pa surgical resident handbook

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PA Surgical Resident Handbook

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Page 1: PA Surgical Resident Handbook

PA Surgical Resident

Handbook

Page 2: PA Surgical Resident Handbook

I. Introduction A. Introductory Letter B. PA Residency Faculty C. Program Overview D. Physician Assistant Surgical Residency Mission Statement E. Department of Surgery Mission Statement F. Physician Assistant Surgical Residency Vision G. Department of Surgery Vision H. Values H. General Surgery Residents’ Web

II. General Policies & Procedures A. Prerequisites to Start the Surgical Year

B. Duty Hours i. Eighty-Hour Work Week ii. Clinical Activity

iii. Resident Leave iv. Unplanned Absence v. Interviewing

C. On-Call D. Record Keeping

i. Duty Hours ii. Procedure/OR case log

E. Performance Evaluation of PA Surgical Residents F. Rotation Schedule Changes G. Resident’s Evaluation of Rotations and Attendings

H. Attire I. Hospital Policies

i. Verbal Orders ii. Physician-Extender Orders iii. DEA number

J. Ordering Narcotics K. Housing L. Benefits i. Health Insurance ii. Malpractice Insurance iii. Fitness Center M. IPAQ’s N. List of Floors/Services O. Meals P. Meetings Q. Online Resources i. CME Central Line Course ii. HIPPA iii. PACS Training iv. Protocols R. OR Coding Services S. Parking T. Patient Confidentiality/HIPPA U. Pyxis V. Scrubs

W. Corrective Action X. Withdrawal from the Program Y. Human Resources Policy Manual Z. Moonlighting

III. Tips/FAQ’s A. What to do before you arrive at Duke

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I. Introduction A. Greetings To the Physician Assistant Surgical Residents,

Welcome to the Duke Physician Assistant Surgical Residency Program and to Durham, North Carolina, birthplace of the physician assistant profession. The PA Profession originated at Duke in the mid 1960s. Dr. Eugene A. Stead, Jr., then Chairman of the Department of Medicine, believed that physician assistants could increase consumer access to health services by extending the time and skills of the physician. His vision, guidance, and influence were instrumental in founding the Duke PA Program that continues to flourish as one of the premier PA training programs in the country. The PA Surgical Residency Program was started in 2002 as an extension of the vision of Eugene Stead, MD and as the vision of Ted Pappas, MD and Paul Hendrix, PA-C. The program was developed to train PAs in the surgical discipline while increasing access to care for the hospitalized patient in the current hospital environment. The Physician Assistant Surgical Residency Program demands a PA with the highest degree of professionalism and motivation. This rigorous 12-month program will provide the PA with the knowledge, technical skills, and confidence needed to commence a fulfilling career as a surgical PA. The Residents will have the opportunity to work side-by-side with renowned surgical attendings, in an academic, tertiary care environment and care for the most complex of patients with rare disease processes and multiple comorbidities. The faculty of the Physician Assistant Residency looks forward to guiding you through this challenging experience. Welcome to Duke and the City of Medicine! Sincerely, Faculty of the Physician Assistant Residency

B. PA Residency Faculty http://dukehealth1.org/surgery/pa_faculty.asp

C. Program Overview

The residency is not designed to produce technicians. The goal is to train physician assistants who are competent in offering a continuum of care for their patients. Emphasis is placed on pre-operative and post-operative care with adequate importance to operative skills. As a PA resident, you will serve as the primary contact when it comes to everyday patient care, be it completing history and physicals, ordering and interpreting appropriate labs, diagnostic tests, implementing a treatment plan, and formulating a discharge plan, or responding to floor emergencies; however, you are never alone. It is a symbiotic relationship between you and the junior and senior residents, the chief resident, the attending surgeons, physician assistants, nurses, and social workers that help make a difference in your patients’ lives.

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D. Physician Assistant Surgical Residency Mission Statement

The Duke University PA Surgical Residency Program is dedicated to being an innovator in the future of medicine and creating proficient and confident physician assistants capable of administering exceptional patient care.

E. Department of Surgery Mission Statement

The Department of Surgery is committed to excellence, innovation, and leadership in meeting the health care needs of the people we serve, improving community health, and fostering the very best medical education and biomedical research.

