Policy and Procedure Guide for Physicians

• ACGME Glossary of Terms (Word)

• Resident Handbook (PDF)
• Clinical Teaching (Word)

• 1.1 Rationale for the Involvement (Word)
• 1.2 Definition of GME Programs (Word)
• 1.3 ACGME Approved Residencies
• 1.4 Non-ACGME Accredited Fellowship Programs
• 1.5 Guidelines for Residency Programs
  • I. Accreditation Process (Word)
  • II. Requirements for Accreditation (Word)
  • III. Funding (Word)
  • IV. Distribution of Institutional Resources (Word)
  • V. Residencies Accredited at SLU (Word)
• 1.6 Guidelines for Non-ACGME Accredited Fellowship Programs (Word)
• 1.7 Non-ACGME Accredited Fellowship Program Application (Word)

• 2.1 Operation of Residency and Fellowship Programs (Word)
• 2.2 Final Confidential Evaluation Form (Word)
• 2.3 Special Review Policy (Word)
  •    2.3a Responsibilities of Special Review Team Members (Word)
  •    2.3b Meeting with Program Director and Coordinator (Word)
  •    2.3c General Competencies (Word)
  •    2.3d Meeting with Faculty (Word)
  •    2.3e Meeting with Residents (Word)
  •    2.3f Special Review Report (Word)

Appendix A  (Word)

•  2.4 Discharge and Transition of Care Policy (Word)

• 3.1 Appointment of Physicians as Residents and Fellows (Word)
• 3.2 Graduate Medical Education Appointment Request Form (Word)
• 3.3 Appointment Letter (Word)
• 3.4 Responsibilities and Benefits (Word)
• 3.5 Re-Appointment Letter (Word)
• 3.6 Re-Appointment Request Form (Word)

• 4.1 Assignment of Residents and Fellows from Other Institutions (Word)
• 4.2 Application for Residents Rotating from Other Institutions (Word)
• 4.3 Memorandum of Agreement – Non-Compensated Educational or Research Appointment (Word)
•   4.3a Application for Clinical or Research Fellows (Word)
• 4.4 Application for Residents Rotating to Other Institutions (Word)
• 4.5 Memorandum of Agreement – Research Fellow (Word)
• 4.6 Application for Health Care Professionals (Word)
• 4.7 Memorandum of Agreement – Non-Compensated Educational or Research (Health Care Professionals) (Word)
• 4.8 Memorandum of Agreement – Compensated Educational or Research (Word)
• 4.9 Application for Observers (Word)
• 4.10 Memorandum of Agreement – Observership (Word)
• 4.11 Memorandum of Agreement – for External Sponsorship (Word)
• 4.12 Application: Program for Away Rotation (Word)
  • 4.12a Resident Research Grant Application (Word)
  • 4.12a (Part II) Resident Research Grant Description (Word)

• 5.1 Stipends for Residents and Fellows
  The term resident applies to all individuals who are in programs which are approved and/or accredited by the Accreditation Council for Graduate Medical Education and lead to eligibility for examination for board certification.  Many individuals previously characterized as fellows such as those individuals in subspecialty areas of Medicine or Pediatrics, e.g., Pulmonology, Hematology, Gastroenterology, etc., are now considered residents.  Saint Louis University School of Medicine utilizes the term “fellow” only for individuals who are in programs not approved nor accredited by the ACGME.  Section 1, Pages 8-9 lists the residency programs and fellowship programs respectively presently operating at Saint Louis University School of Medicine.
  
  The residents during this academic year will receive stipends on the following schedule, depending on their postgraduate year of training. All trainees at similar levels of experience and training in all of Saint Louis University School of Medicine’s residency programs should receive a comparable level of financial support. Exceptions must be requested in advance and justified to the Graduate Medical Education Committee.
  
  *See definition of Extraordinary or Unranked Faculty in the Faculty Manual of Saint Louis University 1987, Page 33 and following.

• 5.2 Stipends Schedule

• 6.1 Appointment of International Visiting Fellows (Word)
• 6.2 Application-International Visiting Fellows (Word)
• 6.3 Memorandum of Agreement - International Visiting Fellows - Compensated (Word)
• 6.4 Memorandum of Agreement- International Visiting Fellows - Non-Compensated (Word)

• 7.1 Awarding of Certificates
  Certificates for residents and/or fellows are awarded (1) upon successful completion of a postgraduate program, (2) when an individual leaves a program, having successfully completed the contract year; and (3) following the successful completion of the PG-1 year.
  
  Certificates for residents will include the wording “Program Accredited by the Accreditation Council for Graduate Medical Education”.
  
