WAKE FOREST UNIVERSITY DEPARTMENT OF NEUROSURGERY HOUSESTAFF MANUAL

WAKE FOREST UNIVERSITY DEPARTMENT OF NEUROSURGERY HOUSESTAFF MANUAL Created January 1, 2003 Revised February 2, 2010

Table of Contents Introduction Faculty Training Program Rotational Block Diagram Competencies Conferences Policies Housestaff Fringe Benefits

MISSION STATEMENT The Department of Neurological Surgery at Wake Forest University Baptist Medical Center has three primary missions. Firstly, we are completely dedicated to providing timely, compassionate, and superb medical care to our patients. Secondly, we are dedicated to the training of superb resident physicians. Thirdly, through clinical and basic research we are dedicated to the advancement of the field of Neurological Surgery. INTRODUCTION The Wake Forest University Baptist Medical Center Department of Neurological Surgery is committed to training residents to become expert practitioners, capable of providing the highest quality of neurosurgical care to their patients. The training includes education in the clinical and technical skills necessary to practice neurosurgery, the basic sciences, and the development of sufficient knowledge base such that clinical judgment can be appropriately applied in the care of neurosurgical patients. The professional attitudes valued by this program include the ability to make scientific and ethical judgments in the care of patients, complete dedication to the care of patients, the ability to work as a member of a neurosurgical team, and the capacity for working hard with a positive attitude. We expect residents in our program to teach and share knowledge with colleagues, students and other health care providers. The well-trained surgeon must be aware of the cost and societal implications of decisions and be able to adapt to the evolving health care system in this country. We anticipate that these lessons learned during residency will provide the basis for the resident to become valued leader of their medical community whether that is in an academic or private practice setting. The program offers an excellent experience appropriate for both the academic and the general practice of neurological surgery. All patients are located in one modern medical center, and both faculty and resident patients form a unified service. The complete spectrum of neurologic disease is seen in our patient population and extensive operating experience is offered at all resident levels. During their residency, the neurosurgical residents rotate on the services of all the allied fields of neurologic medicine. The resident on neuroradiology is instructed by four full-time neuroradiologists and performs selected neuroradiological procedures. The latest CAT scanner, MRI/MRA scanners, PET scan, SPECTS, ultrasound, and other imaging equipment are available. Two neuropathologists supervise individual instruction and conference preparation. The productive relationship with 20 full-time neurology faculty includes abundant exchange of both information and patients.

There are four neurosurgical operating rooms equipped the most up to date equipment including a laser, intraoperative angiography, ultrasound, ultrasonic surgical aspirator, operating microscopes, and stereotactic capability. Anesthesia is supervised by neuroanesthesiologists. There is a resident library and a microvascular laboratory. Publications and presentations are expected from the residents. There is also ample interaction available with the outstanding basic neuroscience faculty and trainees. The opportunity to work with a committed faculty and well-qualified, cohesive resident staff creates a challenging and rewarding experience for the neurosurgical resident. Four neurosurgical nurse clinicians are employed to assist the residents and staff with ward duties. In addition, there are mid-level practitioners who assist the residents with patient care responsibilities. Extensive experience with complex spine surgery is available, with ample opportunity provided to learn instrumentation and fusion techniques. In the area of brain surgery, operations for tumor (i.e., pituitary, acoustic, and all types of skull base tumors), arteriovenous malformation, aneurysm, seizure, and hydrocephalus provide a wide range of experience. Cerebral revascularization, including carotid endarterectomy as well as ECIC bypass, provides extensive operative experience in vascular surgery. In addition, procedures for the alleviation of the pain of carpal tunnel syndrome and tic douloureux, for example, are numerous. Wake Forest University School of Medicine is a leading medical center for stereotactic radiofrequency lesioning procedures (pallidotomy, thalamotomy) and deep brain stimulators for movement disorders. There is also ample experience with the surgical treatment of epilepsy. Exposure to the rapid advances of neuro-oncology is extensive. Stereotactic radiosurgery training is provided on both our Gamma Knife and linear accelerator based systems. The department is one of seven academic medical centers that participate in the National Cancer Institutes New Approaches to Brain Tumor Therapy (NABTT) consortium, ensuring that trainees have the opportunity to become familiar with state-of-the-art therapies. Different surgical navigation systems are used in the operating room, providing familiarity with these important image-based tools for pre-surgical planning and stereotactic lesion localization. Wake Forest University Baptist Medical Center is an accredited Level One Trauma Center. The treatment of trauma patients provides a wide range of experience in the area of closed head injury and increased intracranial pressure control. In addition, there is a substantial pediatric experience, encompassing the full range of pediatric neurosurgery.

