leadership of the health care team.

c.

Develop effective written communication skills.

d.

Maintain relevant and legible medical records

f.

Effectively communicate with out-of hospital personnel as well as non-medical personnel.

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g.

Involve patients in medical decisions

h.

Strengthen listening and non-verbal communication skills.

5.

Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds. At a minimum, residents are expected to:

a.

Treat patients/family/staff/ paraprofessional personnel with respect.

b.

Demonstrate sensitivity to patients pain, emotional state, and gender/ethnicity issues.

c.

Discuss death honestly, sensitively, patiently, and compassionately.

d.

Exemplify integrity

e.

Accept responsibility/accountability

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f.

Demonstrate reliability

g.

Maintain calm, even temperament

h.

Exhibit self-awareness and knowledge of limits.

i.

Respond to the comments of other team members, patients, families, and peers openly and responsibly.

6.

Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. At a minimum, residents are expected to:

a.

Understand, access, appropriately utilize, and evaluate the effectiveness of the resources, providers, and systems necessary to provide optimal neurosurgical care.

b.

Understand different medical practice models and delivery systems and how to best utilize them to care for the individual patient. 127

c.

Practice cost-effective health care and resource allocation that does not compromise quality of care.

d. e.

Advocate, coordinate, and facilitate patient care. Understand principles of and advance practices for patient safety at the institutional and individual level.

D.

Clinical Components A current, well-organized, written plan for rotation of residents among the various services and institutions involved must be maintained and must be available to the residents and faculty. 1. Patient Requirements There shall be sufficient patients admitted each year to ensure that the resident participates in the care of patients suffering from the full spectrum of neurosurgical diseases. 2. This participation must include substantial experience in the management (including critical care) and surgical care of adult and pediatric patients and should include the full spectrum of neurosurgical disorders. a. A program must demonstrate to the satisfaction of the RRC that it has both the volume of patients under neurological care and the breadth and depth of academic support to ensure that it has the capability of providing excellent neurological surgery training to residents. The former must be substantiated in part by a compilation of annual institutional operative data and resident operative data (including that from residents rotating on the service from other programs) provided in a fashion prescribed by the RRC. Under some circumstances, the program may be required to include data for a period of up to 3 years prior to the date of the submitted program information forms for accreditation or reaccreditation. The entire surgical experience of the most recently graduating resident(s) must be submitted each time the program has its periodic review.

b.

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c.

The profile of clinical experience reported to the RRC must be limited to that utilized in the resident's educational program. It also is understood that the educational requirements of the resident must be considered at all times, and assignment to a clinical service that limits or precludes educational opportunities will be adversely considered in evaluation of the program. Within the total clinical facilities available to the training program, there should be a minimum of 500 major neurological surgery procedures per year per finishing resident. It must be understood that achievement of this minimum number of clinical procedures will not ensure accreditation of a training program. The presence within a given training program of this neurological surgery workload and the distribution of the surgical experience are equally important. For instance, the cases should be appropriately distributed among cranial, extracranial, spinal, and peripheral nerve surgical procedures and should represent a well-balanced spectrum of neurological surgery in both adults and children. This spectrum should include craniotomies for trauma, neoplasms, aneurysms, and vascular malformations; extracranial carotid artery surgery; transsphenoidal and stereotaxic surgery (including radiosurgery); pain management; and spinal procedures of a sufficient number and variety using modern techniques. No affiliated hospital in the training program should be a component of a training program unless there are a minimum of 100 major neurological surgery procedures per year distributed appropriately among the spectrum of cases as described in paragraph e, above. An exception may be made if a hospital offers special clinical resources, e.g., stereotaxic surgery, trauma, or pediatric neurological surgery, that significantly augment the resources of the training program.

d.

e.

f.

3.

