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Department of Orthopaedic Surgery Resident Handbook

2009-2010

Table of Contents I. Department Mission Statement II. History of the Department III. Program Description 1. Participating Hospitals 2. Faculty 3. Resident Position Description 4. Call 5. Resident Team Functions 6. Hospital Admission Protocols 7. Reports, Consults, Discharge Summaries IV. Program Goals and Objectives 1. General 2. Rotation Specific V. Administrative Procedures 1. Conduct and Appearance 2. Department Social Events 3. Moonlighting Policy 4. Leave Policy 5. Salary 6. Contracts 7. Benefits 8. Disciplinary Action 9. Ethical Relationships with the Orthopaedic Industry VI. Evaluation 1. Resident 2. Faculty 3. Quality of Resident Education Evaluation 4. Evaluation of Lectures VII. Education 1. Board Requirements 2. Conferences 3. Meetings/Courses/Travel 4. Travel Procedures 5. Library 6. Skills Lab VIII. Research IX. Appendices 1. ACGME Program Requirements 2. Liability Coverage 3. Medical Licensure 4. Resident Rotation Schedule 5. Department Phone Numbers 6. AdvaMed Code of Ethics on Interactions with Health Care Professionals 7. American Medical Association Guidelines Regarding Relations Between Industry and Physicians

8. AAOS Standards of Professionalism

DEPARTMENT OF ORTHOPAEDIC SURGERY MISSION STATEMENT The mission of the Indiana University Department of Orthopaedic Surgery Residency Training Program is to train orthopaedic surgery residents to become proficient in all aspects of orthopaedic surgery. This experience includes clinical training to become competent with the delivery of high quality care to patients with a variety of musculoskeletal conditions and to become familiar and involved with clinical and basic science orthopaedic research. This program also has the responsibility of educating medical students and allied health personnel in the basic aspects of orthopaedic surgery.

History of the Department of Orthopaedic Surgery Indiana University School of Medicine The Orthopaedic Residency Training Program started in the early 1930’s. This was a program that was directed by several early Orthopaedists practicing in the city. In the 1940’s the program became more organized under the direction of George Garceau, M.D. At that time, it was the Division of Orthopaedic Surgery within the Department of General Surgery. The education was performed by private physicians within the city and there was no full-time faculty. The residents were assigned to any one of several hospitals throughout their training program. These hospitals included Marion County General Hospital (Wishard Memorial Hospital), Veteran’s Administration Hospital, St. Vincent’s Hospital, Methodist Hospital, or University Hospital. The residents did not rotate from one hospital to another with the exception that all the residents rotated through Riley Hospital for children’s orthopaedics, under the direction of George Garceau, M.D. It is this common tie to the previous graduates of the Indiana Orthopaedic Residency Training Program that the alumni organization is called the Riley Alumni Association for the Department of Orthopaedic Surgery. In 1960, Dr. Garceau was instrumental in separating the Orthopaedic Service from the Department of General Surgery and formed an independent Department of Orthopaedic Surgery. In 1966 James B. Wray, M.D. became the first full-time Chairman of the Department of Orthopaedic Surgery and joined Bob Palmer, M.D., who was the first full-time member of the Department. Richard Lindseth, M.D. joined the Department in 1967. Since that time, the Department has significantly increased its number of full-time faculty members, including two full-time doctorate researchers. After his untimely death, Dr. Wray was succeeded by Donald Kettlekamp, M.D. who ultimately retired to become President of the American Board of Orthopaedic Surgery. The next Chairman, G. Paul DeRosa, M.D., also retired from the Department in 1994 to become President of the American Board of Orthopaedic Surgery following in the footsteps of Dr. Kettlekamp. His successor, Richard E. Lindseth, M.D., then became Chairman in 1995. Dr. Lindseth recently retired from that position, but continues to work as a full-time faculty member with robust clinical and academic responsibilities. In July 2001, Dr. Stephen B. Trippel became the Departmental Chairman. His successor, Dr. Randall T. Loder, became Interim Chairman in July 2003. In February 2005, Dr. Jeff Anglen assumed the duties of Chairman.

Program Description The Indiana University Department of Orthopaedic Surgery Residency Training Program is a fully accredited, five-year program offering prospective resident candidates a broad spectrum of orthopaedic experience as graduate medical education. This training includes an initial PGY-1 year as a general surgical internship with rotations through a variety of surgical subspecialties and other related rotations as required by the Accreditation Council for Graduate Medical Education to prepare residents for specialty education in orthopaedic surgery. Upon successful completion of the PGY-1 year, residents then enter and progress through four years of comprehensive orthopaedic training in full compliance with the requirements outlined by the ACGME for residency education in orthopaedic surgery. Service rotations during the five years of training are located at medical facilities both on and off the campus of Indiana University Medical Center. These hospitals include Indiana University Hospital, James Whitcomb Riley Hospital for Children, Wishard Memorial Hospital, Methodist Hospital, the Richard L. Roudebush Veterans Administration Hospital, and St. Vincent’s Hospital. Presently, there are no rotations outside of the Indianapolis area.

Participating Hospitals Indiana University Hospital first opened in 1970 and has since been renovated. This modern adult hospital serves as a tertiary referral center for the state of Indiana. Major orthopaedic surgery emphasis includes total joint arthroplasty, musculoskeletal oncology, adult spinal deformities, and reconstructive upper extremity surgery. James Whitcomb Riley Hospital for Children remains the only Indiana hospital specializing solely in the care of children. As such, it is one of the largest children’s hospitals in the United States. This facility offers state of the art comprehensive care for diverse and often rare conditions afflicting children of all age groups. A recent multimillion-dollar addition to the children’s hospital is the Riley Outpatient Center (ROC), which considerably expands outpatient care of this preeminent children’s hospital and includes ambulatory surgical suites. Wishard Memorial Hospital currently has in excess of 600 inpatient beds and is a busy city/county hospital. It is an integral part of the Indiana University Residency Training Program in all disciplines. It offers full-time faculty staffing, a wide variety of general orthopaedics, musculoskeletal trauma, reconstructive surgery, and arthroscopy, as well as foot and hand surgery. As a Level I Trauma Center, Wishard Memorial Hospital provides ample clinical experience for orthopaedic trauma. Richard L. Roudebush Veterans Administration Hospital has in excess of 600 inpatient beds with a dedicated orthopaedic surgery ward. This facility offers the orthopaedic resident a busy clinical experience with a large adult reconstructive practice, mostly in the area of total joint arthroplasty, as well as spine surgery. A full-time faculty member assisted by other part-time faculty provide ample supervision of residents during this rotation. Methodist Hospital is one of the largest private hospitals in the country and boasts greater than 1100 beds with an Orthopaedic Surgery ward. Residents gain experience in a number of areas of orthopaedic surgery while rotating at this facility to include trauma, adult reconstruction, and sports medicine. Adjacent to this facility is the Thomas A. Brady Sports Medicine Clinic, one of the largest sports medicine clinics in the country and home to the Methodist Sports Medicine Group. St. Vincent’s Hospital, located on the north side of Indianapolis, is a large private hospital with greater than 650 beds with a busy general orthopaedic surgery service. It provides the resident with an opportunity for general orthopaedics and spine surgery in a community setting. Adjacent to St. Vincent’s Hospital is the world famous Indiana Center for Surgery and Rehabilitation of the Hand and Upper Extremity where the residents in Orthopaedic Surgery obtain an extremely valuable experience in the care of upper extremity conditions, both traumatic and elective reconstructive problems.

Faculty Full-Time Thomas A. Ambrose, II, M.D. Clinical Associate Professor Jeffrey O. Anglen, M.D. Professor and Chairman Christine B. Caltoum, M.D. Assistant Professor William N. Capello, M.D. Professor Judd E. Cummings, M.D. Assistant Professor Jan P. Ertl, M.D. Assistant Professor Paul E. Kraemer, M.D. Assistant Professor Randall T. Loder, M.D. Professor John P. Lubicky, M.D. Professor G. Peter Maiers, M.D. Assistant Professor Russell D. Meldrum, M.D. Associate Professor Alexander D. Mih, M.D. Associate Professor Brian H. Mullis, M.D. Assistant Professor J. Andrew Parr, M.D. Assistant Professor Stephen B. Trippel, M.D. Professor Mark D. Webster, M.D. Assistant Professor L. Daniel Wurtz, M.D. Clinical Assistant Professor Volunteer Clinical Faculty – Chiefs of Service Thomas J. Fischer, M.D. Volunteer Clinical Associate Professor Indiana Hand Center St. Vincent Hospital David A. Porter, M.D. Volunteer Clinical Assistant Professor Methodist Sports Medicine Center Methodist Hospital Lance Rettig, M.D. Volunteer Clinical Assistant Professor Methodist Sports Medicine Center Methodist Hospital Rick C. Sasso, M.D. Volunteer Clinical Associate Professor Indiana Spine Group Volunteer Clinical Faculty with Academic Appointments Dr. Steven K. Ahlfeld Dr. Robert M. Baltera