CLINICAL FACULTY NAME TITLE MEDICAL SCHOOL RESIDENCY Charles L. Branch, Jr., M.D. Professor and Chairman University of Texas-SW Wake Forest University Daniel E. Couture, M.D. Assistant Professor University of Virginia Wake Forest University Thomas L. Ellis, M.D. Associate Professor UNC Chapel Hill University of Florida Carol Geer, MD Assistant Professor Johns Hopkins University University of Michigan David L. Kelly, Jr., M.D. Chairman Emeritus and UNC Chapel Hill Wake Forest University Professor Alexander K. Powers, M.D. Assistant Professor University of South Florida Wake Forest University Thomas A. Sweasey, MD Assistant Professor University of Cincinnati University of Michigan College of Medicine Stephen B. Tatter, M.D., Ph.D. Professor Cornell University Massachusetts General Hospital Harvard Medical School John A. Wilson, M.D. Associate Professor Jefferson Medical College Allegheny General Hospital New York University Tufts-New England Med Ctr. RESEARCH FACULTY Name Title Research Area Waldemar Debinski, M.D., PhD. Professor Brain Tumor Therapy H. Caldas, Ph.D. Assistant Professor Brain Tumor Therapy Akiva Mintz, M.D., Ph.D. Assistant Professor Molecular Imaging of Brain Tumors *Clinical in Radiology CROSS APPOINTMENTS Name Title Research Area Glenn Lesser, M.D. Professor Neuro-oncology Pearse Morris, M.D. Associate Professor Endovascular Therapy for Cerebrovascular Disease M.S. Siddiqui, M.D. Assistant Professor Neurology

TRAINING PROGRAM OVERALL GOALS AND OBJECTIVES The goals and the objectives of neurosurgical residency training program at Wake Forest University are to satisfy the General Requirements of the Essentials of Accredited Residencies and Graduate Medical Education and all Special Requirements for Residency education in neurological surgery. RESIDENCY EDUCATIONAL GUIDELINES Currently the Department of Neurological Surgery Residency Program at Wake Forest University includes six years in training after completion of a surgery/basic clinical skills internship. During the PGY 1 year the resident will complete 3 months of neurosurgery, 3 months of neurology, 1 month rotations in neuro critical care and neuro-ophthalmology and the remaining 4 months being spent on various general surgery services. During the next four years the resident will complete 36 months of clinical neurosurgery which will include 3 month rotations in neuroradiology, endovascular neurosurgery, radiosurgery/outpatient, and neuropathology. Twelve months will be spent on a research/scholarly activity. During the PGY 6 year the resident spends 12 months as co-chief resident. The final year allows for 12 months of advanced neurosurgical electives or the possibility of an in-folded fellowship. The rotation order may vary slightly for each resident, with the rotations being tailored to meet the specific needs of the individual resident. GRADUATED LEVELS OF RESPONSIBILITY Medical education is based on the principle of graduated levels of responsibility, under the supervision of faculty, while caring for patients. These levels are defined as postgraduate years (PGY), referring to the years of training after completion of medical school. The program director in conjunction with the neurosurgical faculty are responsible for the evaluation and progress of each resident to determine if they should be promoted to the next level of training. At each level of training we have defined a specific set of competencies that the resident is expected to master. At each successive level greater independence is given to the resident at the discretion of the neurosurgeon attending who remains responsible at all times for patient care. Our neurosurgery program is a six year program of training after medical school. Generally, the PGY-1 year is dedicated to the acquisition of basic clinical skills with the resident rotating on a variety of surgical services. In addition, this year includes three months of neurology during which the resident learns the basics of management of various emergent and chronic neurologic conditions including stroke, epilepsy, multiple sclerosis, ALS, Parkinson's disease and other movement disorders,. The PGY-2 and 3 years are spent as the junior resident on the clinical service. It is during this time that the resident learns how to take care of critically ill neurosurgical patients in the ICU and on the wards and gains initial experience in surgical procedures appropriate to his or her level of training. The PGY-4 and 5 years are considered

