Education Training Activities & Standards

A.  SCHEDULING CLINIC AND CALL FOR RESIDENTS
The general schedule for residents who are not away and who are on call for the LFMC service will be distributed at least three months before the month being scheduled allowing the residents one week to review for errors and requests for changes.  Final schedules will be out three months before the month being scheduled.

1. Criteria for developing schedules are as follows:

• Second year residents should have 2-3 clinics per week.
• Third year residents should have 3-4 clinics per week.
• The number of residents per clinic should be no more than four.
• Residents should equally divide 35 call days during LFMC Service Call rotations.
• Each resident will be scheduled for 1 - 2 half-days/month for community project upon discussion with Program Director.
• Each resident will be scheduled for 1 - 2 half-days/month for rural continuity clinic upon discussion with Program Director.
• Clinic stacking may be requested by residents doing ED, Cardiology, Perinatology, surgery or other rotations that would benefit from full day experiences (afternoon/evenings on Monday and/or Wednesday evenings).  Clinic stacking may only be done if it allows for a minimum of two residents per session (i.e., at least two residents must be scheduled in clinic at the same time).

2. Scheduling Process:

• The rotation schedule should be reviewed to determine which residents are away vs. non-away for the rotation.
• Determine which residents are taking LFMC Service call.
• Check for approved time-off requests.
• Determine which two rotations overlap into the calendar month you are scheduling.
• Prioritize the schedule by blocking out approved time away, then schedule call and post-call afternoons off then clinics, then project and rural time if applicable.
• To maintain the required number of clinics, project and rural clinic time may be scheduled for a full day instead of two half- days in the PM to avoid conflicting with a clinic opportunity.
• Every effort should be made to keep clinic schedules consistent for each resident, realizing that some specialty rotations have certain time preferences.
• Residents who are taking time off during the rotation may not be able to take two half days for rural or project time and still meet their clinic requirements.  Minimum clinics are top priority.

B.  SCHEDULE CHANGES

A form for schedule changes can be obtained at the Residency office.  Many of the rotations depend on the resident’s presence.  All requests for rotation changes must be submitted in writing to the program Director. 

C.  REQUIRED ROTATIONS

Each resident is required to complete a rural rotation outside of Santa Fe in rural New Mexico during the second and third year of training.

D.  PROCEDURAL DOCUMENTATION

Residents are responsible for documenting procedures and home visits, as listed below.

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Residents will receive quantitative information biannually, as part of their written evaluation, which will guide their educational planning of additional procedures and experiences.

E.  PROGRAM REQUIREMENTS

The 1st year of the Family Medicine residency program is very structured and the resident follows a set course of clinical rotations in 13 four-week blocks.  Second and third year rotations are arranged in conjunction with the resident’s faculty advisor/residency director and are designed to allow some flexibility in scheduling within the general guidelines and board specific requirements. 

NNMFMRP FAMILY MEDICINE RESIDENCY CURRICULUM REQUIREMENTS 

F.  FACULTY MENTOR

Each Family Medicine resident is assigned to a mentor from the Northern New Mexico Residency Program.  One of the mentor’s roles is to help the resident devise an appropriate curriculum which meets the requirements of the American Board of Family Medicine for graduation, and at the same time prepares the resident for the individual needs of his/her anticipated practice.  Identifying the mentor will be a negotiation between the faculty, resident and program director. 

The mentor meets with residents two times per year or more often if needed. Meetings with mentors are designed to review evaluations, monitor progress toward graduation, and to discuss any problem areas that may have developed.

Residents may change mentors by requesting a change from the program director.

Faculty mentors are expected to:

• review the resident’s academic progress by going over evaluations in the resident’s personnel file at least two times a year
• review audits of FMC charts
• assist residents in devising an appropriate schedule for the following year
• be available to residents for discussing any problems that the resident may be experiencing

G.  EVALUATION AND ADVANCEMENT

The Northern New Mexico Family Medicine Residency Program has an extensive evaluation process which includes a resident evaluation of the overall program on an annual basis.  There is resident evaluation by faculty on an ongoing basis; the annual American Board of Family Medicine In-service Exam; faculty review of resident charts in the clinic; faculty review of resident case presentations; faculty review of resident rotations on the in-patient service; resident evaluations of each month rotation.  These are in addition to the scheduled meetings between resident and faculty which are set up to facilitate evaluation.

The faculty, within the two month period prior to advancement and/or graduation of any given resident, will review and evaluate the accumulated knowledge, common skills and professional growth of each resident, utilizing our evaluation format.  If necessary, a written review will be given to the resident regarding the cumulative assessment of his/her performance.  Since we do this verbally one time a year, a written assessment summary will only be given if the resident requests it or the resident’s faculty mentor feels that a collective faculty assessment is necessary.  After reviewing the above, a decision is made to advance each resident to a position of higher responsibility and/or graduation as appropriate.  All evaluation material will be kept in the resident’s personnel folder, and will be available through the residency administrator’s office to each resident at any time.