Herbert M. Biel, MD Dr. David Brokaw Dr. Michael F. Coscia Dr. Jack Farr Dr. David A. Fisher Dr. Jeffrey A. Greenberg Dr. Hill Hastings Dr. Richard Idler Dr. Philip H. Ireland Dr. William B. Kleinman Dr. Stephen L. Kollias Dr. Thomas E. Klootwyk Dr. Sanford S. Kunkel Dr. Dean C. Maar Dr. Thomas W. Marshall Dr. John R. McCarroll Dr. Gary W. Misamore Dr. Jeffery L. Pierson Dr. Arthur C. Rettig Dr. Merrill A. Ritter Dr. Peter Sallay Dr. D. Kevin Scheid Dr. David G. Schwartz Dr. K. Donald Shelbourne Dr. James B. Steichen Dr. James W. Strickland Dr. Terry R. Trammell Dr. Charles D. VanMeter Jeffrey O. Anglen, MD, FACS Professor and Chairman Dr. Anglen took over as Chairman in February of 2005. He received his medical degree from the Johns Hopkins School of Medicine in Baltimore in 1983, and stayed at Hopkins for a surgical internship and orthopaedic residency. After completing training in 1988, he entered private practice in Kansas City, Missouri for the next 3 years. Pursuing an interest in orthopaedic traumatology, he spent 6 months as a clinical instructor at Harborview Medical Center in Seattle, and 6 months as orthopaedic trauma fellow at Tampa General Hospital. His next 10 years were served on the faculty of University of Missouri at Columbia, practicing academic orthopaedic traumatology. He is a recent past President of the Orthopaedic Trauma Association, a Director of the American Board of Orthopaedic Surgery, and a member of the American College of Surgeons Committee on Trauma. His clinical interests are fractures of the pelvis and acetabulum, high energy periarticular fractures, nonunion and malunion, post-traumatic infection. Dr. Anglen has four children, ages 6 to 13, and his outside interests include Anthropology and American Literature.

Thomas A. Ambrose II, MD, FACS Associate Professor of Orthopaedic Surgery Chief of Service, Clarian West Medical Center Dr. Ambrose joined the Department in 1989. He received his medical doctorate from The Ohio State University College of Medicine, where he also completed his specialty training in Orthopaedic Surgery. Dr. Ambrose then went on to complete fellowships in Pediatric Orthopaedics at the Denver Children’s Hospital/University of Colorado and in Orthopaedic Trauma with the AO Group in Hannover, Germany and Basel, Switzerland. He then joined the Department and for the next 13 years, worked primarily in orthopaedic trauma at Wishard Hospital, ending his tenure there as Chief of Orthopaedic Trauma. For the past few years, Dr. Ambrose has focused his clinical interests in the area of adult reconstruction, with a special emphasis on joint replacement surgery and treatment of post-traumatic complications such as nonunion, infection, malunions and post-traumatic arthritis. He is one of only two orthopaedists in the city certified by the FDA in the performance of the Oxford unicompartmental knee replacement. Dr. Ambrose continues to work with the Trauma Service in an ancillary capacity. Dr. Ambrose’s research interests include developing new technologies for the treatment of severe musculoskeletal injuries as well as methods to improve the functioning and durability of total knee arthroplasties. David B. Burr, Ph.D. Professor of Anatomy and Orthopaedic Surgery Dr. Burr is Professor and Chair of the Department of Anatomy and Cell Biology, and Professor of Orthopaedic Surgery. He received his PhD degree from the University of Colorado in 1977, and joined the University in 1990 following appointments at the University of Kansas and West Virginia University. Dr. Burr's primary research interests center on the causes, prevention and treatment of osteoporosis, and on changes to collagen in diabetes. He has served as consultant to the U.S. Congress Office of Technology Assessment, American Institute of Biological Sciences and NASA. He served as President of the Orthopaedic Research Society in 2008-2009. He is the author of more than 190 peer-reviewed journal articles, 20 book chapters and 4 books. He has won grant awards from the Orthopaedic Research and Education Foundation, the National Institutes of Health, the Bi-national Science Foundation and the National Operating Committee on Standards for Athletic Equipment. William N. Capello, M.D. Professor Emeritus of Orthopaedic Surgery Dr. Capello joined the Department in 1975 and takes an active role in the clinical teaching of residents and interns, with an emphasis on hip surgery. Over the years, he has been instrumental in the development of several hip prostheses and related research investigations of these implants. He has given international and national symposiums on hip replacement and has participated in many other national and international meetings on adult hip surgery. He is past president of The Hip Society and The Society for Arthritic Joint Surgery. He was elected to the prestigious International Hip Society in 1995. Judd E. Cummings, M.D. Assistant Professor of Clinical Orthopaedic Surgery Dr. Cummings joined the faculty in 2008. He received his medical degree in 2002 and completed his orthopedic surgery residency at The Campbell Clinic / University of Tennessee in 2007. He completed his fellowship training in Musculoskeletal Oncology at the University of Utah Huntsman Cancer Institute in 2008. His specialty interests include the treatment of both benign and malignant tumors of the musculoskeletal system in adults and children.

Thomas J. Fischer, M.D. Volunteer Associate Professor of Orthopaedic Surgery Thomas J. Fischer, M.D. is a graduate of Butler University and earned his medical degree from Indiana University School of Medicine. Following his residency in Orthopaedic surgery at the University of Washington Affiliated Hospitals in Seattle, Dr. Fischer completed fellowships in hand and microsurgery at The Indiana Hand Center, Duke University in Durham, North Carolina, and a six-month fellowship in Switzerland and Germany. In 1986, Dr. Fischer joined The Indiana Hand Center staff where he is active in clinical practice, research, and teaching. In addition, Dr. Fischer is a Clinical Associate Professor in the Department of Orthopaedics at the Indiana University School of Medicine. He is in charge of the full-time hand surgery rotation for Indiana University Orthopaedic residents. In addition to publications in scientific journals and presentations before physicians, Dr. Fischer has been recognized for his written and spoken contributions to industry, insurance companies, and safety organizations alike. He is a member of the Hand Education Committee for AO North America and is a member of the Hand Expert Group for the AO Technical Committees. He is Chairman of the AONA Hand & Wrist Course and is the Co-Chair of the AO Trauma Hand and Wrist Course in Davos. He is a member of the Board of Trustees for Butler University and a team Physician for the Butler Athletic Department. Melissa A. Kacena, Ph.D. Assistant Professor of Orthopaedic Surgery Dr. Kacena joined the Department in 2007. Dr. Kacena received her Ph.D. in Aerospace Engineering from the University of Colorado, Boulder in collaboration with Harvard Medical School and NASA Ames Research Center. Dr. Kacena completed her postdoctoral training in the Department of Orthopaedics and Rehabilitation at Yale University School of Medicine. While at Yale she was promoted to Assistant Professor of Orthopaedics and Rehabilitation. Dr. Kacena’s research focuses on the regulatory interactions between skeletal and hematopoietic cells. She has received numerous honors, young investigator awards, and grants for her research, including NIH funding. Paul E. Kraemer, M.D. Assistant Professor of Orthopaedic Surgery Paul E. Kraemer, M.D., an orthopaedic spine surgeon recently joined Indiana Spine Group. Additionally, he is an assistant professor at Indiana University School of Medicine, Department of Orthopaedics. Dr. Kraemer specializes in all aspects of spine surgery, including cervical, thoracic and lumbar. Dr. Kraemer received his medical degree from the University of Iowa College of Medicine in Iowa City, Iowa. He completed his residency at the University of Wisconsin in Madison, Wisconsin. Dr. Kramer completed his fellowship in orthopaedic spine surgery at Harborview Medical Center, University of Washington in Seattle. His special medical interests include orthopaedic spinal trauma, adult spinal deformity, and the prevention and treatment of adjacent segment disease. Involved in clinical research, Dr. Kraemer was the recipient of the OREF Resident Research Award in 2004 for his research study entitled, The Correlation of Microdiscectomy Outcomes with Apolipoprotein E and Catechol-O-Methyltransferase Genotype. He is a member of the North American Spine Society.

Randall T. Loder, M.D. Professor of Orthopaedic Surgery Chief of Pediatric Orthopaedics, James Whitcomb Riley Hospital for Children Residency Program Director Dr. Loder joined the Department in 2002. Dr. Loder obtained his M.D. at Washington University School of Medicine, St. Louis and completed his orthopaedic residency at the Medical College of Ohio, Toledo. Dr. Loder completed his fellowship as the Harrington Fellow in Pediatric Orthopaedics and Scoliosis at the Texas Scottish Rite Hospital for Crippled Children in Dallas. Dr. Loder is nationally known as a clinician, researcher, and educator, and is the recipient of multiple honors and awards. Dr. Loder will devote his clinical practice to the treatment of pediatric orthopaedic disorders. John P. Lubicky, M.D. Professor of Orthopaedic Surgery Dr. Lubicky joined the Department in 2006. His clinical interest is pediatric spine surgery, including all types of deformities (including fusionless techniques; vertebral body stapling and growing rods), tumors, infections and trauma; chest wall/thoracic insufficiency surgery; VEPTR; limb lengthening and deformity correction, spinal cord injury; neuromuscular and bone dysplasia conditions and general pediatric orthopaedics and trauma. Dr. Lubicky obtained his M.D. at Jefferson Medical College, Philadelphia and completed his orthopaedic residency at the Medical College of Virginia in Richmond. Dr. Lubicky completed a pediatric orthopaedic fellowship at Shriners Hospitals for Children in Chicago and a spine fellowship at Rush-Presbyterian-St. Luke’s Medical Center in Chicago. His current research interests include spinal deformities, limb length discrepancies and deformities, and pediatric spinal cord injury. G. Peter Maiers, II, M.D. Assistant Professor of Orthopaedic Surgery Dr. Maiers earned his undergraduate degree at Indiana University-Bloomington and obtained his medical degree in 2001 at the Indiana University School of Medicine. Following his residency in Orthopaedic Surgery at Indiana University, Dr. Maiers completed a Fellowship in Sports Medicine at the Cincinnati Sports Medicine and Orthopaedic Center in Cincinnati, Ohio, and then completed a Fellowship in Hip Arthroscopy at Nashville Sports Medicine in Nashville, Tennessee In 2007 Dr. Maiers joined the Department of Orthopaedic Surgery and Methodist Sports Medicine Center where he is active in clinical practice, teaching and research. His clinical interests include sports medicine with a focus on total knee care, ligament reconstruction, cartilage restoration and hip arthroscopy. He is also the team physician for Hanover College. Russell D. Meldrum, M.D. Assistant Professor of Orthopaedic Surgery Dr. Meldrum joined the Department in 2000. His clinical specialty is total joint replacement and osteotomies. He attended medical school at the University of Utah and did his internship at UCLA-Harbor Medical Center. His orthopaedic residency was at the San Francisco Orthopaedic Residency program and fellowship at Massachusetts General Hospital in adult reconstructive surgery. His research interests include the mechanical testing of prosthetic implants and their biocompatibility.