senior resident years. During this time the residents are given increasing levels of responsibility and independence in the care of patients. The PGY 6 year is the chief resident year during which the resident will hone their surgical and patient management skills and achieve independence in all aspects of neurosurgical practice. PGY-I The PGY-I spends six four-week rotations on the neurosurgical service, three four-week rotations on the neurology service and one month rotations on neuro critical care and neuroophthalmology. The remainder of the year is distributed among 4 week rotations on selected surgical services. Residents at the PG- I level are closely supervised by faculty and senior residents as they acquire basic clinical skills in the above listed specialties. They typically take in house call every four to six nights. While on call they are closely supervised within house backup from a PGY-IV. PGY-II and III Residents during the second and third year of postgraduate education are considered junior residents on the neurosurgery service. The PGY- II resident spends 12 months on the neurosurgery service. The PGY-III spends 6 months on the neurosurgery service, and 3 months on diagnostic neuroradiology, and a 3 month block doing radiosurgery/nsu Outpatient Clinic or Endovascular Neuroradiology. Junior residents typically take in house call every sixth night. While taking first call, the level of backup supervision is commensurate with the level of training. So the PGY-II resident is backed up by a PGY-V resident who takes call from home. During this time the PGY-II residents should be able to demonstrate increased sophistication in the acquisition of knowledge and skills in the practice of neurosurgery. They should also demonstrate further ability to function independently in determining the appropriate plan for patient care and for evaluating patients with critical neurosurgical problems. When taking in house call, the PGY-III resident has back up from the chief resident. They should be able to largely function independently in terms of the initial evaluation and management of patients with neurosurgical conditions presenting to the Emergency Department and in the ICU s. The PGY-III receives supervision in these activities from the attending neurosurgeon. The chief resident backs up the PGY-III on operative cases and when the resident requests help. PGY IV and V During this time the residents are regarded as senior residents on the neurosurgery service. The PGY-IV year typically includes 3 months on the neurosurgery service, 3 months of neuropathology and 3 months of endovascular neurosurgery/icu and the first three months of their twelve month block of research/scholarly activity. During this time period the residents will have the opportunity to take a review course to help in preparation for the ABNS primary written examination which in the PGY-IV year they take for credit. The PGY-V spends the first 9 months performing research (constituting a full year of research) followed by 3 months on the neurosurgery service. Residents during these years gain increasing independence both operatively and in the evaluation and management of neurosurgical patients. The PGY-IV takes call as an in house back up to the PGY-I s. They will gain more extensive experience in the direct supervision and teaching of more junior residents. PGY-V year has increasing levels of responsibility in the operating rooms. They back up the more senior PGY-III residents from

home and are available as a resource to assist them. Additionally the PGY-V will occasionally take chief resident call under the supervision of the attending physician. PGY-VI The PGY-VI year is the chief resident year. The chief year responsibilities will be shared by the 2 PGY-VI s and divided between Admin Chief/OPD/Emergent and Elective Service. The chief resident has first choice of participation amongst all procedures occurring on that day. The chief resident is to direct a resident team in the ongoing management of all patients coming to the neurosurgical service. It is also during this time that the chief resident, with direct faculty supervision has primary responsibility for the surgical management of patients with all types of pediatric and adult neurosurgical disorders. The chief resident has the primary responsibility for the management of all neurosurgical emergency cases. He or she sees emergency patients with the junior or intermediate residents and is available for immediate consultation when the more senior residents are taking backup call. The chief resident has major responsibility for the postoperative management of all neurosurgical patients in the intensive care unit. This includes daily rounds in the intensive units and close consultation with junior and senior residents. He or she is also expected to provide instruction about neurosurgical problems to medical students and junior residents and to instruct junior residents in basic neurosurgical operative techniques. The chief resident also has the following administrative responsibilities: a. the daily assignment of resident manpower to the operating room and clinics; (These assignments should be made in advance so that each resident has the opportunity to study and prepare.) b. the resident call schedule; c. the monthly chief resident clinical conference; d. the weekly preoperative case conferences; this should be prepared in advance with the Chief Resident reviewing the available images, selecting several cases and preparing to lead a discussion about each case the following day at conference. e. the quarterly morbidity and mortality conference. These responsibilities are divided equally between the co-chief residents. They typically rotate responsibilities on a weekly basis with one chief assuming primary responsibility for the administrative duties as well as emergent surgical cases and cases arising from the residents OPD clinic. The other chief takes primary responsibility for the elective neurosurgical cases. By the completion of the PGY-VI, the resident will be capable of independent practice in the field of neurological surgery.

BLOCK DIAGRAM OF ROTATIONS WAKE FOREST UNIVERSITY NEUROSURGERY BLOCK DIAGRAM OF ROTATIONS PGY 1 RES 1 PGY 1 RES 2 Month 1 Month 2 Month 3 Month 4 Month % Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 NSU NSU NICU GS/TRAUM A GS/TRAUM A NICU GS NEURO OPTHO NEURO OPTH GS NEURO CONSULT NEURO NEURO GS GS/ENT NSU NSU GS NSU GS GS/ENT GS NEURO NEURO NEURO CONSULT NSU July to September October to December January to March April to June PGY 2 RES A PGY 2 RES B PGY3 RES A PGY 3 RES B PGY 4 RES A PGY 4 RES B PGY 5 RES A PGY 5 RES B NEUROSURG NEUROSURG NEUROSURG NEUROSURG NEUROSURG NEUROSURG NEUROSURG NEUROSURG NEUROSURG Neuro Rad NEUROSURG Gamma Knife/ Outpatient Neuro Rad NEUROSURG NEUROSURG Endovascular/ICU Endovascular/ICU NEUROSURG Neuro Path Research/Scholarly Activity NEUROSURG Neuro Path Gamma Knife/ Outpatient Research/Scholarly Activity Research/Scholarly Activity Research/Scholarly Activity Research/Scholarly Activity NEUROSURG Research/Scholarly Activity Research/Scholarly Activity Research/Scholarly Activity NEUROSURG PGY 6 RES A Chief Resident Admin Chief/OPD/Emergent Chief Resident Elective Service Chief Resident Admin Chief/OPD/Emergent Chief Chief Resident Elective Service PGY 6 RES B Chief Resident Elective Service Chief Resident Admin Chief/OPD/Emergent Resident Elective Service Chief Resident Admin Chief/OPD/Emergent

