MedStar Union Memorial Hospital – Division of Hand Surgery

Policies

Policy on Trainee Eligibility and Selection Criteria

Recruitment, selection and appointment of fellows are performed by the Program Director and Core Faculty with oversight by the Institution’s GMEC and in accordance with the ACGME program requirements.

  1. Applicants

To be eligible for the hand and microsurgery fellowship at MedStar Union Memorial Hospital, applicants must fulfill the following selection criteria:

  1. A) A graduate of an LCME accredited (Liaison Committee on Medical Education) medical school or Canadian accredited Medical School or:

B) A graduate of a college of osteopathic medicine in the United States accredited by the

American Osteopathic Association (AOA).

  1. A U.S. citizen or possess a Permanent Resident Card or appropriate educational visa.
  2. If a graduate of a medical school outside the United States, they must have completed their residency training and successfully passed the required ECFMG examinations to obtain a J-1 Visa.
  3. Meet Maryland Board of Physicians requirements for Unlicensed Medical Practitioners (UMP).
  4. A graduate of an ACGME accredited orthopaedic surgery, general surgery or plastic surgery residency program as applicable to the fellowship.
  1. Selection
  1. The selection of trainees will be made via the National Resident Matching Program (NRMP) Combined Musculoskeletal (Hand Surgery).
  2. Applications are reviewed by the Program Director and appointed faculty. Required documents include:
  3. Curriculum Vitae
  4. Un-mounted 2X2 photograph
  5. Universal Hand Surgery Fellowship Application
  6. Examination scores from USMLE Part I, II, and III
  7. Three letters of recommendation, one of which should be from the Chief of Service under whom the applicant has recently trained.
  8. The Program Director and appointed faculty select applicants who will be offered an opportunity for a personal interview.
  9. Each applicant is interviewed by two to three appointed faculty members. Four interview sessions are conducted for each applicant so they have the opportunity to meet with a total of 8 to 10 faculty members.
  10. This program does discriminate based upon age, race, sex, religion ethnicity, national origin, sexual orientation, physical or mental disability, marital status or veteran status.
  11. Group discussion and rank order of applicants is performed following the final interview.

Policy on Duty Hours

MedStar Union Memorial Hospital and its Board of Directors require that the fellowship training program foster both quality fellow and resident education and facilitate quality patient care. Fellow and resident duty hours are structured in accordance with ACGME requirements to provide the maximum educational opportunity and experience to provide safe and optimal patient care in a scholarly environment.

Duty hours must be limited to 80 hours per week, averaged over a four-week period. Work schedules are designed so that on the average, excluding exceptional patient care needs, fellows and residents are provided a minimum of one day free of duty every week (when averaged over four weeks). One day is defined as one continuous 24 hour period free from all clinical, educational and administrative duties. Hand Surgery Fellow Call at MedStar Union Memorial Hospital is “at home call”. Fellows will take 2nd call every 5thday/night approximately 6 times per month.

Fellows are required to report and log all duty hours on New Innovations. Fellows must log in at least once every week. The Site Coordinator for GME will review each fellow’s reported duty hours to ensure compliance.

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

Under those circumstances, the fellow must:

  • Appropriately hand over the care of all other patients to the team responsible for their continuing care.
  • Document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the Program Director.
  • The Program Director must review each submission of additional service, and track both individual fellow and program-wide episodes of additional duty.

The MedStar Union Memorial Hospital Hand Surgery Call Policy described below was developed to insure:

  1. Communication is consistently and predictably maintained between the transitioning call teams
  2. Learning opportunities are maximized for rotating house staff
  3. Work hour restrictions are observed

The Hand Service has instituted the following policies:

  • First Call

Coverage is provided by the (2) physician assistants 84 hrs per week. Depending upon how many residents there are on the Hand Service (usually three or four) each resident will carry the first call pager for an average of 21 to 28 hours per week. The residents on a rotating basis will carry the first call pager for the 24 hour period on Saturdays and Sundays when there is no PA coverage and when a PA is off for vacation time and/or holidays. A typical week of first call for the residents and physician assistants is outlined below:

First call week / Home-call shared by all residents
on hand service
pager #6690 / Physician Assistant (pager #s)
Glick (x0379) / McNeely (x0991)
Monday / 7 am-8 am
430 pm-830 pm (5hr) / 8:30 pm-7 am
Tuesday / 7 am-8 am (1hr) / 730 am-830 pm / 830 pm-7 am
Wednesday / 7 am-8 am
430 pm-830 pm (5hr) / 730 am-430 pm / 830 pm-7 am
Thursday / 7 am-8 am (1hr) / 730 am-830 pm / 830 pm-7 am
Friday / 7 am-8 am
430 pm-7 am (15.5 hrs) / 730 am-430 pm
Saturday / 7 am-7 am (24 hrs)
Sunday / 7 am-7 am (24 hrs)

Monday through Thursday from 830 pm to 700 am, first call is provided by the night shift PA. At 700 am Tuesday through Friday, the on-call resident resumes first call duties. Throughout the day, call responsibility is exchanged between Jill Glick and the resident on call according to the above schedule.