Alexander D. Mih, M.D. Associate Professor of Orthopaedic Surgery Dr. Mih joined the Department in 1990. His clinical specialty is hand and upper extremity surgery. He received his medical doctorate from the Johns Hopkins University School of Medicine and completed his residency at the Mayo Clinic. Dr. Mih completed his fellowship training at the Indiana Center for Surgery and Rehabilitation of the Hand and Upper Extremity in Indianapolis. His research interests are the study of patients undergoing repair of the brachial plexus, congenital hand disorders and tendon transfers. Brian H. Mullis, M.D. Assistant Professor of Orthopaedic Surgery Chief of Orthopaedic Trauma Service Dr. Mullis joined the Department in September 2006 and became Chief of Orthopaedic Trauma in December 2006. His clinical interests include acute trauma (periarticular, pelvis and acetabulum), malunions, nonunions and acute and chronic infections. He received his M.D. from the University of North Carolina School of Medicine in Chapel Hill and completed his residency at the University of North Carolina Department of Orthopaedics in Chapel Hill. Dr. Mullis completed his trauma fellowship training at Florida Orthopaedic Institute in Tampa. His research interests include basic science, biomechanical, retrospective, and prospective trauma projects. J. Andrew (Drew) Parr, M.D. Assistant Professor of Orthopaedic Surgery Chief of Adult Services, Indiana University Hospital Dr. Parr joined the Department in September 2004. He received his M.D. from Indiana University. He then completed his orthopaedic surgery residency at Case Western Reserve University School of Medicine. A fellowship in Adult Total Joint Reconstructive Orthopaedics was performed at Rush-Presbyterian-St. Luke’s Medical Center in Chicago, Illinois. He then returned to Indiana University to join the faculty. His primary clinical interests are in the treatment of adult degenerative joint disease, primarily involving total arthroplasty techniques and osteotomies. His research interests are in the basic science areas of total joint prosthetic fixation and prosthetic interface mechanics with the bone. His clinical research interest is in the long-term follow up studies of patients with total joint arthroplasties. David Porter, M.D., Ph.D. Volunteer Assistant Professor of Orthopaedic Surgery David Porter, M.D., Ph.D. is a graduate of Ball State University and earned his medical degree from Indiana University School of Medicine. Dr. Porter also received his Ph.D. in Human Bioenergetics (Sports and Exercise Physiology) from Ball State University’s internationally recognized Human Performance Laboratory. Following his residency in Orthopaedic surgery at Wright State University in Dayton, OH, Dr. Porter completed his fellowship in Foot and Ankle surgery with Tom Clanton, M.D. and Don Baxter, M.D. in Houston, TX. Prior to his fellowship Dr. Porter also completed a 3 month senior elective in Foot and Ankle surgery with James Amis, M.D. in Cincinnati, OH. In 1996, Dr. Porter joined Methodist Sports Medicine Center staff where he is active in clinical practice, research, and teaching. In addition, Dr. Porter is a Volunteer Clinical Instructor in the Department of Orthopaedic Surgery at the Indiana University School of Medicine. He participates and is the primary instructor in the foot and ankle surgery rotation for Indiana University Orthopaedic residents.

In addition to publications in scientific journals and presentations before physicians, Dr. Porter has been involved in written and spoken contributions to the NFL team physicians, American Orthopedic Foot and Ankle Society, and the American College of Sports Medicine. Dr. Porter just released his first book entitled “Baxter’s, The Foot and Ankle in Sports”. He is the Chief Editor of this international treatise on the diagnosis, care and treatment of athletic injuries to the foot and ankle. Dr. Porter also serves as the Foot and Ankle consultant to the Indianapolis Colts, Indiana and Purdue University as well as numerous other colleges in central Indiana. Dr. Porter has also been integrally involved in the care of professional athletes including the NFL, NBA and professional Ballet performers. Lance Rettig, M.D. Volunteer Assistant Professor of Orthopaedic Surgery Lance A. Rettig, M.D. earned his undergraduate degree at Indiana University-Bloomington and obtained his medical degree in 1997 at the Indiana University School of Medicine. Following his residency in Orthopaedic Surgery at Indiana University, Dr. Rettig completed a fellowship in hand and microsurgery at the Curtis National Hand Center in Baltimore. In 2003, Dr. Rettig joined the Methodist Sports Medicine Center staff where he is active in clinical practice, teaching, and research. He is also a member of Reconstructive Hand Surgeons of Indiana. Dr. Rettig is in charge of the sports medicine rotation for Indiana University Orthopaedic residents. In addition, he is team physician for Lebanon High School and is an upper extremity consultant for Indiana State University. Rick C. Sasso, M.D. Volunteer Associate Professor of Orthopaedic Surgery Dr. Sasso earned his undergraduate degree at Wabash College in Crawfordsville, Indiana and obtained his medical degree in 1986 at the Indiana University School of Medicine. Dr. Sasso completed a residency in Orthopaedic Surgery at the University of Texas. Dr. Sasso is the Chief-of-Service of the Spine Rotation for Indiana University Orthopaedic residents. In addition, he is the Vice-Chairman of the Department of Orthopaedic Surgery at St. Vincent Hospital in Indianapolis. Stephen B. Trippel, M.D. Professor of Orthopaedic Surgery Dr. Trippel joined the Department in 2001. His clinical specialty is arthritis surgery. His research interests are in cartilage cellular and molecular biology. He received his medical doctorate from Columbia University College of Physicians and Surgeons. His internship and general surgical residency years were at the Peter Bent Brigham Hospital in Boston. His orthopaedic training was in the Harvard Combined Orthopaedic Residency Program. Fellowships included an Orthopaedic Research Fellowship at Massachusetts General Hospital and a Pediatric Endocrinology Fellowship at the University of North Carolina, Chapel Hill. Prior to coming to Indiana University School of Medicine, he served on the faculty at Harvard Medical School and practiced at Massachusetts General Hospital.

Charles H. Turner, Ph.D. Chancellor's Professor of Biomedical Engineering and Orthopaedic Surgery Dr. Turner received his Ph.D. degree in biomedical engineering from Tulane University in 1987 and joined the faculty at Indiana University in 1991 after four years with the Osteoporosis Research Center at Creighton University. He has won numerous awards for his research in musculoskeletal biomechanics and bone biology. Dr. Turner is the Director of Orthopaedic Research and the Associate Chair for Biomedical Engineering at IUPUI. Mark D. Webster, M.D. Assistant Professor of Clinical Orthopaedic Surgery Chief, Veteran’s Administration Hospital Dr. Webster joined the Department in August 2004. He received his M.D. from the State University of New York in Syracuse. He performed his orthopaedic residency at Northwestern University in Chicago. He has been in private practice in Illinois since that time. His practice is that of a general orthopaedist in the private community and is a significant asset to our general orthopaedic rotations. He has interests in sports medicine, total joints, and common trauma. L. Daniel Wurtz, M.D. Associate Professor of Clinical Orthopaedic Surgery Dr. Wurtz joined the faculty in 1997. He received his medical doctorate in 1984 and completed his orthopaedic surgery residency at Wilford Hall USAF Medical Center in 1991. After he served as an active duty orthopaedic surgeon in the U.S. Air Force, he completed his fellowship training in Musculoskeletal Oncology at the University of Chicago in 1996. his special area of expertise is the treatment of both benign and malignant tumors of the musculoskeletal system. He has a continuing interest in soft tissue and bone sarcomas.

Resident Position Description and Responsibilities

Indiana University Medical Center Resident/Fellow House Staff Position Description Qualifications Residency or Fellowship appointment from the Indiana University Medical Center and affiliated hospitals with a signed appointment letter on file in the Office of House Staff Affairs. • Valid Indiana medical license (temporary or permanent) Supervision The Resident/Fellow is supervised by Attending Physicians for all aspects of patient care. The Attending Physician is a credentialed member of the teaching and medical staff. The Attending Physician maintains full responsibility for patient care. Ultimately, resident/fellow performance is under the direction of the director of the residency training program. The competence of the house staff is evaluated on a regular basis. The program maintains a confidential record of the evaluation. Responsibilities The Resident/Fellow: • Provides initial medical care to assigned patients in ambulatory/outpatient or inpatient settings appropriate to the resident’s experience and ability. Patient care responsibilities assigned to residents will be commensurate with their level of training, according to ACGME Special Requirements for the training program and the judgment of the Program Director. • Where appropriate, formulates a plan of care based on a thorough assessment of the patient’s history, current condition, and needs. • Writes orders for the implementation of the plan of care. • Coordinates consultations with physicians and other members of the multidisciplinary health team. • Facilitates communications regarding the plan of care with the patient, family, Attending Physician(s), and any other involved member(s) of the health team. • Performs and/or assists in procedures according to the level of delegation appropriate to the resident’s experience and ability.