NEUROPATHOLOGY SERVICE A firm understanding in neuropathology is vital to a solid foundation in the treatment of neurosurgical diseases. The neuropathology service provides critical diagnostic information after neurosurgical procedures for degenerative or neoplastic diseases. The objectives and goals of the neuropathology rotation are: A. to expose residents to the logical processes involved in the interpretation of neuropathologic specimens; (The neurosurgical residents are expected to become capable of identifying common neoplasms.) B. to provide residents with comprehensive exposure to diagnostic methods including frozen sections, permanent sections, immunohistochemical studies, and electron microscopy; C. to provide residents with the chance to study the teaching slide files of the neuropathology section as well as an in-depth study of the commonly used neuropathology textbooks; and D. to expose residents to the processes involved in conducting a clinical pathologic conference; (In light of this, the residents are expected to conduct at least one neuropathologic conference during the course of their rotation, and are expected to attend all neuropathologic conferences.) E. To provide the residents the opportunity to participate in post mortem examination of the brain during brain cutting. This will facilitate clinicopathologic correlation of neurologic disease processes, and increase understanding of normal brain anatomy. NEUROLOGY SERVICE The complete understanding of medical neurology and neurologic diagnostics skills are vital to the performance of optimal neurosurgical care. The neurology service includes experience in the neurology in-patient service, the consult service, the clinical electro physiology laboratory, and the neuro rehabilitation service. The neurology service rotation has the following specific goals and objectives: a. to introduce residents to the diagnoses and management of common neurological disorders such as vascular, infectious, and degenerative disorders of the central nervous system;

b. to provide residents with a detailed review of the neurological diagnostic method including the performance of a detailed neurological history and physical examination; c. to introduce residents to the principles and practice of clinical electrophysiology including EEG, a volt potentials, and EMG; and d. to introduce residents to the diagnoses and management of medical neurological emergencies. The accomplishment of these goals will facilitate the residents ability to formulate thorough differential diagnosis of neurologic disorders that distinguishes between surgical and non-surgical conditions. NEURORADIOLOGY SERVICE The ability to interpret neuroradiological studies is vital to the diagnoses of neurosurgical disorders as well as the planning of neurosurgical procedures. Endovascular techniques have become increasingly common and represent an important adjunctive treatment for many neurosurgical disorders. The goals and objectives of the neuroradiology rotation are: a. to introduce residents to the performance and interpretation of spinal and cerebral angiograms; (Residents are expected to participate in both diagnostic and interventional spinal and cerebral angiographic studies.) b. to introduce residents to the skills necessary in the interpretation of CT and MRI studies; (Residents are expected to attend all CT/MRI scope reading sessions.) c. to expose residents to the methodology used during the course of radiosurgery; (Residents are expected to participate in radiosurgical procedures.) d. to expose residents to endovascular surgery, including the treatment of vasospasm, the embolization of arteriovenous malformations and the coiling of aneurysms. RESEARCH YEAR Every resident in the program is expected to perform at least one year (a dedicated 12- month block) of clinical or basic scientific research. He or she has great latitude in choosing the subject of their research although they will be mentored by one or more of the neurosurgical or basic neuroscience faculty. The research project must be approved in advance by the program director. The Department of Neurosurgery believes that the

research experience aids in the development of the skills necessary for reading and understanding the scientific literature. These skills are critical to the ongoing education of all neurosurgeons and the advancement of our field. The goals and objectives of the research rotation are: a. to expose residents to ongoing application of the scientific method; b. to introduce residents to scientific writing; (Each resident is expected to become the author or co-author on multiple papers throughout the residency but particularly during the research year.) c. to expose the resident to an area of scientific research that may form the basis for a future academic career in neurosurgery; A wide range of clinical research is in progress: natural history of cavernous and venous angiomas, the use of EC-IC bypass, stereotactic radiosurgery and interstitial radiation therapy, spine stabilization techniques and devices, spine fusion with BMP, cerebrospinal fluid shunt devices, clinical utility of transcranial Doppler, studies on closed head injury, spinal cord injury treatment, intraoperative monitoring in carotid endarterectomy, neuropsychologic outcomes after aneurysm surgery, microvascular Doppler in cerebrovascular surgery, hypothermia in aneurysm surgery, telemedicine applications via computer hookup, carotid Doppler flow in head trauma and cerebral vasospasm, outcomes research in spinal fusion, gliomas, carotid stenting, pharmacologic intervention in severe closed head injury, and novel treatments of brain tumors including implantable chemotherapeutic and brachytherapy agents. In addition, the residents have the opportunity to engage in a wide variety of basic science research projects under the supervision of Dr. Waldemar Debinski or any of the neuroscience faculty of the Wake Forest University School of Medicine. The clinical faculty also has several projects in which they are collaborating with the neuroscience faculty including investigation of mrna expression in the cap cells of carotid plaques.