F. Physician Assistant Surgical Residency Vision

As the birthplace of the Physician Assistant profession, we wish to remain at the forefront of PA education by providing licensed PA’s with the knowledge at technical skills required to excel in the surgical subspecialties. This will improve surgical outcomes and patient satisfaction not only at Duke, but also at academic and community hospitals throughout the Nation.

G. Department of Surgery Vision

As one of the leading national and international academic departments of surgery, we will assemble and integrate a comprehensive range of health care resources providing the very best in patient care, medical education, and clinical research. As the health care providers of choice in the region, we will improve the health of the communities we serve through the development of new, better models of health care. Through careful stewardship of our resources, we will preserve and promote our core missions of outstanding clinical care, discovery research, and improve health for the communities we serve.

H. Values

i. We earn the trust our patients place in us by involving them in their health care planning and treatment, and by exceeding their service expectations.

ii. We maintain a work environment that nurtures respect for the individual within an atmosphere of cultural diversity.

iii. We foster personal achievement and team accomplishments by encouraging honesty, commitment, and initiative.

iv. We enhance the effective use of our resources through continual improvement of our performance.

v. We improve patient care and the ways in which it is delivered by supporting innovation and excellence in education and research.

vi. We achieve new levels of success by partnering with individuals and organizations that share our vision.

vii. We fulfill our societal responsibilities through our commitment to community citizenship.

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I. General Surgery Residents’ Web

http://gsresidency.surgery.duke.edu II. General Policies & Procedures

A. Prerequisites to Beginning the Surgical Year

i. Graduation from a PA Training Program approved by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). A bachelor's degree is required and applicants must have passed or be eligible to take the National Commission on Certification of Physician Assistants (NCCPA) Certification Examination.

ii. A credentialing file must be completed with Duke University Medical Center

iii. Application process must be completed with the North Carolina Medical Board

B. Duty Hours

i. Eighty-Hour Work Week

Providing PA Surgical Residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and trainee well being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on trainees to fulfill service obligations. Didactic and clinical education must have priority in the allotment of trainees' time and energies. Duty hour assignments must recognize that faculty and trainees collectively have responsibility for the safety and welfare of patients and adherence to this policy. The institution is committed to the promotion of an educational environment, support of the physical and emotional well being of its graduate medical trainees, and the facilitation of high quality patient care. a. Duty hours are defined as all clinical and academic

activities related to the graduate medical education program, ie, 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. Trainees must be provided with 1 day in 7 free from all educational and clinical responsibilities,

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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.

iii. Clinical Activity

It is required that PA Surgical Residents attend clinic at least once a week upon the service that they are rotating.

iv. Resident Leave

As soon as the resident has knowledge of a need for professional, parental, or disability of sick leave, an immediate meeting with the Program Director is mandatory. 46 weeks of clinical activity is required for completion of the program. Please refer to the Human Resources Policy Manual for more information.

v. Unplanned Absence or Tardiness

If a resident is not able to make it to work or will be late, it is the resident’s responsibility to notify the program director and the Chief resident on their service as soon as possible. The information must be relayed via direct conversation. Emails, text pages, or voice messages on cell phones are not acceptable.

vi. Interviewing

As graduation nears, it may be necessary for the PA Resident to interview for positions outside of Duke. It is the responsibility of the PA Resident to plan ahead for this and discuss with the Chief Resident on their service as well as the Program Director to ensure that coverage is available if time off is required.

C. On-Call

i. 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 workday when trainees are required to be immediately available in the assigned institution.

ii. In-house call must occur no more frequently than every third night, averaged over a four-week period.

iii. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Trainees 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

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(unless further limited by the relevant Program Requirements).

iv. No new patients may be accepted after 24 continuous hours on duty. A new patient is defined as any patient for whom the trainee has not previously provided care (unless otherwise defined in the relevant Program Requirements).

v. When trainees are called into the hospital from home, only the hours trainees spend in-house are counted toward the 80-hour limit.

D. Record Keeping

a. PA Residents are required to log their duty hours and procedures/OR

cases at www.myevaluations.com daily. Compliance with this policy is mandatory. Failure to comply will result in disciplinary action.

i. Duty Hours: PA residents are required to log in daily to record their hours. These hours are regularly reviewed to ensure compliance with the 80-hour workweek. It is important that your entry accurately reflects the actual hours you are in the hospital.

ii. Procedure/OR case log: PA residents are required to keep an accurate and up to date log of all procedures and OR cases. This will be reviewed on a regular basis to ensure compliance.