• Participates in education, research, and patient care experiences required by the particular program within which he/she is a trainee. • Supervises and teaches other house staff and medical students as appropriate. • Adheres to all policies and procedures for the Medical Staff of the Indiana University Medical Center and affiliated hospitals, including the “Personal Information for House Staff” and the Bylaws, Rules, and Regulations for the Medical Staff of the Indiana University Medical Center Hospitals. • Before rotating to another assignment, completes, in a timely fashion, all medical records assigned to him/her. • Participates in institutional orientations, relevant committees, projects, and other leadership assignments and activities involving the clinical staff. • Demonstrates the knowledge and skills necessary to provide care, based on physical, socioeconomic, psychosocial, educations, safety and related criteria, appropriate to the age of patients served in the assigned service area. • Reflects a fundamental concern with and respect for patients’ rights. • Develops an understanding of ethical and medical/legal issues surrounding patient care, hospitals’ policies governing these issues, and structures available to support ethical decision making. • Sensitive to and employs cost containment strategies while caring for patients. • Conducts him/herself professionally, ethically, and personally in a manner consistent with the standards and aims of the medical staff of the hospitals.

General Orthopaedic Resident Responsibilities The following are general responsibilities that each resident is expected to fulfill: 1. Be on time for surgery. 2. If the surgical case is first in the morning, the resident is required to be there at 7:15 a.m. and assist in preparing the patient for surgery. 3. Maintain the dress code as outlined previously in the Orthopaedic Resident’s Handbook. 4. Be courteous, kind, and tactful in all relationships. 5. Promptly answer all pages. 6. A good resident history and physical must be on the chart of each patient. 7. Each resident is expected to attend clinic when scheduled, unless excused by the faculty Service Chief. 8. The first-call beeper is never to left unattended. It is to be handed off at 7:00 a.m. and new patients should be signed out at that time. 9. The chain of command is to be used at all times concerning on-call patients. 10. After the on-call resident evaluates a patient for admission, he/she should notify the Senior Resident on call and discuss the plan. The patient is then discussed with the faculty member on call. 11. While junior residents should discuss patients with senior residents, the faculty member on call is available to educate residents at any level of training and help with patient care issues. 12. Residents are expected to attend all conferences and be on time unless they are involved in surgery or urgent patient care. 13. All orthopaedic patients are the direct responsibility of every resident. When asked to see a patient, respond immediately, act appropriately and cheerfully. 14. No one leaves the hospital on surgery days without permission of the Senior Resident. Remember, the surgery schedule is a team effort. 15. A team member for each service will be responsible for that service’s patients and rounding on those patients every weekend.

The following are specific orthopaedic requirements ** You are responsible for applying and obtaining your ** DEA Certificate immediately upon receiving your Permanent Medical License (a copy should be placed in your file in the Administrative Office) Chief Resident (PGY-5) 1. Is responsible for the daily activities of the service, which includes inpatient, outpatient, and the operating area. 2. Is responsible for resident schedules to insure adequate attendance/coverage for surgeries. 3. Is responsible for getting staff okay and/or coverage for each case going to the operating room. 4. Is responsible for coordinating resident call coverage and working with the Academic Coordinator to publish the On-Call Schedule. 5. Is responsible for the overall management of the inpatients. 6. Is responsible for mentoring and teaching other residents and medical students. 7. Is responsible for organizing and maintaining control in all conferences. Senior Resident (PGY-4) 1. Is to support the Chief Resident. 2. Serves in a direct supervisory category for the Junior Resident. 3. The Senior Resident on the service of the on-call staff for the day is responsible for seeing consults received for the day. 4. If a specific staff member is consulted, the Senior Resident on his service is responsible for the consult and its presentation to the staff member. 5. A Junior Resident is not permitted to perform surgery unless he can demonstrate a workable knowledge of the anatomy entailed. The Senior Resident and staff member are to determine if the Junior Resident is properly prepared. 6. The Senior Resident on the service is responsible for supervising patient care and is to make daily rounds with the Junior Residents. 7. The Senior Resident is responsible for discussing with the appropriate staff member patient care issues and management decisions. 8. The Senior Resident notifies and consults with the staff on all surgical patients and admissions. 9. The Senior Resident is responsible for mentoring and teaching junior residents and medical students.

Junior Resident (PGY-2 and PGY-3) 1. Takes first call for emergencies and inpatient care problems. 2. Is primarily responsible for histories and physicals, preoperative notes, discharge summaries, daily visits to the inpatients, the work-ups on new patients which should be complete, and for completing charts. 3. To directly support the Senior Resident. 4. To provide leadership and teaching for third and fourth year medical students. 5. The Junior Resident should consult with the appropriate Senior Resident when making medical management decisions. 6. Junior Residents are primarily responsible for all ward care and are to write meaningful daily progress notes. 7. A Junior Resident is not permitted to perform surgery unless he/she can demonstrate a workable knowledge of the anatomy entailed. The Senior Resident and staff member are to determine if the Junior Resident is properly prepared. 8. A Junior Resident is not to leave the hospital during the day without notifying his/her Senior Resident first. All Residents (PGY-1 through PGY-5) KNOWLEDGE ACQUISITION Education is an active process, not a passive process. It is very important that each resident create their own reading and studying schedule. At least 2 or 3 hours each day (weekends included) is strongly recommended. Start with the OKU, and continue with standard texts, especially for the rotations which you are on. Similarly, spend time reviewing old OITE exams, and review why the correct response was correct, and why the incorrect response was incorrect, and how they relate. Similarly, in addition to your standard reading schedule, you should also additionally read regarding cases the next day. If the resident comes unprepared regarding the anatomy, exposure, procedure, etc, then the attending surgeon is at liberty to take the case over and/or proceed with other courses of action.

Resident Call ** The phone call to the attending regarding any patient consults seen on call will either come from the senior/chief resident on call, or from the junior AFTER he/she has spoken with the senior/chief on call about the case. It is the responsibility of the senior/chief resident to make sure that the history obtained by the junior is correct and complete, that the physical exam findings are correct and complete, that adequate radiographs have been obtained and properly evaluated, and that the plan of care submitted to the attending is correct and reasonable. In many cases this will require the senior resident to evaluate the patient personally, but if you decide not to do that, better be sure the junior is right when he calls the attending. ** I. Guidelines 1. Prompt, courteous response to all calls is expected and mandatory. 2. All first call residents are to notify the Senior Resident on call if there are any problems, back ups, or surgeries. 3. Residents at any level of training should always ask for the advice or assistance of a more senior resident, then faculty, when presented with problems exceeding his/her level of training or knowledge. 4. All first call personnel should never be away from the hospital. 5. The staff physician on call is to be notified of all patients going to surgery or admitted to the hospital. II. Coverage 1. During the second year of training, the resident will take in house call for the on campus rotations. The resident will be the Junior Resident on call and cover the following hospitals: University Hospital, Riley Hospital, and VA Hospital. The resident, if not busy, is to assist the senior in house resident in coverage of Wishard Hospital. 2. During the third year of training, the resident will take in house call for the on campus rotations. The resident will be the Senior Resident on call and cover Wishard Hospital while on the Adult Reconstruction, Pediatric Orthopaedic, Trauma, and Tumor rotations. The resident will take the Junior Resident in house call while on the VA Hospital rotation. The Senior Resident in house, if not busy, is also to assist the Junior Resident on call. While on the Hand Service, the resident will additionally take at home call within the confines of the RRC work hour limitations. This will be conducted under the strict supervision of the fellow or staff. 3. During the fourth year of training, the resident will take a combination of in house and home call for the on campus rotations. During the Trauma, Pediatric Orthopaedic, Sports, and Private Practice rotations, the resident will function as the Senior Resident taking in house call. During the Adult Reconstruction rotation, the resident will take home call and function as back up for University, Riley, VA, and Wishard call. 4. During the fifth year of training, the resident will take home call for the on campus rotations. The resident will function as the back up Chief Resident for the Wishard, University, Riley, and VA hospitals.

III. Call Rooms and Meals 1. The primary call room is located on the fourth floor of Wishard Hospital. The additional call rooms are located at the following: University Hospital (seventh floor, penthouse floor – above the ICU’s, multi-service resident call rooms) and VA Hospital (fourth floor, surgery resident call room area). 2. Gold cards (meal cards) are distributed to residents in their PGY-1 year. The Residency Coordinator is responsible for making sure your card is credited the appropriate number of meals to cover your call schedule. Also, meal tickets are available for use at the Wishard cafeteria for on call residents. IV. Schedule 1. The call schedule for residents on each rotation is made by the Chief residents and submitted to the Program Director for approval.