COMPETENCIES The ACGME has determined that all residents completing an accredited program should be proficient in six skilled areas. The neurosurgery program at Wake Forest University through its rotations, lectures and conferences, provides the necessary educational experience to obtain these skills. The evaluation system in place is designed to evaluate the residents progress in becoming proficient in each of these six areas. The specific language from the program requirement includes: Residents must become competent in the following six areas at the level expected of a neurosurgical practitioner. 1. Patient Care residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Neurosurgery residents must: a. Develop appropriate technical skills necessary to perform neurosurgical procedures b. Develop clinical skills necessary to evaluate and manage neurosurgery patients in the ED, SICU, or floor. 2. Medical Knowledge residents must acquire knowledge about clinical, biomedical, epidemiological and behavioral sciences and the application of this knowledge to patient care. Neurosurgery residents are expected to: a. Develop knowledge of pertinent clinical and basic science information and apply this knowledge in clinical practice. 3. Practice-Based Learning and Improvement residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Neurosurgery residents are expected to: a. Critique personal practice outcomes. b. Locate (through reading and online means) and apply scientific knowledge to his or her own practice. c. Teach students and other health care professionals.

4. Interpersonal and Communication Skills residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Neurosurgical residents are expected to: a. Work efficiently and effectively with other health care professionals. b. Learn to communicate in a compassionate and effective way with patients and their families. 5. Professionalism residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Neurosurgical residents are expected to: a. Demonstrate respect, integrity and compassion in the course of caring for patients b. Demonstrate sensitivity to gender, age and cultural background of patient s, their families and other health care professionals c. Maintain high standards of ethical behavior 6. Systems-Based Practice residents must demonstrate an awareness of and response to the larger context and system of health care and effectively call on system resources to provide optimal care. Neurosurgical residents are expected to: a. Practice high quality, cost effective patient care. b. Demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management. c. Understand different types of medical practice and health care delivery systems. Each resident is evaluated with regard to competency in each of these areas every six months by each of the faculty members.

CONFERENCES Residents are expected to attend all Tuesday morning conferences and encouraged to attend as many afternoon and Saturday morning conferences as possible. The conference program is designed to provide a didactic and interactive form to augment the residents clinical experience and reading program. Residents are commonly called upon to present at conferences and should spend the time necessary to be well prepared. Attendance at the conferences allows the resident to become exposed to the wide breadth of problems seen in neurosurgical practice. It also allows them to learn from the process of interaction among the attending neurosurgical faculty. Neurosurgical conferences are held every Tuesday morning from 7 a.m. 11 a.m. ICU TEACHING ROUNDS begin at 7 a.m. and include all the neurosurgery residents, the critical care team, medical students, nurse clinicians, and all faculty members. PRE-OP CONFERENCE is held every Tuesday with all neurosurgical faculty in attendance, and involves a review of preoperative imaging by the chief resident. NEUROPATHOLOGY CONFERENCE is held monthly, as supervised by Drs. Stanton and Mott, and involves case presentations by the attending neuropathologist of patients operated upon the previous week. NEURORADIOLOGY CONFERENCE alternates with neuropathology and involves a 30 minute didactic and a variety of subjects of interest of both neurosurgeons and neuroradiologists. ATTENDING CONFERENCE is held on the second Tuesday and represents an opportunity for the faculty member to present on a topic of his or her clinical interest. CEREBRAL VASCULAR CONFERENCE is held on the third Tuesday, as supervised by Drs. Wilson, Geer, and Morris, and involves a multi-disciplinary discussion of all cerebral vascular cases from the previous week (including endovascular cases). RESIDENT CONFERENCE is an opportunity for a junior or senior resident to present a 30 minute talk on any subject related to neurosurgery or neurology and to which he or she has researched thoroughly. MORBIDITY AND MORTALITY conference is held quarterly. It is attended by all faculty and residents and is organized by the chief resident. During this time the chief resident presents select cases and leads a discussion involving complication avoidance in the neurosurgery setting.