Evaluation meetings will occur in the following schedule:

a. Resident Director meets with residents individually, twice each year.

b. Faculty Mentors will meet with residents at least twice each year.

H.  PROGRESSION OF RESIDENT RESPONSIBILITIES

Family Medicine residents are expected to take on progressively more responsibility for patient care, and teaching and supervision of residents at lesser levels of training (as well as medical students) as they advance through the program.  This graduated responsibility is meant to assure there is adequate supervision to assure quality patient care, while allowing resident’s independence in their patient care decisions appropriate to their level of training.  The goal is to produce graduates who are ready to assume full patient care responsibility upon completion of the program.

I.  ESSENTIAL JOB REQUIREMENTS FOR RESIDENTS

The following list includes tasks that are representative of those required of a resident in Family Medicine in the NNMFMRP.  The list is not meant to be all-inclusive nor does it constitute all academic performance measures or graduation standards.  It does not prevent the residency from temporarily restructuring resident duties as it deems appropriate for residents with acute illness, injury, or other circumstances of a temporary nature.

The resident without the use of an intermediary, must be able to:

• Take a history and perform a physical examination
• Administer injections and obtain blood samples
• Use sterile technique and universal precautions
• Perform cardiopulmonary resuscitation
• Move throughout the clinical sites and hospitals to address routine and emergent patient care needs
• Deliver a baby, and repair a pereneal laceration/episiotomy
• Assist at operations
• Communicate with patients and staff, verbally and otherwise, in a manner that exhibits good professional judgment and good listening skills and is appropriate for the professional setting
• Demonstrate timely, consistent and reliable follow-up on patient care issues such as laboratory results, patient phone calls, or other requests
• Input and retrieve computer data through a keyboard, and read a computer screen
• Read charts and monitors
• Perform documentation procedures such as chart dictation and other paperwork in a timely fashion
• Manage multiple patient care duties at the same time
• Make judgments and decisions regarding complicated, undifferentiated disease presentations in a timely fashion, in emergency, ambulatory and hospital settings
• Demonstrate organizational skills required to eventually care for 10 or more outpatient cases per half day
• Take call for a practice or service, which requires appropriate inpatient admissions, discharges and interim progress assessments
• Work stretches up to 30 hours
• Present well organized case presentations to other physicians or supervisors
• Participate in, and satisfactorily complete, all required rotations in the curriculum

J.  RESIDENT DUTY HOURS

Making the environment for training as similar as possible to that of practicing family physicians, second and third year residents covering the inpatient service or OB continuity patients may take calls from home.  After hours call coverage will be no more frequent than every 4th night, averaged monthly.  Residents will have at least one day out of seven without any responsibilities related to the residency program, averaged monthly.  In the event that a resident is unable to perform their duties during call, the resident will make arrangements for alternative coverage.  In the circumstance that no other resident is available, responsibilities of the resident will be covered by the attending physician on call.  If the resident is unable to perform their duties post-call due to fatigue, refer to the procedure described under “Sick Leave”.

A Family Medicine attending physician is scheduled on call 24 hours a day, 7 days per week. This attending is responsible for patients on the Family Medicine inpatient service and for all LFMC patient activities. The attending physician on call has ultimate responsibility for patient care.

K.  SUPERVISION OF RESIDENTS

Refer to University of New Mexico Houseofficers and the University Regulation and Benefit Manual

A resident may not provide patient care within the scope of the Family Medicine residency program unless a faculty member is available "on the spot."  Faculty attending physicians are assigned to the inpatient service, Family Medicine Center, and other educational sites specifically for the purpose of teaching and supervision of training and patient care.  An attending physician will be available 24 hours each day to residents (e.g. home visits).

The program will post call schedules showing the responsible supervising faculty physician for the Family Medicine, clinic, inpatient service and after hours coverage of the Family Medicine center.  Specifics on the process of supervision in the various settings in which educational activities take place are described as follows:

Inpatient Service: All patients must be seen by the attending physician.  The attending physician must immediately co-sign all delivery records, labor progress notes, and admission notes.  Progress notes and orders should be signed prior to the end of the supervision period and, rarely, may be co-signed when the chart is already in the medical records department.  The attending physician must be present for all procedures, including deliveries, and at the time of all hospital admissions.