Residents must have opportunities to evaluate patients referred for elective surgery in an outpatient environment. Under appropriate supervision, this experience should include obtaining a complete history, conducting an examination, ordering (if necessary) and interpreting diagnostic studies, and arriving independently at a diagnosis and plan of management. Consonant with their skills and level of experience, residents should be actively involved in preoperative decision making and subsequent operative procedures under the supervision of the attending physician who has ultimate responsibility for the patient. Residents should similarly be actively involved in postsurgical care and follow-up evaluation of their patients to develop skills in assessing postoperative recovery, recognizing

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and treating complications, communicating with referring physicians, and developing the physician-patient relationship. Preoperative interview and examination of patients already scheduled for a surgical procedure will not satisfy these requirements. E. Didactic Components There must be a well-coordinated schedule of teaching conferences, rounds, and other educational activities in which both the neurological surgery faculty and the residents participate. Conferences must be coordinated among institutions in a training program to facilitate attendance by a majority of staff and residents. A conference attendance record for both residents and faculty must be maintained. G. Other Required Educational Components Graduate medical education must take place in an environment of inquiry and scholarship in which residents participate in the development of new knowledge, learn to evaluate research findings, and develop habits of inquiry as a continuing professional responsibility.

VI.

Resident Duty Hours and the Working Environment Providing residents with a sound didactic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents time and energy. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. A. Supervision of Residents 1. All patient care must be supervised by qualified faculty through explicit written descriptions of supervisory lines of responsibility for the care of patients. Such guidelines must be communicated to all members of the program staff. The program director must ensure, direct, and document adequate supervision of residents at all times. Residents must be provided with rapid, reliable systems for communicating with supervising faculty. Faculty schedules must be structured to provide residents with continuous supervision and consultation.

2.

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3.

Faculty and residents must be educated to recognize the signs of fatigue, and adopt and apply policies to prevent and counteract its potential negative effects. Attending physicians or supervising residents with appropriate experience for the severity and complexity of the patient's condition must be available at all times on site. The responsibility or independence given to residents in patient care should depend on their knowledge, their technical skill, their experience, the complexity of the patient's illness, and the risk of the operative procedures. d. Progressive Responsibility Resident participation in and responsibility for operative procedures embracing the entire neurosurgical spectrum should increase progressively throughout the training period. e. Continuity of Care Graduate training in neurological surgery requires a commitment to continuity of patient care, as practiced by qualified neurological surgeons. This continuity of care must take precedence-without regard to the time of day, day of the week, number of hours already worked, or on-call schedules. At the same time, patients have a right to expect a healthy, alert, responsible, and responsive physician dedicated to delivering effective and appropriate care.

4.

B.

Duty Hours 1. Duty hours are defined as all clinical and academic activities related to the residency program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as 1 continuous 24-hour period free from all clinical, educational, and administrative duties.

2.

3.

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4.

Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call. The program director must establish an environment that is optimal for both resident education and patient care, while ensuring that undue stress and fatigue among residents are avoided. It is his or her responsibility to ensure assignment of appropriate in-hospital duty hours so that residents are not required to perform excessively difficult or prolonged duties regularly. During duty hours residents must be provided with adequate sleeping, lounge, and food facilities. Support services must be such that the resident does not spend an inordinate amount of time in noneducational activities that can be discharged properly by other personnel.

5.

6.

C.

On-call Activities The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day, when residents are required to be immediately available in the assigned institution. 1. In-house call must occur no more frequently than every third night, averaged over a 4-week period. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. No new patients may be accepted after 24 hours of continuous duty. At-home call (or pager call) is defined as a call taken from outside the assigned institution. a. The frequency of at-home call is not subject to the every-thirdnight limitation. At-home call, however, must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.

2.

3. 4.

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b.

When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit. The program director and the faculty must monitor the demands of at-home call in their programs, and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

c.

D.

Moonlighting 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. The program director must comply with the sponsoring institutions written policies and procedures regarding moonlighting, in compliance with the ACGME Institutional Requirements. Any hours a resident works for compensation at the sponsoring institution or any of the sponsors primary clinical sites must be considered part of the 80-hour weekly limit on duty hours. This refers to the practice of internal moonlighting.