E. Performance Evaluation of PA Surgical Residents

At the end of each rotation, Attending Surgeons, Chief-Residents, Junior and Senior Residents, and physician assistants of their choice will evaluate the PA Surgical Residents. The PA resident will be required to submit their names to the program secretary at the end of the rotation.

F. Rotation Schedule Changes

PA Surgical Residents will be scheduled to rotate through the various specialties and sub-specialties to enrich their surgical experience. In addition they have a choice of one or two elective rotations. Every effort will be made to accommodate their preferences. Any concerns, conflicts, or changes should be brought to the attention of the Program Director.

G. Resident’s Evaluation of Rotations

Upon completion of each rotation, PA Surgical Residents are required to complete an evaluation of the service, which is available on myevaluations.com. A score of 1-6 will be given for OR, clinical experience, completion of objectives, and overall team atmosphere.

H. Attire

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The purpose of the dress code is to enhance patient’s confidence in the employees, faculty, and residents of the Department of Surgery as highly competent members of a healthcare team who are strongly committed to quality service. Please refer to the following website for further details: http://staff.surgery.duke.edu/modules/businessofc/index.php?id=8

I. Hospital Policies

i. Verbal Orders

a. Verbal orders should be used only to meet the care needs of the patient when the ordering practitioner is unable to write/enter the order himself/herself because he/she is not physically able to access the medical record or CPOE.

b. A non-physician is in communication with a physician by telephone or in other circumstances in which the Doctors' Orders sheet is not accessible to the physician. The physician orally gives specific orders for a specific patient to be carried out before a physician countersigns the orders. The nonphysician confirms that the order was heard correctly by immediately repeating the name of the patient and the order back to the physician (except during a Code 5) using a 'read back' system of communication. The 'read back' system is where the non-physician writes the order as heard and reads back to the physician the order as written. For sound alike medications, the name is spelled back to the physician. The physician then verifies the accuracy of the read back order. The nonphysician writes the orders and next to them the notation, "V.O. [verbal order] for Dr. xxxxxxxx." Under this the nonphysician signs his/her own name, title, and pager ID# and the orders are then carried out.

c. Verbal orders must be signed by the prescribing practitioner as soon as possible and reflective of the earlier of the following: The next time the prescribing practitioner provides care to the patient, assesses the patient or documents information in the patients medical record or within 48 hours of when the order was given. The signature must be dated and timed. If the prescribing practitioner is not available to authenticate the verbal order, a covering physician may cosign the order. The signature indicates that the covering physician assumes responsibility for the order as being complete, accurate and final. A physician's assistant or nurse practitioner may not authenticate a verbal order given by a physician. In this procedure, the nonphysician serves only as a scribe for the physician. This procedure may not be used unless

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the physician specified the name of the patient and the full and exact content of the order written. The physician will state the order directly to the writer, not indirectly through another nonphysician intermediary.

d. Verbal orders may not be given for: - Cancer chemotherapeutic agents - Investigational drugs - Systemic thrombolytic agents. NOTE:

Verbal orders may be given for alteplase (tPA) for the purpose of declotting a catheter.

- Initial dose of insulin. NOTE: Preprinted insulin order sheet must be used for initial insulin orders.

e. Verbal orders are limited to the attending physician for:

- Limiting cardiopulmonary resuscitation as witnessed by another physician and a registered nurse. See Doctor's Orders to Limit Cardiopulmonary Resuscitation [DNR] Procedure for details.

ii. Physician-Extender Orders

a. Under the provisions of the job description of the nonphysician the nonphysician exercises some discretion in determining which specific orders to write for a particular patient. Under such orders, the nonphysician signs his/her own name and title and states the name of the supervising physician as follows: "(signature of writer), title, for Dr. xxxxxxx." Such orders are carried out when written and thus before the specific orders come to the attention of any physician.

b. Orders written by Nurse Practitioners (NP), Certified Nurse Midwives (CNM) and Physician Assistants (PA) who have been credentialed at Duke University Hospital for less than 6 months: During the first six months as a credentialed member of the Health Professional Affiliate Staff, the extender will indicate the title on orders using the extension '-RS' for 'Requires Signature' (e.g. NP-RS, PA-RS, CNM-RS). Such orders are countersigned by the supervising physician or back-up supervising physician within seven calendar days indicating date of cosignature, name, title and pager ID. The purpose of the countersignature is to document medical supervision of the nonphysician.