Family Medicine Center: All patient encounters must be discussed with the preceptor according to Medicare billing guidelines prior to the end of the teaching session, and preferably before the patient leaves the clinic.  The attending physician must personally evaluate any patient whose diagnosis or management plan is uncertain, as well as any patient who will be billed above a level 3.  In general, discussions will involve general patient management issues as well as more difficult problems.  All charts of patients for whom any Resident at any level has written a note regarding an office visit need to be forwarded to the Attending who was precepting for that session.  By the end of this session this should be done by handing the chart directly to the preceptor.  DO NOT leave the chart on the counter where the preceptor was sitting, or leave it for the preceptor in any other indirect way, as this increases the chances that the preceptor will not see the chart.

Specialty Experiences: The specialty preceptor to whom the resident is assigned has responsibility for immediate supervision.

Required Longitudinal Experiences: Very rarely, if ever, should these experiences require the resident to perform activities in the community settings when they are not under the direct supervision of faculty (e.g. community medicine, school health, nursing home). For emergency clinical questions, the on call FM physician will serve as preceptor. The responsible supervising preceptor/faculty should have the primary responsibility for supervision.

Electives: An individual with appropriate qualifications must be identified and assume responsibility for supervision of any elective experiences.  This individual must be approved by the program director.

L.  DOCUMENTATION REQUIREMENTS BY THE ATTENDING PHYSICIAN
This duty may be shared among a call group

1. The Attending Physician will:

1. Perform an initial history & physical on all inpatient admissions.
2. On a daily basis, personally evaluate and confirm all physical exam findings on all inpatients.
3. On a daily basis, co-sign all progress notes and orders on all inpatients.
4. Confirm and/or revise diagnosis or course of treatment.
5. Personally perform or supervise medical care
6. Be physically present to perform or directly supervise all procedures.
7. Be recognized by the patient as his/her personal physician.

 

2. Records must show:a.

1. Personal involvement* in admission, hospital care and discharge.
2. Physical presence* by the attending is mandatory for all procedures and during  all billable services.
3. Co-signatures on all:
   1. History and Physicals
   2. Operative reports, written orders, progress notes and discharge summaries.
4. Completion of the face sheet by the attending.
5. Transfer of care as appropriate (including coverage by other residents or attendings).

*Physical presence and personal involvement must be documented by a note following the resident’s entry.  The note should summarize the situation – e.g. “23 yr old male with diabetic ketoacidosis.  Exam as documented by resident. ABG’s improved today with a pH of 7.30.  Agree with plan to continue IV fluids and monitor K” OR “ 54 y.o. female with CHF not responding to diuretics.  Agree with addition of ace-inhibitor”.

Co-signatures alone do not reflect a personal or identifiable service by the attending.
 

M.  DOCUMENTATION BY THE RESIDENTS

1. History and Physical

1. Documentation should show evidence of the attending physician having been physically present, having agreed with the plan of treatment or having personally examined the patient.
2. If special procedures are performed, the attending must be present and documented as such.  In case of emergency procedures, note that the attending was consulted as soon as possible.

 

2. Progress Notes

1. Date and time
2. Note presence and/or concurrence of attending physician
3. In case of procedures, document as described in H & P section.
4. Statement of request for consultation if attending is a specialty physician.

 

3. Physician Orders

1. Date and time must be present on every set of orders.
2. Co-sign all verbal/telephone orders given to RNs.
3. Remind attendings to co-sign all documents.

 

4. Emergency Room Services

1. The name of the teaching physician along with his/her involvement must appear in the ER report.

 

5. Discharge Summaries:

1. Note agreement of attending in discharging patient.
2. Face sheet should be filled out.

 

6. Procedures:

1. A procedure note must be completed immediately after the procedure, noting physical presence and supervision of the attending physician.

N.  PROMOTION/REAPPOINTMENT

For reappointment to the next higher level of training, each resident physician must complete a new residency agreement (contract) with the University of New Mexico and training license renewal application.  Determination regarding a decision not to reappoint will be made by the Program Director.

To receive a certificate of successful completion of the program, a trainee must satisfactorily complete programmatic, administrative, patient care and educational requirements.

In the event that academic deficiency is noted, the resident will be so informed.  Written recommendations will be made identifying measures to be taken in order to correct the deficiency.  A time frame will be given within which correction is to be made.  If there is a question regarding promotion to the next level of training, the resident will be notified in writing at least two (2) months prior to the contract end date.  Written receipt will be required from the resident.

O.  CRITERIA FOR PROMOTION

1.  First to Second Year
Promotion to the second year of residency training is based on successful completion of the first year of training as determined by the University of New Mexico Family Medicine Residency Program in Albuquerque.