Hand-Off of Call Residents should not perform any manipulations or reductions of fractures or dislocations, or provide any closed treatment of fractures or dislocations in the Emergency Department of any hospital without discussing it with the attending on call beforehand. There are significant issues of supervision, liability and billing for services involved in care of even the simplest fracture. If nothing else, we lose the opportunity to bill for this care if the attending can't be there because he or she was not told about it until after. On the weekend hand-off of call Saturday morning, Sunday morning and Monday morning, there should be a physical, face-to-face meeting of BOTH the senior and junior residents coming on and going off call. At that time, the team should go through the list not only of patients going to the OR, but fresh post-ops, consults, and any inpatients or outpatients treated in the last 24 hours, or with any pending issues. If someone is in the OR, then delay the hand-off until they are out or have it in the OR. The on call resident team must be familiar with patients treated the day before and with any active consult patients who need follow-up or monitoring. It might be helpful to use an actual written list with check off boxes, patient names, numbers, locations and pending issues - hand the list off like it is a baton. A casual phone call from one junior who has already left to another on campus is not an adequate handoff, and is a recipe for problems and missed issues, and errors in care. It is the responsibility of the PGY-5 Chief residents to make sure this occurs. If necessary, one of them should come in to make sure this handoff procedure happens.

Resident Team Functions This policy will apply to each rotation in which multi-resident teams are assigned to cover a group of patients at one or more hospitals: Trauma (Wishard), Pediatrics (Riley), Veterans Hospital, Adult Reconstructive (IU/Methodist). Team rounds have a long tradition in academic medical centers, on both medical and surgical services. Led by a senior or chief resident, team rounds consisting of all residents, interns, sub-interns, students and ancillary personnel, are central to both the teaching and patient care missions of the teaching hospital. These rounds provide the key opportunities for resident-to-resident and resident-to-student teaching, and maximize resident exposure to patients and clinical problems, which is of increased importance in the era of 80-hour work week restrictions. They optimize the care of the patient by providing for senior resident direction and supervision of all care, and facilitating communication by involving all residents in each patient’s care. Therefore, it is the policy of the Orthopaedic department that: 1. Every resident team should perform team rounds at least once daily, either in the morning before surgery, or in the evening after the surgery schedule is completed, or both. All residents and students will be involved and every patient will be seen. Patients will be presented to the chief or senior resident. 2. If necessary, the residents can perform individual pre-rounds to collect data such as labs, vitals, drain outputs, PT progress, nursing issues on some subset of patients, in order to facilitate the progress of team rounds. 3. The chief or senior resident on the service is responsible for organizing rounds, directing care, communicating important information to the attendings involved. 4. Every resident should be familiar with the history, exam, treatment and progress of each patient on the service each day. 5. In order to minimize pages interrupting the OR, all patient issues should be anticipated and dealt with on rounds. Ask the floor nurses for any concerns before leaving the floor. Make sure all orders are written, prescriptions, forms filled out, clear PT plans, discharge plans. Ask the patient or family if they have any questions. 6. The team should make rounds with the attending surgeon at least twice weekly in which patients are presented and discussed. 7. Every surgical case and every clinic is a valuable learning opportunity. No resident on the team should forego helping in clinic or the OR during working hours in order to read, study, do academic work, prepare for conference or do any other activity unless on approved vacation time. Every resident assigned to a team should be involved in clinical activity during weekday working hours. If there is no clinical activity on the team due to attending absence or other reasons, residents are expected to help out with other teams who may have uncovered clinics or surgeries, e.g. if there are no cases at Riley due to the POSNA meeting, those residents should cover cases/clinics on adult reconstruction, trauma, or the VA, or with other attendings. 8. Residents should not leave for the day before sign-out or team rounds, unless they are post-call. Residents should not leave before the team’s work is done for the day unless excused by the Chief resident. No team clinics or cases should be left uncovered by residents going home.

9. Formal presentation of patient cases to senior residents and attendings on rounds, in clinic, or after consults is very important to the learning process. Preparing for case presentations helps to organize thinking, reduces the risk of overlooking key issues, identifies teaching opportunities, and increases efficiency of care. It is an important skill to master for oral Board exams. The case presentation should be clear, organized, comprehensive, focused and CONCISE. It should never take more than 3-5 minutes. It should include the following elements in approximately this order: a. Identification: name, age, gender, occupation b. Chief complaint c. Brief, chronologic history of the present illness d. Significant past medical history (including pertinent negatives) e. Treatment history f. Studies g. Current vitals and labs h. Examination results i. Plan

Hospital Admission Protocols

Indiana University Hospital Admissions Clinic Admissions 274-7372 Patients are seen initially by staff. Upon staff decision to admit the patient, the resident is notified. Whichever resident is out of the operating room then evaluates the patient and completes the History and Physical Examination and admission orders. Bed control is notified (274-7903) with patient’s name, medical record number, diagnosis, and anticipated length of stay – i.e. 23 hour observation or regular admission. Emergency Room Admissions 274-4705 The patient is evaluated by one of the residents on University service during weekdays from 7 a.m. – 5 p.m., or by the resident on call after 5 p.m. weekdays and on weekends. Appropriate labs and radiographs are obtained. The resident then develops an assessment and plan, with the help of the Senior Resident. Staff is then notified. If the patient is known and followed by a particular staff, then that staff member is notified. If unable to contact the staff then the resident calls the Clarian on-call staff. New patients are staffed with the Clarian staff on call. Bed Control is notified, as above. Outside of the hours of 7:00 a.m. – 5:00 p.m. and on weekends, the on call resident must contact the Senior Resident on call to discuss any patient needing admission or surgery. The residents on call will then notify the staff member on call. The on-call resident should notify the University Senior Resident at 6:30 a.m. of any overnight admissions, if the University Senior Resident was not on back up call at the time of the admission. The resident on call also should leave radiographs and CT scans in the Krannert resident room. Referring physicians with potential transfers are deferred to the on-call staff. Residents do not accept transfers.

Riley Hospital Admissions Clinic Admissions Patients are seen by staff in clinic. History and Physical and orders are then done by the resident assigned to admitting staff for the day. If the staff does not have a resident in clinic, then one of the other Riley residents is then notified. Bed Control is then notified (274-7903) with the patient’s name, medical record number, diagnosis, and anticipated length of stay. Emergency Room Admissions 274-3936 Weekdays 7 a.m. – 5 p.m. Whichever Riley resident is available evaluates the patient and orders appropriate labs and x-rays. The patient is then staffed with the Riley staff on consults for the day (consult schedule is posted in the Riley residents room). If the staff decides to admit the patient, then the resident writes History and Physical and admit orders. Bed Control is notified, as above. Weekdays after 5 p.m. and weekends The junior resident on call evaluates the patient and orders labs and x-rays. The senior resident on in- house call is then notified with any questions. If the senior in-house call resident cannot answer the question or is unavailable, the junior resident should contact the chief resident on home call. The Pediatric on-call staff is then notified and the resident performs the History and Physical and admit orders. Bed Control is notified, as above. The on-call resident should notify the Riley Senior Resident (PGY-4) at 6:30 a.m. of any admission, if the Riley Senior Resident was not on backup at the time of the admission. Films should be left in the Riley residents room. Referring physicians with potential transfers are deferred to the Riley on-call staff. Residents do not accept transfers.

VA Hospital Admissions Clinic Admissions Patients are evaluated by residents and labs and radiographs are ordered. Patient is then staffed with Dr. Meldrum during General Orthopaedic Clinic, or the staff responsible for specialty clinics, i.e. Spine and Foot. History and Physical and orders are then done by the resident and/or medical student. The residents or staff must countersign all medical student signatures. Emergency Room Admissions Patients are seen by the on-call resident and labs and x-rays are ordered. The senior resident is contacted for questions. Orders and History and Physical are done by the on-call resident, then the resident should contact the Clarian on-call staff. The on-call resident should notify the V.A. Chief of any overnight admissions at 7 a.m. and leave films in the Ortho call room. Transfers Any transfers must be accepted by staff physician on call. Do not accept transfers from outside hospitals to the Orthopaedic Service unless the patient is known to the Ortho Service and is healthy. Have the referring physician send the patient to the Emergency Room to be evaluated by the ER physician and Orthopaedic resident.

Wishard Hospital Admissions Clinic Admissions 630-7318 Patients are evaluated by residents and appropriate studies are performed. Patients are then staffed with whichever Wishard staff is responsible for the clinic. Orders and History and Physical are then done by residents. Admitting is notified by clinic nurses. Emergency Room Admissions From 7 a.m. – 5 p.m., Emergency Room consults are seen by residents and staffed with the Wishard staff on consults for the day. After 5 p.m. weekdays and on weekends, patients are evaluated by the on-call resident. The Wishard PGY-5 on backup call is contacted for questions. The on-call resident then staffs the patient with the Wishard staff on call. Orders and History and Physical are then done by the resident. Admitting is notified by the resident or Emergency Room nurses (630-7306). The resident on call then reviews admissions and consults with the Wishard team at morning report at 6:00 a.m. the following morning.