c. Orders written by Nurse Practitioners (NP), Certified Nurse Midwives (CNM) and Physician

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Assistants (PA) who have been credentialed at Duke University Hospital 6 months or more: Such orders do not require a cosignature. The orders are signed with the individual's name, title (NP, PA, CNM) and pager ID. Supervision of the extender will be demonstrated through ongoing review by the supervising physician in accordance with state regulations and in a manner defined by the supervising physician.

iii. DEA Number

All prescriptions written in North Carolina require the prescriber’s DEA number. PA Residents will be given a temporary DEA (Drug Enforcement Administration) number for use while in training at Duke. These numbers are issued by the Department of Pharmacy and are unique to each prescriber. These DEA numbers are valid only at authorized Duke practice sites.

J. Ordering Narcotics

i. PA Residents are not allowed to write for the following medications: Dilaudid and Oxycontin

ii. Oxycodone is limited to 35 tablets on all services with the exception of Cardiothoracic, where the limit is 50. Please see the rules and regulations for PA’s in the state of North Carolina for further information.

K. Housing

The PA Surgical Resident will be responsible for securing housing.

L. Benefits

i. Health Insurance During September, the month of Orientation, PA Surgical Residents will meet with the Benefits Manager to discuss the health insurance options for the individual and their immediate family. In addition, information will be provided regarding Reimbursement Accounts, Disability Benefits, Life Insurance, Retirement Savings Program, Live for Life Program, Long Term Care Insurance, Personal Assistance Service, and Personal Casualty Insurance. Contact: Mr. Bill Phillips, Benefits Manager 705 Broad Street Durham, NC 27705 919-681-4615 [email protected]

ii. Malpractice Insurance

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PA Residents are covered under the same Liability Insurance Policy and to the same limits as Duke attending physicians.

iii. Fitness Center An exercise center is located in the basement of Parking Deck II.

Lockers and showers are available. The hours are from 6:30 am - 12:00 midnight. There is no charge for using this facility.

M. IPAQ’s

Each resident will receive a Palm Pilot to facilitate patient care. The palm pilot is interfaced with the Duke Hospital’s e-browser and is programmed with useful resources such as e-pocrates. Residents will be able to manage patient lists and be able to synchronize patient labs to stay up to date and current in patient care. The palm pilot is the property of Duke and must be returned at the end of the residency.

N. List of Floors/Services Ninth Floor: Oncology Eighth Floor: Medicine Seventh Floor: Cardiology/Pulmonology Sixth Floor: Plastics/ENT/Ortho/Urology Fifth Floor: Pediatrics Fourth Floor: Neurology/Neurosurgery Third Floor: Cardiothoracic Surgery/ Operating Rooms Second Floor: General Surgery First Floor: Radiology/ Cafeteria

O. Meals

The cafeteria on the first floor of Duke North is open from 6:00 a.m. until 3:00 a.m. the next day. There is also a Hardee’s in the basement of the Children’s Center of the hospital, and a cafeteria in Duke South.

Residents have the option to set up a Flex Account on their ID badge. This allows money to be credited to the ID badge and can be used as a debit card in the cafeteria. This can be set up in the Traffic Control Office.

Residents “on-call” will have the benefit of “house staff meals” at the cafeteria past 5:30pm. This past year $6.60 per call night was credited to the ID card. Monies do not accumulate and any unused amount cannot be reclaimed after the call. This money is only to be used when the resident is scheduled for a 24-hour call shift.

P. Meetings i. Case Conference PA Surgical Residents are required to attend weekly Case Conference. Click here to view Case Conference page ii. Grand Rounds

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PA Surgical Residents are required to attend weekly Grand Rounds Click here to view Grand Rounds page iii. Resident Conference

PA Surgical Residents are encouraged, rotation and schedule permitting to attend the weekly resident conference.

Click here to view Resident Conference page

Q. Online Resources

i. CME Central Line Course Click here for CVC Training http://cvcourse.mc.duke.edu/

(Be sure to print the certificate of completion and give a copy to the program secretary.)

ii. HIPPA Click here for HIPPA Training http://www.gme.duke.edu/current_trainees/hipaa.asf

iii. PACS Training Click here for PACS Training.