 

2.  Second to Third Year
Promotion from the second to third year of training is based on successful completion of the second year of training as determined by the following criteria:

 

• Satisfactory evaluations of training experiences during the second year of training.  This includes performance on the Family Medicine inpatient service, in the Family Medicine center, during specialty rotations, and in required areas such as behavioral science, nursing home and community medicine.  In the event of unsatisfactory performance in any area of training, promotion may be granted contingent upon satisfactory completion of remedial training according to a remedial plan approved by the faculty and residency director.
• Maintaining proper documentation of training experiences as required by the program.
• Fulfilling responsibilities for patient care, including call responsibility and proper charting/documentation of patient care.
• Demonstrated ability to work effectively as a member of a patient care team.
• Adherence to employee policies and procedures, as they apply to residents.
• Maintaining ethical standards of patient care and professional behavior.

 

A summary evaluation will be completed by the Residency Director at the end of the second year of training in order to determine each resident’s readiness for promotion to the third year of training.

 

3.  Completion of Program

 

• Summary evaluation of each resident will be completed by the Program Director at the end of the third year of training in order to determine successful completion of the program.  Graduation from the NNMFMRP is based on successful completion of all three years of training, following successful completion of PGY I and II.  Criteria for completion of the third year of training are:
• Satisfactory evaluations of all training experiences during the third year of training.  This includes performance on the Family Medicine inpatient service, in the Family Medicine center, during specialty rotations, in required areas such as behavioral science and nursing home, and in any remedial educational experiences
• Maintaining proper documentation of training experiences as required by the program.
• Competence in procedures relevant to Family Medicine and the resident’s practice plans. 
• Documentation of experience performing procedures.
• Fulfilling responsibilities for patient care, including call responsibility and proper charting/documentation of patient care.
• Demonstrated ability to work effectively as a member of a patient care team.
• Adherence to employee policies and procedures, as they apply to residents
• Maintaining ethical standards of patient care and professional behavior

 

P.  JOB DESCRIPTION: PGY-II Family Medicine Resident 

Under the supervision of the Program Director/NNMFMRP Teaching Faculty or Sub-Specialty Preceptor, the PGY-II resident:

1. Provides inpatient care under the direct supervision of attending  physician. 
2. Takes first call after hours for hospital on-call duties. 
3. Will perform on-call duties as required by the program.  
4. Deliver OB continuity patients and take call for OB patients under appropriate supervision.  Residents are required to physically evaluate every patient who presents to testing and triage while they are on call.  Physical presence in the hospital is required when caring for any patient undergoing induction/augmentation of labor, epidural anesthesia, or in active stage of labor. 
5. When assigned to the FMC will see on average 6-8 patients per session under the supervision of FM faculty or sub-specialty preceptors. 
6. Will perform clinic assignments 2-3 half days per week.  
7. When in the FMC will discuss all patient encounters with a precepting FM  physician according to Medicare billing guidelines. 
8. Complete all charting duties in a timely fashion. 
9. Attend assigned educational activities. 
10. Attend radiology rounds as necessary.
11. Participate in the annual American Board of Family Medicine In-Training
12. Examination. 
13. Participate one half day per week in a didactic teaching module at the FMC. 
14. Initiate and implement a community health project. 
15. Complete all required block rotations. 
16. Complete a practice management/orientation rotation and a community medicine rotation. 
17. Will follow an average of 2 nursing home patients at any time under the direct supervision of an attending physician, to include call responsibilities. 
18. Will identify a rural experience and will work at the rural site as agreed upon by the Program Director.

Q.  JOB DESCRIPTION: PGY-III Family Medicine Resident

Under the supervision of the Program Director/,NNMFMRP Teaching Faculty or Sub-Specialty Preceptor, the PGY-III resident:

1. Provides inpatient care under the supervision of an attending physician. 
2. Takes first call after hours for hospital on-call duties. 
3. Delivers OB continuity patients and takes OB call for OB continuity patients.  Residents are required to physically evaluate every patient who presents to testing and triage while they are on call.  Physical presence in the hospital is required when caring for any patient undergoing induction/augmentation of labor, epidural anaesthesia, or in active stage of labor. 
4. When assigned to the FMC will see on average 8-10 patients per session under the guidance of FM faculty. 
5. Will perform continuity clinic assignments at least 3 half days per week.   
6. When in the FMC will discuss all patient encounters with a precepting FM physician according to the Medicare billing guidelines. 
7. Complete charting duties in timely fashion. 
8. Attend assigned educational activities. 
9. Participate in the annual American Board of Family Medicine In-Training Examination 
10. Participate one half day per week in a didactic teaching module at FMC. 
11. Complete at least two rotations as chief resident of the in-patient LFMC hospital service. 
12. Complete required block rotations.  
13. Will follow 2 nursing home patients under the direct supervision of attending physician, to include call responsibilities. 
14. Will complete a community health project and present findings at CSVRMC grand rounds. 
15. Will work at an approved rural clinic site.