History and Physical Exam 1. Each patient admitted to the Orthopaedic Service must have a History and Physical. This can be dictated – one History and Physical per patient, per admission. 2. Student History and Physical’s must be cosigned by a physician. 3. The format for the History and Physical must include the following: • Chief complaint in patient’s own words • History of present illness • Past medical history • Past surgical history • Medicines • Allergies • Social history • Family history • Review of systems • Physical exam of all systems – with emphasis on range of motion of joints, description of wounds, muscle strength (0/5 – 5/5) and neuro exam. • Laboratory results at admission excluding EKG. • X-rays – within normal limits or if abnormal, a description of findings of all x- rays, including CT scans, MRI’s, tomograms, etc. • Diagnosis • Suggested plan of treatment • Work status – please write clearly with distinct answers

Operative Reports 1. Each surgery is to be dictated immediately after the surgery is performed. 2. The resident in charge of each case is responsible for the dictation. 3. Each Operative Report must include the following: • Staff name (State if staff was present – Very Important) • Date of Surgery – VERY IMPORTANT – not always the date dictated • State whether in-house patient or outpatient – VERY IMPORTANT • Surgeon and assistant • Anesthesia method (general, regional, etc.) • Pre and post op diagnosis • Name of procedure – VERY IMPORTANT • Short summary before procedure outlining the history and indications. • Work related injury or non work related injury • Dictation of definitive procedure to include amount of blood loss, hardware used, etc. • Include whether “sign your site” was followed, whether pre-operative antibiotics were given, whether “time out” was performed. • No abbreviations may be used 4. Please understand that dictation is a requirement for our Department by the hospital. This is monitored by the Department. Should this dictation not be done as required, the hospital could lose accreditation and the surgeon may lose privileges. 5. Never dictate “opinion” in medical record – only the facts! MEDICAL RECORDS, DICTATIONS, ETC. It is important that you keep these up and not get into delinquency situations. We need to have all records completed on the 15th and 30th of each month. Finally, at the end of each rotation we will ask that you finish all your records. If they are not done, then the resident’s next vacation will be postponed for that year until finished.

ER and Floor Consults Fill out a consult sheet with STAMPED patient name and number. Consult must include the following information in a LEGIBLE fashion: 1. Date and time 2. Chief complaint 3. HPI – pertinent to reason consulted, referring physician 4. PE – pertinent to reason consulted 5. X-rays – description of each taken 6. Pertinent lab work 7. Diagnosis 8. Procedure with CPT code (do not forget post splinting/casting x-rays) Each consult sheet must have the following: 1. Staff on call 2. Diagnosis 3. Treatment 4. Follow up

Discharge of Patient 1. Pre-plan discharge by consulting the appropriate Orthopaedic Department nurse and the Social Worker, if necessary. 2. Write the discharge order. Write discharge prescriptions. 3. In the progress notes write a FPN (Final Progress Note) to include: • Diagnosis • Operation (if any) • Disposition 4. Fill out entirely the Patient Discharge Summary (Face Sheet). No abbreviations are allowed. No space can be left out. If nothing is applicable to the patient, write none. Write out diet and activity under discharge instructions. (You may use abbreviation for disposition only – example: “See Discharge Orders”) 5. A Discharge Summary must be dictated when the patient is discharged. When dictating the Discharge Summary, be sure to dictate the date of admission, the date of discharge, and indicate copies to be sent to other physicians involved.

Residency Program Goals and Objectives

Program Objectives 1. Provide adequate clinical training for an outstanding resident experience. 2. Provide the resident with opportunities to learn how to perform procedures under graduated supervision, and master surgical judgment and technique. Ultimately the resident will be capable of performing orthopaedic surgical procedures independently. 3. Guide the resident in development of critical diagnostic and analytic skills, both in patient care and in interpretation of orthopaedic literature. 4. Stimulate and develop the resident’s investigative skills through opportunities for clinical and basic research guided by orthopaedic faculty. 5. Help the resident to develop teaching, writing, and speaking skills to enhance career options and opportunities. 6. Provide the resident with the skills, resources and motivations to be a life-long learner, and continue their professional development after formal training ends. 7. Stimulate, encourage and reward professionalism in accordance with the values of Orthopaedic Surgery.

Rotation Goals and Objectives (See goals and objectives for each service)

Adult Reconstruction Rotation Rotation Goals & Objectives PGY-2 and PGY-4 GOAL: The Adult Reconstruction Rotation is designed to provide the Orthopaedic Resident a broad exposure to adult reconstructive extremity surgery. This is a unique opportunity to gain valuable insight to the way in which patients are managed in a health delivery system that emphasizes efficiency, technology, cooperation, patient education, compassion and empathy. The resident will experience the entire spectrum of orthopaedic care delivery, from initial evaluation, diagnosis, evaluative studies, determination of treatment plan, performance of therapeutic intervention, peri-operative care and post-operative follow-up and rehabilitation. EDUCATIONAL STRATEGY The duration of the Adult Reconstruction rotation is 10 weeks for each level resident. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: TEXTBOOKS JOURNALS Pages: Pages: Campbell’s Operative Orthopaedics Journal of Bone and Joint Surgery - american Insall’s Surgery of the Knee Journal of Arthroplasty Hungerford and Krackow: Total Knee Arthroplasty Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3, AAOS Color Atlas for Osteotomy of the Hip, Macnicol COGNITIVE OUTCOMES After completing this rotation, residents will be able to: 1. Perform a thorough history and physical examination of adult patients with extremity complaints of pain, deformity or impairment 2. Evaluate, diagnose, and manage patients with the following: - Osteoarthritis of the hip, knee, and ankle - Degenerative joint disease of the upper extremity - Avascular necrosis of the femoral head - Limb malalignment - Joint infection 3. Support and execute the preoperative preparation of each patient

4. Support and execute the postoperative care and follow up for each patient 5. Anticipate, identify and manage common post-operative complications 6. Practice the principles of peri-operative patient protection and demonstrate an awareness of surgery associated safety issues 7. Construct a sophisticated knowledge base (sufficient to teach others, including patients) in: - preoperative preparation, especially in consideration of existing comorbid factors - operative procedure including pertinent anatomy and technical considerations - cost-effective strategies for patient evaluation - management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure - surgical decision-making principles - outcomes based on principles of Evidence based medicine 8. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 9. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Demonstrate reliability and responsibility for patient care 5. Communicate the details of patient progress and complications to attending in a timely fashion 6. Judge when to seek available assistance from attending 7. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1) Show appropriate written documentation skills, especially with consult information 2) Demonstrate surgical technique appropriate for level under supervision of attending 3) Interpret radiologic studies that are common in the evaluation of the orthopaedic patient 4) Record and demonstrate competency in performing various surgical procedures including: a. total knee arthroplasty b. unicompartmental knee arthroplasty c. total hip arthroplasty d. hip hemi-arthroplasty e. revision total joint surgery f. osteotomy about the knee and hip g. knee and ankle arthrodesis 5) Demonstrate teaching skills essential for creating an excellent learning environment including: a) Confirm and review pertinent history and physical findings with attending staff b) Review subjective and objective evidence of patient progress or complications with attending staff c) Review pertinent laboratory and imaging data with attending staff d) Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of orthopaedic patients

BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY-2 Resident The PGY-2 resident will 1. Gather essential information from the patient, available charts. The resident will demonstrate an ability to perform an adequate physical examination of the entire musculoskeletal system, specifically the upper and lower extremities, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-2 resident will be able to discuss the differential diagnosis and prognosis for the patient, and list treatment options with pros and cons, including both surgical and non-surgical treatment options. 3. The PGY-2 resident will become competent in preparing patients for surgery in the operating room by assisting in obtaining consent, appropriate pre-op consultations and clearances, writing appropriate pre-op orders, patient set-up and draping in conjunction with the attending physician. 4. The PGY-2 resident will be able to demonstrate the qualities of a good surgical assistant, including retraction, suction, wound closure. The resident will demonstrate use of orthopaedic tools and instruments in portions of each procedure consistent with their knowledge, experience and talent. 5. The PGY-2 resident will be able to satisfactorily demonstrate awareness of patient safety issues, and patient protection measures both in and out of the operating room, including confidentiality. The resident will demonstrate the ability to manage post operative care in patients undergoing standard orthopaedic procedures. 6. The PGY-2 resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. The resident will demonstrate appropriate respect and reverence for their elders, especially attendings. 7. The PGY-2 resident will improve their skills in obtaining historical and physical examination information, by taking advantage of every patient contact as a learning experience. They will be able to begin formulating differential diagnoses and treatment plans on their own and then present those to the attending staff. 8. The PGY-2 will become proficient in common surgical procedures, such as placement of IV lines and foley catheters, and begin to learn the techniques of more advanced skills, such as arthroplasty and osteotomy. PGY-4 Resident The PGY-4 resident will 1. Gather essential information from the patient, available charts. The resident will demonstrate an ability to perform an adequate physical examination of the entire musculoskeletal system, specifically the upper and lower extremities, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff, including a differential diagnosis and proposed treatment plan. 2. After discussion with the attending staff, the PGY-4 resident will be able to formulate the treatment plan for common musculoskeletal disorders. 3. the PGY-4 will demonstrate the ability to perform a comprehensive pre-operative plan, and will teach this skill to more junior residents.