At 830 pm

  • If there are active issues/ER cases being performed at the time of 1st call transition, a verbal sign-out will be conducted and work completed in a manner that is optimal for patient care and mutually agreeable for both 1st call providers. Efforts should be made to relieve the person going off call and get them home ASAP.
  • After verbal sign-out occurs between 1st call providers, the PA should report to the OR if a case is underway. This will enable the operative team to remain informed of the activity of the evening, and will provide the PA with an opportunity to participate in OR cases.

After 830 pm

  • All cases should be evaluated by the PA within 30 minutes of consultation request.
  • After evaluation of the patient, the PA will call the Hand Surgery Fellow to discuss the management of all cases, regardless of disposition (OR/admit/discharge). The residents are not to serve as backup or intermediate phone/ER consultant. The attending may request to be contacted directly by the PA regarding ER consults/cases while on call.
  • The PA should present to the OR during nighttime cases to assist if there are no other active issues in the Emergency Department.

After 615 am (Monday-Friday)

  • A mourning rounds team will assemble on the 8th floor ward to review the management of the cases from the previous evening and the current inpatients. This will include the overnight PA, floor nurse, fellow and resident on call from the previous evening, and any resident or fellow with inpatients on their service. The overnight PA will round with the fellow from the night before to maximize teaching (splinting, post exam, discharge planning, etc). The Saturday 1st call provider is exempt from Monday morning ward rounds and will arrive for Monday Conference at 645 am. The Sunday 1st call provider is exempt from clinical responsibilities as of 645 am Monday morning, should depart after Monday morning conference, and then return for Tuesday conference at 700 am.

Note – The 1st call pager X6690 is passed among the residents only. When 410-932-6690 is paged, the x6690, x0379 (Jill) and x0991 (DaShaun) will all alarm. During off duty hours, the PA’s turn off their pagers. Likewise, while not on call the resident carrying the x6690 pager may turn it off. The residents should keep their individual pagers (i.e. x6673, x6674) on so they may be contacted for issues not related to call duty. This arrangement eliminates the need for the residents to pass off the pager between the PA’s. The only pager that is handed off is the x6690 pager between the residents on call each day. The residents and PA’s are required to promptly assume 1st call duties at the start of their shifts by simply turning on their respective call pagers (x6690, x0379 and x0991).

  • Second Call

Coverage is provided by the hand fellow throughout the 24-hour call period. Exceptions should not be made to this policy. Divergence from this policy may inadvertently cause miscommunication and delays in patient care. Assumptions that 2nd call providers may not want to be contacted can lead to difficulty providing operative services within a desirable timeframe for the particular injuries (i.e. open fractures, infection), or cause conflicts with the 2nd call fellow’s participation in elective cases the following day.

The participation of the Hand Surgery PA in night call is not only intended to improve the efficiency of our patient care, but also enhance the educational opportunities at the Hand Center throughout the week. Efforts should be made to support and teach the 1st call provider throughout the 24-hour call period.

Residents on the Hand Service will only be required to miss elective surgery workdays in one situation: the Sunday call resident will be required to be absent from clinical duties on Monday. This policy should protect the residents’ ability to participate and learn from elective cases and office hours during the day.

Each resident is responsible for carefully recording their weekly work hours. Home call hours (after 5 pm) should be spent outside the hospital if not involved in clinical duties. These hours at home should not be tallied in cumulative weekly work hour calculations. If a resident’s weekly tally approaches/exceeds 80 hours, the resident should notify Dr. Higgins within one week so schedule adjustments may be made.

This policy will be monitored to insure that fellow and resident work hour restrictions are observed.