CRITICAL CARE CONFERENCE is held on the fourth Tuesday of each month during which a member of that team presents a 30 minutes didactic talk on the subject of mutual interest to both the neurosurgery and critical care services. BRAIN TUMOR BOARD is held every Tuesday afternoon, is supervised by Drs. Tatter and Ellis from the neurosurgery service and Dr. Lesser from medical oncology. It involves a multi-disciplinary discussion of all brain tumors operated the previous week. Selected faculty and residents attend. EPILEPSY CONFERENCE is held every Tuesday, is attended by Drs. Ellis and Couture and involves a detailed review of the preoperative data on epilepsy patients. Additional attendees include the Epileptology and Neurology Fellows, the EMU Technicians, the EMU nurses and social workers. Selected residents attend. INVITED LECTURES are scheduled for one Tuesday per quarter. JOURNAL CLUB is held during lunch once each month and is supervised by alternate faculty members with all residents attending. TEXTBOOKS The Department of Neurosurgery maintains an up-to-date library of the most current editions of all the major neurosurgical textbooks. In addition, each resident is given a $550 book allowance each year. The resident is expected to develop a rigorous program of reading the major textbooks. In addition to general reading and especially of neurosurgery, the residents should direct their daily reading toward events they encounter in the operating room or in the setting of patient care. Each resident should master the material in the standard textbooks by the end of the fourth year. In addition, the resident is expected to read about surgical procedures that they are going to perform prior to the day of surgery. Lastly, the resident is expected to begin the habit of reading the two major neurosurgery journals. Funds should generally be used to purchase neurosurgical textbooks Unused funds can be used to purchase technology applicable to neurosurgery. Amounts available/used will be tracked by Margaret Herring and any issues regarding items to be purchased by the fund will be decided with Margaret Herring IN-TRAINING EXAMINATION The American Board of Neurological Surgery provides a yearly examination for neurosurgical residents in late March of each year. All of the neurosurgery residents at Wake Forest University take this test yearly for on-going assessment. During the PGY- IV year the resident will take the examination for credit and must pass this examination for credit prior to advancing to the level of Chief Resident. The residents are expected to

take the exam every year and demonstrate improving scores. They can choose to take it for credit at any time and if they score better than 85th percentile they do not have to take it again.

POLICIES CODE OF CONDUCT All residents are expected to comply with hospital established standards of conduct. All house staff should maintain a professional attitude, conduct and appearance as well as demonstrate behavior that is exemplary of the medical profession. All residents must be identified by the Wake Forest University identification badge, which should be worn at al times. CONFIDENTIALITY The Department of Neurosurgery recognizes that the rights and individual dignity of each patient should be respected during the delivery of any health care services. Responsible behavior on the part of the house staff with regard to the privacy of patients and their families is expected. Individual patients are not to be discussed except in the course of the care of this patient. These discussions should not take place in the elevator, lunch room or other public places. Occasionally colleagues, public personages or even friends may be admitted to the hospital. Unless the residents are directly involved in the care of these individuals, it is considered a breach of medical ethics and confidentiality to read the chart, the online medical record, or otherwise seek to obtain information on these patients. No specific information about any patient should be released without the prior written consent of the patient or their guardian. CASE LISTS Neurological surgery residents are required to maintain a case list, conforming to the format required by the Accreditation Council for Graduate Medical Education (ACGME). To facilitate this, the Department of Neurosurgery provides a computer workstation and a computerized database in which all residents can enter their cases. It is imperative that residents maintain an ongoing record of cases in which they have participated. Attempting to reconstruct a case list after fact simply will not work. Maintaining this log is essential to the resident s subsequent ability to take the oral board for certification and for the program to remain accredited by the RRC. DRESS CODE Appropriate standards of dress are required for all residents providing for patients. While in contact with patients all residents will wear a white coat. While in contact with

patients residents should not wear cut-offs, shorts, jeans, or similar casual clothing. Name tags should be worn at all times while on duty in the hospital. Hair and facial hair should be trimmed and groomed appropriately. Footwear should be clean and appropriate to the occasion. No flip-flops or heavy boots are permitted. Hospital supplied scrub clothing should be worn by those working in specified areas and shall not be worn outside of the hospital. SUPERVISION Every patient seen by the Department of Neurosurgery is assigned to a faculty level physician, who supervises every aspect of care, whether it is in the clinic, operating room, emergency room, or hospital. Junior level residents are paired with senior level residents. They round together and discuss all patient issues at least once daily with the attending physician. The chief residents and attending physicians are available at all times, by beeper or telephone or onsite, for further consultation. The responsibility given to residents depends upon their individual level of knowledge, manual skill, experience, and the complexity of the patient s illness and the risk of operation, as determined by the attending physician. Every operative procedure is supervised, directly and onsite, by the attending physician. The Faculty of the Department of Neurosurgery exhaustively reviews complications on neurosurgical patients on a regular basis. The residents see all the hospitalized patients in the morning before 7:00AM and contact the faculty each morning to discuss each patient. This type of consultation goes on throughout the day as problems arise. The faculty commonly makes rounds in the evening alone or with a mid-level nurse or resident. The faculty is in attendance at all operations even when the resident has the primary operative responsibility. Each patient seen in the emergency room is discussed with the faculty prior to making a decision to admit or discharge the patient. All inpatient consults are reviewed and seen with a member of the faculty. For the specific details of the Department of Neurosurgery policy on resident supervision please see that policy document, included in this kit. EVALUATION An effective system of resident evaluation is vital to the individual resident s development and to improving the program at the Department of Neurosurgery. Evaluation of both the system of education as well as the individual is intended to provide valid data about the performance of each and to provide data that can be used to improve the education experience of neurosurgical training. The system is felt to be consistent with the ideas embedded in the AGCME outcomes project. This system provides for multiple observations over time and multiple observers providing input regarding the performance of each resident. The Department of Neurosurgery is committed to continuous improvement of the education experience of residents.