  The Office of Graduate Medical Education will request from the programs a written list stating exactly how an individual’s name and the name of the program should appear on a certificate.  This information should be returned 8 weeks before the program’s completion for a certificate to be issued.  The certificate will not be released until the Final Evaluation Form (or final letter in the case of a fellow) is received.
  
  Certificates lost or damaged should be requested by the “Lost Original Certificate Affidavit and Agreement” form (Form 6.1, Page 4) which must be filled out completely and notarized.  There is a charge for any reissued certificates. Make a check or money order for $25.00 payable to: Saint Louis University School of Medicine and send to the Office of Graduate Medical Education, Schwitalla Hall, M260, School of Medicine.

7.2 and 7.3 are examples of certificates issued to a resident and to a fellow:

• 7.2 Resident Certificate (Word)
• 7.3 Fellow Certificate (Word)
• 7.4 Lost Original Certificate Affidavit and Agreement (Word)

• 8.1 GMEC Policy (Word)
• 8.2 Delinquent Medical Records (Word)
• 8.3 Impaired Practitioner
  It is the policy of Saint Louis University School of Medicine and its Graduate Medical Education Programs to protect patients from harm by maintaining a safe, drug-free workplace while complying with the requirements of the Americans with Disabilities Act.  Trainees with physical or mental impairments or a history of chemical dependency will be evaluated and/or monitored as appropriate by the Employee Assistance Program (EAP). Restrictions and/or accommodations for impaired trainees will be incorporated into the appointment and reappointment process.
• 8.4 Ombudsman (Word)
• 8.5 Principles to Guide the Relationship between Graduate Medical Education Programs and Industry (Word)
  • 8.5a Medical Center Conflicts of Interest in Patient Care and Service (Word)
• 8.6 Resident Duty Hours and the Working Environment (Word)
  • 8.6a Duty Hour Exception (Word)
• 8.7 Office of Graduate Medical Education Security Policy
  The Office of Graduate Medical Education, Room 260 will be locked at all times other than when a member of the GME Staff is present.
  
  Files of current residents will be kept in a locked drawer in Room 260, unless, they are currently being used by a member of the GME staff, or an authorized member of the Dean’s staff. Persons authorized to remove a file are the Dean, the Associate Dean for Graduate Medical Education, Departmental Chairperson, Program Directors, and the Director of the Employee Assistance Program.
  
  When an authorized member of the Dean’s staff removes a resident file from the GME Office to his/her own office, he/she will keep the file in a locked drawer when not using it.  At the time the file is removed from the GME Office, it will be signed out by the borrower.
• 8.8 Drug Testing Policy
  The Joint Commission on Accreditation for Healthcare Organizations is requiring all of our affiliated teaching hospitals to provide drug testing of their employees as well as personnel who will be seeing patients in their hospitals. Therefore, all residents and/or fellows will be required to pass pre-appointment drug testing prior to beginning their duties.
• 8.9 Moonlighting Policy (Word)
  •  Resident Moonlighting Exception Policy (Word)
• 8.10 H1-B Visa Approval Process
  The University will consider sponsoring H1-b visas for NRMP matched candidates to our participating residencies (hence meeting ERAS and selection committees criteria as qualified) only if the candidates have taken and passed USMLE 3 prior to March 31 of the year in which they intend to matriculate in our Programs.  At their own expense, matched candidates will be required to pay the $1,440 expedited review fee to the State Department.  Matched candidates who have not passed USMLE 3 as of April 1 will receive a packet of materials in support of a J-1 visa, and will be expected to participate fully in its processing and accept their appointment on this visa.  This policy and procedure will be explained in detail to interviewing candidates, and posted to several public websites, including the University’s GME and Program sites, and FREIDA (the AMA site for medical students seeking information about residency programs).
  
  Each department may at its discretion set a budgetary limit upon the number of such visas for which it will support and request sponsorship ($960 initial fee which includes a $500 fraud detection fee and a $460 filing fee, plus upon renewal, an additional $460 filing fee). However, the criteria for selection must be established in advance (i.e. place on rank list), and explained to the applicants in advance; as they must have this information for their considerations regarding constructing their rank list.

• 8.11 Disaster Policy: Eastern Missouri/Southern Illinois GME Coalition (Word)
• 8.12 Disaster Policy: Jesuit Medical Schools GME Coalition (Word)
• 8.13 Completion of USMLE Step 3 Examination (Word)
• 8.14 Interaction with Medical Technology Representatives Procedure for School of Medicine Notification (Word)
• 8.15 Diversity Policy
  • Policy: Each year Graduate Medical Education will review the data on diversity within the GME programs.
  • Procedure: Diversity data will be distributed to programs for use at the annual program evaluation by the Program Evaluation committee to assess the program’s efforts to recruit and retain a diverse workforce.

• Code of Professional Conduct for Residents and Fellows (Word)