Specifically:

  1. When not on call residents will have 10 hours off between workdays.
  2. There will be three overnight home-call shifts (Friday, Saturday and Sunday) assigned to residents each week. Overnight home-call will average 1:7 to 1:9, depending on the number of residents on the service during a particular month.
  3. When three residents are on the Hand Service, each will have an average of over five days off per four week period. When four residents are on the Hand Service, each resident will have an average of seven days off per four week period. A day off is defined as a 24 hour consecutive period free of all clinical duties.
  4. Weekend call sign-out should occur at 7 am. Residents will each have two days off on the weekends they are not on call. If a resident is assigned Saturday call he/she will have Sunday off. If a resident is assigned Sunday call he/she will have Saturday and Monday off.
  5. The Friday night call provider must leave the hospital no later than 0700 Saturday morning. They should arrive adequately early on Saturday morning to round, sign-off and hand-off the pager at exactly 0700.
  6. The Saturday call provider must arrive at 0700 Saturday to receive the sign-out and the call pager. They should leave the hospital no later than 0700 on Sunday morning. They should arrive adequately early on Sunday morning to round, sign-off and hand-off the pager at exactly 0700. On Monday morning the Saturday call provider is exempt from 615 am ward rounds and should arrive for Monday Morning Conference at 645 am.
  7. Total in-house work hours should never exceed 80 hours per work week.
  8. Residents engaged in educational conferences outside of UMH (i.e. their home institutions on Thursday mornings) should not include these hours in their work hour tally submissions for the UMH Hand Service.

If patient care, communication, or work hour difficulties arise, Dr. Higgins should be contacted to discuss methods to improve our services or revise/create policies to address these issues.

Post call the resident should complete discharge paperwork, sign-out to the appropriate team, give the call pager to the resident on call and attend educational conferences before leaving the hospital.

When special/unusual circumstances (exceptional patient care needs, illness of colleagues, times of national emergency, etc.) require a fellow to be continuously working in the hospital for greater than 24 hours, he/she will be instructed to leave the hospital for at least a 10 hour period at the conclusion of that call and the attending on call is responsible to see that this is accomplished.

Under those circumstances, the fellow must:

  • Appropriately hand over the care of all other patients to the team responsible for their continuing care.
  • Document the reasons for remaining to care for the patient in question and submit the documentation in every circumstance to the Program Director.
  • The Program Director must review each submission of additional service, and track both individual fellow and program-wide episodes of additional duty.

Duty hours are monitored on a weekly basis by the Site Coordinator. Fellows are required to log their duty hours into New Innovations daily. Residents should log their duty hours per their home program’s requirements (i.e. New Innovations or some other electronic version).

Hand Surgery Emergency Line Procedures

  • All calls for transfers to the Hand Surgery Service come to a phone at the Heart Line Desk that is specific for this purpose.
  • The phone numbers for the “Emergent Hand Line” are:

885-540-HAND (4263)

410-261-8100

The associate answering the emergency hand line will obtain the physician name, phone number and name of facility the physician is calling from and tell them a physician from Hand Surgery will be contacting them shortly. The hand fellow on call will be paged and the above information will be passed on to the fellow.

If a transfer is accepted, the hand fellow will call back the Hand Line and give the necessary information to include the recommended method of transportation (e.g. ambulance, helicopter, private vehicle.)

The hand line associate will call the sending facility to setup the transfer to MUMH ED and gather the following information: patient name, date of birth, type of injury, height and weight. Then call the Charge Nurse in the Emergency Department at ext. 8041 to alert them of the transfer and give them the following information:

  1. Patient name
  2. Date of birth
  3. Sending facility
  4. Type of injury
  5. Accepting physician name (fellow or attending)

If the hand surgeon declines a transfer, he/she will call the hand line associate and give the necessary information which is documented.

All transfers whether they are accepted or declined are documented by the hand line associate in the hand surgery call log.

All declined transfers should be documented by the hand fellow/attending and emailed to Tori Wilson.

The hand surgery call log and all documented declined transfers are monitored by the ER/OR Services Committee on a quarterly basis.

Policy on Moonlighting

Professional activities outside the scope of training

  • Policy:

Professional activities outside the scope and intent of fellow training detract from the educational experience and may adversely affect patient care. It is the policy of the MedStar Union Memorial Hospital Division of Hand Surgery that no such activities or any type of outside employment may occur during the hand surgery fellowship.

Policy on Supervision

  • Roles

Fellows in hand surgery are physicians who have completed their accredited residency training in orthopaedic surgery, plastic surgery or general surgery. In each case, the fellows have completed at least five years of core residency training, and are board eligible prior to beginning their hand surgery fellowship. At the inception of fellowship, the fellows already have basic training in fracture repair, wound management, soft tissue repair (including nerves, tendons, vessels), and the diagnosis of common hand conditions. During the fellowship program, they learn added complex skills that compliment their core training through didactic sessions, structured anatomy sessions, reading, and patient care under the supervision of the attendings. As part of their training, they are given progressively greater responsibility according to their level of education, ability and experience. They are already experienced in the orthopaedic and plastic surgery problems of the hand and upper extremity that relate to their core residency program. The fellowship program allows them to apply for a Certificate of Added Qualifications in Hand Surgery (administered by their respective American Board of Medical Specialties Board) after completing a 12-month accredited program.