Resident Evaluation Evaluation forms are given to the faculty for each resident every 6 months. In addition, patients will be asked to evaluate the performance of residents whom they encounter. These evaluations are done in the form of the hospital survey which patients are given upon discharge. In this evaluation, the patients are asked to evaluate all of their doctors. These evaluations are then reviewed by the faculty during their weekly meetings. Evaluations will also be obtained from peers in the residency as well as other health care professionals working with the residents. Residents also receive evaluations on their participation at conference as well as the quality of their presentations. The Board examination is considered an important evaluation of residents practice based learning and of their medical knowledge. The faculty as a group meets twice a year to review the evaluations and to discuss resident performance and program issues. Twice yearly the program director will meet with the resident to review evaluations and prepare a written summary of that meeting. The final evaluation of each resident who finishes the program will be performed and placed in the permanent record, verifying that the resident can pursue practice independently. Faculty Individual faculty evaluations are provided to each resident who are asked to evaluate the faculty on a yearly basis. Results of these evaluations are tabulated and provided to each faculty member, the chair, and a program director. Program At the end of each year the resident is asked to evaluate each rotation on which they have performed service. These evaluations are discussed at the faculty meetings and are used to improve the educational content of the neurosurgery program. Occasional meetings between the program director and the residents allow for feedback on faculty and on individual rotations. PROMOTION/PROBATION/TERMINATION Promotion to the next level of training is determined by the faculty s assessment of the resident s ability to assume the responsibilities of the new level. Competency at each level is assessed according to the requirements outlined in the Neurosurgery Residency Competency Evaluation Syllabus. The resident must master the competencies defined at each level before being allowed to progress to the next level. Progress is also based in part on the resident s performance on the American Board of Neurological Surgery Annual In-Training examination. Lastly, promotion and retention are also dependent on continued appropriate moral, ethical and professional conduct by the resident.

If the faculty determines that a resident s progress is not satisfactory, the faculty may vote to terminate the resident, place the resident on probation or require that the resident repeat the year. If the faculty decides to terminate the resident, the resident will be notified by the program director and will be given the right to appeal as outlined in the Disciplinary/Hearing and Review Policy of the Institutional Housestaff Policies/Procedures Manual. If the decision is to place the resident on probation, the program director will send the resident a letter outlining the resident s deficiencies and suggesting remedial action. The program director will set the terms of probation and the circumstances that will result in lifting the probation or proceeding to termination. Probation is meant to be a very serious warning to the resident that their performance does not meet the standards set by the faculty of the Department of Neurological Surgery. Serious violations of hospital policy, acts that endanger patient safety, or breaches of accepted moral or ethical standards may result in summary termination at the discretion of the Program Director. GRIEVANCES A grievance is defined as dissatisfaction when a resident believes that any act, decision, or condition affecting his or her program of studies is arbitrary, illegal, unjust, or creates unnecessary hardship. Such grievance may involve, but is not limited to, mistreatment by any university employee or student, failure to progress academically, records and registration errors, discipline, wrongful assessment of fees, and discrimination because of race, gender, religion, national origin, disability, marital status, or age. A House Officer and his or her supervising Chief of Service should attempt to resolve between themselves any disputes or disagreements that arise with respect to the work or conduct of the House Officer or the supervision of the Chief of Service. Disputes or disagreements that cannot be resolved to the satisfaction of the House Officer and the supervising Chief of Service may be referred to the Graduate Medical Education Committee of the Hospital for review and recommendation, the final decision on behalf of the Hospital shall rest exclusively with the Chief of Service and Hospital President. The process and procedures established by the Graduate Medical Education Committee shall be applicable with respect to any grievance brought by a House Officer against the Program. TERMINATION The contract between the Hospital and the House Officer shall be deemed automatically terminated if the House Officer for any reason becomes unable to perform services required by this Agreement. Upon termination of the House Officer s appointment and this Agreement under this section, the only obligation of NCBH shall be to pay the House Officer any salary that may be due, on a prorated annual basis, up to the date of such termination. By way of illustration, and not limitation, this would apply if, for example,