2.

3.

E.

Oversight 1. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the residents and the faculty. Duty hours must be monitored with a frequency sufficient to ensure an appropriate balance between education and service. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care. cii. Duty Hours Exceptions

2.

An RRC may grant exceptions for up to 10% of the 80-hour limit to individual programs based on a sound educational rationale. Prior permission of the institutions GMEC, however, is required.

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VII.

Evaluation A. Resident 1. Formative Evaluation The faculty must evaluate in a timely manner the residents whom they supervise. In addition, the residency program must demonstrate that it has an effective mechanism for assessing resident performance throughout the program, and for utilizing the results to improve resident performance. a. Assessment should include the use of methods that produce an accurate assessment of residents competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Assessment should include the regular and timely performance feedback to residents that includes at least semiannual written evaluations. Such evaluations are to be communicated to each resident in a timely manner, and maintained in a record that is accessible to each resident. Assessment should include the use of assessment results, including evaluation by faculty, patients, peers, self, and other professional staff, to achieve progressive improvements in residents competence and performance.

b.

c.

2.

Final Evaluation The program director must provide a final evaluation for each resident who completes the program. This evaluation must include a review of the residents performance during the final period of education, and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. The final evaluation must be part of the residents permanent record maintained by the institution.

B.

Faculty The performance of the faculty must be evaluated by the program no less frequently than at the midpoint of the accreditation cycle, and again prior to the next site visit. The evaluations should include a review of their teaching abilities, commitment to the educational program, clinical knowledge, and

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scholarly activities. This evaluation must include annual written confidential evaluations by residents. C. Program The educational effectiveness of a program must be evaluated at least annually in a systematic manner. In particular, the quality of the curriculum and the extent to which the educational goals have been met by residents must be assessed. Written evaluations by residents should be utilized in this process. At least annually, the program rotations and conferences must be evaluated by both residents and faculty. The results of these evaluations must be documented. 1. Representative program personnel (i.e., at least the program director, representative faculty, and one resident) must be organized to review program goals and objectives, and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution, and the residents confidential written evaluations. If deficiencies are found, the group should prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting. The teaching staff should periodically evaluate the utilization of the resources available to the program, the contribution of each institution participating in the program, the financial and administrative support of the program, the volume and variety of patients available to the program for educational purposes, the performance of members of the teaching staff, and the quality of supervision of residents.

2.

The program should use resident performance and outcome assessment in its evaluation of the educational effectiveness of the residency program. Performance of program graduates on the certification examination should be used as one measure of evaluating program effectiveness. The program should maintain a process for using assessment results together with other program evaluation results to improve the residency program.

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D.

The process, maintenance, and utilization of program evaluations, as well as accurate and timely provision of program-related information to the RRC will be monitored as part of the overall review of the residency program.

VIII. Experimentation and Innovation Since responsible innovation and experimentation are essential to improving professional education, experimental projects along sound educational principles are encouraged. Requests for experimentation or innovative projects that may deviate from the program requirements must be approved in advance by the RRC, and must include the educational rationale and method of evaluation. The sponsoring institution and program are jointly responsible for the quality of education offered to residents for the duration of such a project. IX. Board Certification A. Certification Requirements Residents who plan to seek certification by the American Board of Neurological Surgery should communicate with the office of the board regarding the full requirements for certification. The current address of this office is published in each edition of the Graduate Medical Education Directory. Requests regarding evaluation of educational programs in neurological surgery and all related program inquiries should be addressed to the Executive Director of the Residency Review Committee for Neurological Surgery, 515 N State St/Ste 2000, Chicago, IL 60610. B. Performance on Examination One measure of the quality of a program is the participation in and performance of its graduates on the examinations of the American Board of Neurological Surgery. The number of residents completing training and taking and passing the certification examinations will be part of the RRCs evaluation of the program. All residents must pass the ABNS primary examination before completing the program.

ACGME: June 2005 Effective Date: January 2006

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