(Be sure to print the certificate of completion and give a copy to the program secretary.)

iv. Protocols Click here for emergency/trauma protocols http://surgeryweb.duhs.duke.edu/gensurg/resident/traumpro.htm

R. OR Coding Services

The PA Surgical Resident should become familiar with the coding offices and the proper way to report those services for which reimbursement can be applied.

Office Locations and contacts are as follows: Edie Hamilton, CPC (Revenue Mgmt) [email protected] Pager: 970-3496 (current phone 684-3616) Donna D Morris, CPC (PDC Compliance) [email protected] 668-5165 Duke North OR’s Elizabeth Davis, CPC 3415 Duke North

681-3290

Charlie Brantley, CPC 3415 Duke North

681-3226

Ambulatory Surgery Center

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Shirley Wilson, CPC 2122 Ambulatory Surgical Center 668-2019

S. Parking The PA Surgical Resident will be issued a parking permit. Parking and Transportation Services 0100 Facilities Center (off Research Drive) Phone: (919) 684-7275 Hours: Monday-Friday 7:30am-5:00pm Online: parking.duke.edu T. Patient Confidentiality/HIPPA

PA Residents are required to follow all HIPPA guidelines. Please refer to the DUMC employee handbook for further information.

U. Pyxis

This is the unit that holds all the medical supplies needed on the floor (i.e. Gauze, tape, staple removers, needles, etc.) Every floor has a Pyxis, some floors more than one. PA Surgical Residents will receive training and a password to access it.

V. Scrubs Duke University Medical Center will provide scrubs to PA Surgical

Residents. A Scrub Card will be assigned in September, the month of orientation. This card will be credited with three pairs of scrubs. Once the three pairs are checked out, they must be returned to gain credit toward a clean pair. Please see Attire (II, D, x, a-d) for DUMC guidelines to properly incorporate scrubs into the clinical attire.

W. Corrective Action

If a PA Resident consistently performs below expectations as evidenced by poor performance on evaluation(s) or verbal complaints by faculty or staff, a written warning will be issued and a meeting will be held to discuss the issue and correct it. If the PA resident does not improve, further disciplinary action will be pursued on an individual basis, and may result in probation with remediation and/or termination of employment. Please see http://www.hr.duke.edu/policies/staff_handbook.pdf for more detailed information.

X. Withdrawal from the Program

The PA Resident has the option to withdraw from the residency at any time without cause and for any or no reason and be excused from further obligation or liability provided that any such termination shall be upon at least thirty days’ prior written notification (the “Notification Period”). Failure by the PA Resident to give at least thirty days’ notification would work an unquantifiable hardship on the Hospital and will be remedied by

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the PA Resident’s payment to the Hospital of liquidated damages equal to fifty percent (50%) of the PA Resident’s monthly compensation at the time of the PA Resident’s termination.

Y. Human Resources Policy Manual

For comprehensive details about Duke’s Human Resources policies, procedures, and forms, please visit the HR website at: http://hr.duke.edu/policies/index.html.

Z. Moonlighting

PA Surgical Residents are not permitted to moonlight during the residency program.

III. Tips/FAQ’s

A. What to do before you arrive at Duke

i. Secure Housing ii. Appointment with Employee Health and Wellness Duke South Clinic Basement/Ground Red Zone/PRT Level 684-3136 (Bring your immunizations record) iii. Fitting for your whites The Medical Center Bookstore 106 Facilities Center Durham, NC 27708 Phone: (919) 684-2717 Hours: Monday-Friday 8:30am-5: 30pm Saturday 10:00am-4:00pm Sunday Closed Online: www.dukestores.duke.edu/medical.html

iii. Apply for your North Carolina Medical License. (**Important** this may be daunting and most time consuming, and hence an early start is warranted. Please take the PANCE exam as soon as you graduate and start the application for licensure immediately; as it may take up to 3 months after the license materials are received. You will need 3 letters of reference. You will also need 3 letters for credentialing at DUMC. Have your letters of reference include references to both the hospitals and for your license, so you won’t have to get 6 different letters.) Follow up with the medical board frequently to ensure that all of you application materials have been received and are complete (especially fingerprints). http://www.ncmedboard.org/paform.htm

iv. Get your credentialing completed. (Cindy Cayton is very efficient

and organized and will assist you in this endeavor.)

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