the physician's license to practice medicine were revoked. This Agreement between the Hospital and the House Officer shall be terminated by the Hospital: a) if the House Officer becomes physically or mentally unable to perform the services required by this Agreement; b) if the supervising Chief of Service determines that the House Officer is not making satisfactory progress toward achieving the educational goals of the Program; c) if the supervising Chief of Service and Hospital President determine that the House Officer is not performing the services required by this Agreement in a satisfactory manner; or d) if the House Officer engages in conduct or activities which the supervising Chief of Service and Hospital President determine will make continuation in the Program undesirable. The House Officer agrees that his/her continued training is conditioned upon satisfactory performance of assigned duties and academic progress, in accordance with Section 3 of this Agreement. Failure to maintain such performance and progress may result in termination of the House Officer s appointment and this Agreement, subject to the appeal mechanism provided in the North Carolina Baptist Hospital s, Inc. Handbook (Disciplinary/Hearing and Review). In addition, any misrepresentation by act or omission in the House Officer s application for appointment in the Residency Training Program, or documents in support thereof, or in any application for appointment to an affiliated hospital shall be basis for termination of such appointment and this Agreement. Should the supervising Chief of Service and Hospital President conclude that a House Officer should be suspended for misconduct or pending an investigation of his performance or conduct of activities, notice of such suspension shall be given in writing to the House Officer with a statement of the reason. If the supervising Chief of Service or Hospital President determine that a House Officer should be terminated for any of the reasons stated, or other good and valid reason, written notice of the intent of the Hospital to so terminate the House Officer, together with a statement of the reasons, shall be provided to the House Officer. A House Officer notified of a suspension, or of an intent to terminate, shall receive a hearing with respect thereto if, within seven (7) days of such notice, a written notice of appeal is delivered to the supervising Chief of Service and/or Hospital President. If the suspension or notice to terminate is based upon grounds or charges other than the professional progress or performance of the House Officer, the decision of the Graduate Medical Education Committee shall be binding upon the Chief of Service or Hospital President.

Except as noted above, withdrawal from, or termination from, the Program shall not automatically disqualify a House Officer from seeking a contract in another program. The withdrawal or termination will be a factor to consider in such cases. HEARING AND REVIEW PROCEDURE A House Officer who has been given notice of suspension, or notice of intent to terminate, and who has given written notice of appeal within seven (7) days of the receipt of the notice of suspension or notice of intent to terminate, shall, upon request, be entitled to a hearing before the Appeals Committee established within thirty (30) days of the notice of appeal. The Appeals Committee ("Committee") shall consist of the Executive Committee of the Chiefs of Professional Services. The hearing before the Committee shall be formal or informal, as requested by the appealing House Officer. If the House Officer advises that he or she desires an informal hearing, the Committee shall meet with the House Officer, his supervising Chief of Service (and Hospital President when appropriate), for an informal discussion of the reasons for the suspension or termination, and the reasons the House Officer believes the suspension or termination should not be made. At the informal hearing the proceedings shall not be recorded, witnesses need not be sworn in, and in general, the formalities of a formal proceeding shall not be required. If the House Officer requests a formal hearing, the following provisions shall apply: 1) the House Officer may be represented by counsel; 2) all witnesses will be sworn in; 3) the House Officer may examine and cross-examine all witnesses, and may introduce relevant documentary evidence; 4) the proceedings will be recorded mechanically, but the House Officer or his/her counsel may make arrangements, at their own expense, for a court reporter or other recording of the proceedings; 5) the rules of evidence applicable in a court of law shall not be applicable to the hearing, but witnesses shall be admonished to testify only as to matters relevant to the inquiry before the Committee; 6) the Chief of Service and Hospital President, or Committee, may be represented by counsel; 7) the findings and conclusions of the Committee shall be reduced to writing, shall be based on the evidence presented, and shall be delivered to the House Officer, Chief of Service, and Hospital President; 8) if the suspension or notice of intent to terminate is based upon a determination by the Chief of Service that the House Officer's professional progress or performance is not satisfactory, the decision of the Committee shall be advisory to the Chief of Service only; provided, however, if the Committee in such cases determine that

the actions of the Chief of Service are arbitrary and capricious, the decision of the Committee shall be binding on the Chief of the Service. HEARING AND REVIEW PROCEDURES The process and procedures described in the House Officer s Handbook (Disciplinary/Hearing and Review) shall be applicable with respect to any proposed disciplinary action by NCBH involving the House Officer and with respect to appeals by the House Officer of any adverse actions taken by NCBH. HARASSMENT (INCLUDING SEX/GENDER) NCBH prohibits harassment and exploitation. Harassment on the basis of race, color, religion or national origin is a form of unlawful discrimination and is prohibited under Title VII of the Civil Rights Act of 1964. (Section 25, Resident Training Program Agreement, and Handbook [Sexual Harassment]). What to Do About Harassment: 1) Learn the Wake Forest University School of Medicine policies and procedures. 2) If possible, speak up when an incident occurs and tell the offender to stop the offensive behavior in a clear and firm manner. 3) Consider communicating with the offender by writing a letter detailing your concerns and asking the person to stop. 4) Keep a written record and any evidence that might corroborate your story. 5) Seek information about your options from the COM designated counselor, if desired. This will not initiate a formal investigation, and will give you an opportunity to discuss your concerns confidentially; provide counseling about the options for resolving the current situation and preventing future incidents; assist in conflict resolution; and advise, if deemed appropriate, how to file a formal complaint to the Chair of the Sexual Harassment Committee to proceed with a full investigation. To File A Complaint: Contact the appropriate institutional representative Program Director Chair Chair, Graduate Medical Education Committee Director, Physician Services Hospital Administration