4. The PGY-4 resident will be able to perform and teach simple orthopaedic surgical. The PGY-4 will be able to perform the surgical exposure for many of the common procedures (proximal femoral osteotomy, open reduction of fractures, etc.). 5. The PGY-4 resident will be able to satisfactorily manage post operative care in patients undergoing standard orthopaedic procedures. The PGY-4 resident will demonstrate leadership by organizing daily rounds on inpatients to address patient concerns and teach more junior residents. 6. The PGY-4 resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. 7. The PGY-4 resident will continue to improve their skills in obtaining historical and physical examination information. 8. The PGY-4 will become proficient in common surgical procedures, and begin to master the techniques of more advanced skills, and become more independent in performing common orthopaedic reconstructive procedures, such as primary total knee and hip arthoplasty. REQUIREMENTS Residents are to assume the following responsibilities: 1) develop a personal program of self-study and professional growth, including a personal reading schedule 2) participate in 1 full day or 2 half days of patient care clinics per week 3) complete medical records promptly 4) document duty hours 5) document all procedures in the ACGME Surgical Operative Log 6) monitor themselves for fatigue 7) dress professionally, as each resident represents both the department and the attending physicians 8) participate in effective and compassionate patient care 9) organize M&M reports 10)provide a formal educational forum for medical students and junior staff at least once a week 11)complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attending complete the Orthopaedic Department Resident Performance evaluation. 2. Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 3. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and

chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Foot and Ankle Rotation Goals and Objectives PGY-2 GOAL: Orthopaedic surgery residents will develop the essential knowledge, attitudes, and skills in the diagnosis, operative care, and postoperative management of patients with foot and ankle ailments. The major thrust of the rotation is to allow the resident to be involved in the evaluation and care of patients with a wide range of foot and ankle disorders, as well as do initial evaluation, become proficient in foot and ankle examinations. In addition, the resident will be trained and educated in an office based orthopaedic practice, which includes learning appropriate closure techniques including patient instruction and post op dressing, bracing and cryotherapy. The residents will understand the duties and responsibilities of each team member and function accordingly within this training schema. EDUCATIONAL STRATEGY The duration of the Foot and Ankle rotation is 10 weeks for each PGY-2 level resident. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Pages Pages Mann RA, Coughlin MJ (eds). Baxter DE: The foot in running. Surgery of the Foot and Ankle. 2nd ed. In Mann RA, Coughlin MJ (eds). St Louis: Mosby-Year Book, 1993. Surgery of the Foot and Ankle. 2nd ed. St Louis: Mosby-Year Book, 1993. Beckham SG, Grana WA, et al: A comparison of 36-40 Bourne RB, Rorabeck CH: 97-104 anterior compartment pressures in competitive Compartment syndromes of the runners and cyclists. Am J Sports Med 1993;21 lower leg. Clin Orthop 1989;240 Eisele SA, Sammarco GJ: Chronic exertional 213-217 Bennell KL, Malcolm SA, et al: 211-217 compartment syndrome. Instr Course Lect 1993;42 The incidence and distribution of stress fractures in competitive track and field athletes. A twelve month prospective study. Am J Sports Med 1996;24 Eisele SA, Sammarco GJ: Fatigue fractures of the 175-183 Kaufman KR, Brodine SK, et al: 585-593 foot and ankle in the athlete. Instr Course Lect The effect of foot structure and 1993;42 range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999;27 Rettig AC, Shelbourne KD, McCarroll JR, et al: 250-255 Bassett FH, Speer KP: 354-357 The natural history and treatment of delayed union Longitudinal rupture of the peroneal stress fractures of the anterior cortex of the tibia. tendons. Am J Sports Med 1993;21 Am J Sports Med 1988;16 Brage ME, Hansen ST: Traumatic 423-430 Leach RE, Schepsis AA, Takai H: 208-212 subluxation/dislocation of the peroneal tendons.. Long term results of surgical Foot Ankle 1992;13 management of Achilles tendonitis in runners. Clin Orthop 1992;282

Lutter LD: Hindfoot problems. Instr Course Lect 195-200 Maffulli N: Rupture of the Achilles 1019-1036 1993;42 tendon. J Bone Joint Surg 1999;81A Maffulli N, Binfield PM, King JB: Tendon 142-144 Mandelaum BR, Myerson MS, 392-395 problems in athletic individuals. J Bone Joint Surg Forster R: Achilles tendon rupture. 1998;80A A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995;23 Porter DA, Mannarino FP, Snead D, et al: Primary 557-564 Baxter DE: Functional nerve 185-194 repair without augmentation for early neglected disorders in the athlete’s foot, Achilles tendon ruptures in the recreational athlete. ankle, and leg. Instr Course Lect Foot Ankle Int 1997;18 1993;42 Lau JT, Daniels TR: Tarsal tunnel syndrome: A 201-209 Schepsis AA, Bill SS, Foster TA: 430-435 review of the literature. Foot Ankle Int 1999;20 Fasciotomy for exertional anterior compartment syndrome: Is lateral compartment release necessary? Am J Sports Med 1999;27 Gill LH, Kiebzak GM: Outcome of nonsurgical 527-532 Kwong PK, Kay D, Voner RT, 119-126 treatment for plantar fasciitis. Foot Ankle Int White MW: Plantar fasciitis: 1996;17 Mechanics and pathomechanics of treatment. Clin Sports Med 1988;7 Marotta JJ, Micheli LJ: Os trigonum impingement 533-536 Marumoto JM, Ferkel RD: 777-784 in dancers. Am J Sports Med 1992;20 Arthroscopic excision of the os trigonum: A new technique with preliminary results. Foot Ankle Int 1997;18 Barrett JR, Tanji JL, et al: High- versus low-top 582-585 Baumhauer JF, Alosa DM, et al: A 564-570 shoes for the prevention of ankle sprains in prospective study of ankle injury basketball players, A prospective randomized risk factors. Am J Sports Med study. Am J Sports Med 1993;21 1995;23 Gerber JP, Williams GN, et al: Persistent disability 653-660 Hamilton WG, Thompson FM, 1-7 associated with ankle sprains: A prospective Snow SW: The modified Brostrom examination of an athletic population. Foot Ankle procedure for lateral ankle Int 1998;19 instability. Foot Ankle 1993;14 Hopkinson WJ, StPierre P, Ryan JB, et al: 325-330 Feder KS, Schonholtz GJ: Ankle 382-385 Syndesmosis sprains of the ankle. Foot Ankle arthroscopy: Review and long-term 1990;10:325-330. results. Foot Ankle 1992;13 Ferkel RD, Scranton PE: Current concepts review. 1233-12 Kumai T, Takahura Y, et al 1229-1235 Arthroscopy of the ankle and foot. J Bone Joint 43 Arthroscopic drilling for the Surg 1993;75A treatment of osteochondral lesions of the talus. J Bone Joint Surg 1999;81A Loomer R, Fisher C, et al: Osteochondral lesions of 13-19 McCarroll JR, Schrader JW, 257 the talus. Am J Sports Med 1993;21 Shelbourne KD, et al: Meniscoid lesions of the ankle in soccer players. Am J Sports Med 1987;15 Rodeo SA, O’Brien S, Warren RF, et al: Turf toe: 280-285 Sammarco GJ: Turf toe. Instr 207-212 An analysis of metatarsal phalangeal joint pain in Course Lect 1993;42 professional football players. Am J Sports Med 1990;18 COGNITIVE OUTCOMES After completing this rotation, the resident will be able to: 1. Evaluate, diagnose, and manage patients with the following: - Bunion, hallux rigidus, neuroma, hammertoes - Midfoot and Hindfoot arthritis - Achilles, peroneal, posterior tibial tendon tears, acute and chronic

- Lateral ankle instability, anterior ankle impingement - Fractures of ankle, syndesmosis, metatarsals, calcaneus - Midfoot dislocations, ankle sprains, turf toe 2. Support and execute the preoperative preparation of each patient 3. Support and execute the postoperative care and follow up for each patient 4. Construct a sophisticated knowledge base (sufficient to teach others) in: a. preoperative preparation, especially in consideration of existing comorbid factors b. operative procedure including pertinent anatomy and technical considerations c. cost-effective strategies for patient evaluation d. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. surgical decision-making principles 5. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 6. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, the resident will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Show the ability to work in an orthopaedic care team 5. Demonstrate reliability and responsibility for patient care 6. Communicate the details of patient progress and complications to attending in a timely fashion 7. Judge when to seek available assistance from attending 8. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, the resident will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of the orthopaedic patient 4. Record and demonstrate competency in performing various surgical procedures including: a. ankle arthroscopy b. closure of all foot and ankle wounds c. ankle fractures d. Achilles repair 5. Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a. Confirm and review pertinent history and physical findings with attending staff b. Review subjective and objective evidence of patient progress or complications with attending staff c. Review pertinent laboratory and imaging data with attending staff d. Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of orthopaedic patients

BASIC DUTIES, GOALS, AND OBJECTIVES The resident will 1. Gather essential information from the patient, available charts. The resident will demonstrate an ability to perform an adequate physical examination of a patient for the entire musculoskeletal system, specifically the foot and ankle and leg, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the resident will be able to formulate the treatment plan for patients with common foot and ankle ailments, common fractures, common bone and joint infections, and common acquired disorders [flat foot, Achilles rupture, ankle sprain]. 3. The resident will become competent in preparing patients for surgery in the operating room by assisting in patient set-up and draping in conjunction with the attending physician. 4. The resident will be able to perform simple orthopaedic surgical procedures such as removal of hardware. 5. The resident will be able to satisfactorily manage post operative care in patients undergoing standard orthopaedic procedures, such as ankle fracture, Achilles repair, ankle reconstruction. 6. The resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. REQUIREMENTS The residents is to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in 1 full day or 2 half days of patient care clinics per week 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. organize M&M reports 10. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation 11. read self-assessment exam foot/ankle, foot/ankle sports text EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attendings complete the Orthopaedic Surgery Department Resident Performance evaluation. 2. Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 3. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director.

Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Foot and Ankle Rotation Scrub Policy If a clinic day, residents should not wear scrubs but a tie and dress shirt. For OR days residents can wear scrubs in between cases with a white coat if we see a patient. Residents are not to wear scrubs from home to wear in the OR.

Hand Rotation Goals & Objectives PGY-3 GOAL: Orthopaedic surgery residents will develop the essential knowledge, attitudes, and skills in the diagnosis, operative care, and postoperative management of patients with upper extremity orthopaedic conditions. The major thrust of the rotation is to allow residents to be involved in the evaluation and care of adults and children with a wide range of including traumatic, pathologic, rheumatologic, idiopathic, and congenital musculoskeletal disorders. In addition, each resident will be trained and educated in an office based private orthopaedic practice, which includes routine hand, wrist, and elbow pain and deformity. Residents will understand the duties and responsibilities of each team member and function accordingly within this training schema. EDUCATIONAL STRATEGY The duration of the IHC Upper Extremity Orthopaedic rotation is 10 weeks for each PGY3 level resident. Residents are assigned to Dr. Thomas Fischer. In addition to partaking in this rotation, residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Green’s Operative Hand 5th ed Green’s Operative Hand 5th ed Pages: Pages: Acute and Chronic Infections in the Hand 55-158 Elbow Dislocation and 907-938 Instability Dupuytren’s Contracture 159-188 Elbow Arthroscopy 959-972 Extensor and Flexor Tendon Injuries 187-276 Elbow Arthroplasty 973-998 Fractures of the Metacarpals and Phalanges 277-342 Compression 999-1046 Neuropathies Dislocations and Ligament Injuries of the Hand 343-388 Nerve Palsy and Nerve 1075-1196 Repair The Perionychium 389-416 Tetraplegia 1271-1296 Basilar Thumb Arthritis 461-488 Brachial Plexus Injury 1297-1374 Arthrodesis of the Wrist 489-534 Embryology 1375-1380 Carpal Instability 535-604 Deformities of the 1381-1506 Forearm and Hand Distal Radius Fractures 645-710 Principles of Microvascular 1529-1568 Surgery Carpal Fractures 711-768 The Mangled Upper 1569-1628 Extremity Wrist Arthroscopy 769-808 Grafts and Flaps 1629-1776 Fractures About the Elbow 809-906 Compartment Syndrome 1985-2006

COGNITIVE OUTCOMES After completing this rotation, residents will be able to: 1. Evaluate, diagnose, and manage patients with the following: a. common rotational and angular deformities b. osteomyelitis and septic arthritis c. superficial and deep space infections of the hand d. nerve compression syndromes e. common tendonopathies, including DeQuervain’s, stenosing tenosynovitis, rupture, and fibrosis f. tumorous conditions of the upper extremity g. progressive or traumatic arthropathies 2. Support and execute the preoperative preparation of each patient 3. Support and execute the postoperative care and follow up for each patient 4. Construct a sophisticated knowledge base (sufficient to teach others) in: a. preoperative preparation, especially in consideration of existing comorbid factors b. operative procedure including pertinent anatomy and technical considerations c. cost-effective strategies for patient evaluation d. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. surgical decision-making principles 5. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 6. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Show the ability to work in a private community based upper extremity orthopaedic care team 5. Demonstrate reliability and responsibility for patient care 6. Communicate the details of patient progress and complications to attending in a timely fashion 7. Judge when to seek available assistance from attending 8. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique appropriate for each level under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of the hand and upper extremity 4. Record and demonstrate competency in performing various surgical procedures including: a. fractures, both closed and open reductions b. nerve compression releases c. mechanical re-alignment (ulnar shortening osteotomy, distal radius wedge osteotomy) d. surgical care of septic arthritis and osteomyelitis e. surgical procedures in arthropathy (CMC arthritis, SLAC wrist)

f. surgical management of basic tendonopathy (STS, DeQuervain’s, epicondylitis) g. excision or resection of tumors h. wrist and elbow arthroscopy 5. Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a. Confirm and review pertinent history and physical findings with fellows and attending staff b. Review subjective and objective evidence of patient progress or complications with attending staff c. Review pertinent laboratory and imaging data with attending staff d. Educate medical students in basic orthopaedic disorders of the hand, and the conduct of pre, intra, and postoperative care of upper extremity orthopaedic patients BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY-3 Resident The PGY-3 resident will 1. Gather essential information from the patient. The resident will demonstrate an ability to perform an adequate physical examination for the entire upper extremity. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-3 resident will be able to formulate a treatment. 3. The PGY-3 resident will become competent in preparing patients for surgery in the operating room by assisting in patient set-up and draping in conjunction with the attending physician. 4. The PGY-3 resident will be able to perform common upper extremity procedures, such as closed reductions of forearm and hand fractures, drainage of joint infections, carpal tunnel releases, and pulley releases. The PGY-3 will be able to perform the surgical exposure for many of the common procedures (wrist, elbow, forearm) 5. The PGY-3 resident will be able to satisfactorily manage post operative care in patients undergoing standard orthopaedic hand procedures. 6. The PGY-3 resident will show appropriate respect and compassion to family needs concerning the patients progress, complications, and future plans for rehabilitation. 7. The PGY-3 resident is expected to spend time in the Hand Rehabilitation Center, which provides acute and long-term hand therapy and functional rehabilitation for our patients. The close relationship between the staff surgeons and the therapists is an indispensable part of our program, improving final hand function and lessening the degree of impairment. Through this association, the residents are expected to learn proper therapeutic management and the benefits of a close working liaison between surgeon and therapist. 8. The PGY-3 Resident will provide on-call support in the emergency room working closely with the Hand Fellow at St. Vincent’s Hospital. This is in conjunction with his call duties at the University and in compliance with work hour guidelines. 9. The PGY-3 Resident is expected to review data and prior treatment plans for patients scheduled for surgery, and dictate all Admission History and Physicals and provide postoperative notes and orders following surgery. 10. The PGY-3 Resident must make daily rounds on patients in the hospital and keep accurate and timely notes, communicating and working closely with the Hand Fellow.

11. PGY-3 Residents must maintain good professional relations with all referring entities, internal staff and external health care professionals. They are expected to conduct themselves in a courteous and professional manner at all times. 12. PGY-3 Residents must attend all required educational meetings including Fracture Conference, Journal Club, and monthly physician lectures, as directed by Dr. Fischer. REQUIREMENTS Residents are to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in all clinical and surgical cases 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attendings complete the online Surgery Department Resident Performance evaluation. 2. Evaluate residents’ teaching, time management skills, professionalism, communication skills, patient care, and medical knowledge by having peers complete an evaluation after each rotation. 3. Review faculty, and peer evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 4. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director and Medical Educator. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident and staff. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty. The attending faculty are always present and/or immediately available at this institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Hand Rotation Scrub Policy On the hand service we prefer a lab coat in the clinic. Better yet a collared shirt and or tie underneath the lab coat. If it is a day when we do both office and OR or office and ER call, then a lab coat over the scrubs will suffice. Name badge and lab coat are more preferable than anything else. No scrubs alone. No dirty scrubs with ANY kind of body fluids on them.

Musculoskeletal Oncology Rotation Goals and Objectives The Musculoskeletal Oncology Rotation is a comprehensive course designed to introduce Orthopaedic Surgery residents to all aspects of contemporary evaluation and treatment of patients with benign and malignant bone and soft tissue tumors of the extremities, pelvis, and spine. This course includes didactic lectures and clinical experience in managing patients with these and related conditions. Currently, this course is designed as a 10-week rotation for the PGY-3 level residents; however, other year level residents also receive continued exposure throughout their residency to the oncology service lectures and weekly unknown cases. GOAL: Orthopaedic surgery residents will develop the essential knowledge, attitudes, and skills in the diagnosis, operative care, and postoperative management of patients with musculoskeletal tumors and related conditions. Residents will be involved in the evaluation and care of adults and children with a wide range of conditions, including both benign and malignant tumors of bone and soft tissue. Each resident will be trained and educated in aspects of inpatient and outpatient care in orthopaedic oncology. Residents will understand the duties and responsibilities of each team member of a multidisciplinary oncology team. They will function accordingly within this training schema. EDUCATIONAL STRATEGY The duration of the Musculoskeletal Oncology rotation is 10 weeks for each PGY-3 level resident. Residents are assigned to Dr. Daniel Wurtz. In addition to partaking in this rotation residents participate in teaching conferences, as well as other pathology and oncology conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Surgery for Bone and Soft Simon and Musculoskeletal Oncology Service Tissue Tumors Springfield, Service (Resident Duties Hand-out by 1998 and Responsibilities) Dr. Wurtz Service Musculoskeletal Tumor Hand-out by --Natural History pp. 3-7 Syllabus Dr. Wurtz Orthopaedic Knowledge --Cellular and Molecular pp. 9-20 Update – Musculoskeletal AAOS 2002, Biology Tumors First Edition S. Weiss --Diagnostic Strategies pp. 21-30 Soft Tissue Tumors 4th Edition Musculoskeletal Surgery Sugarbaker, for Cancer – Principles and Malawar, --Diagnostic Imaging pp. 31-45 Techniques Thieme 1998 --Staging Systems pp. 47-53 --Biopsy pp. 55-65

--Management of Surgical Specimens pp. 67-75 --Surgical Margins pp. 77-92 --Radiation Therapy pp. 93-95 --Principles of Chemotherapy pp. 97-103 Section: Benign Bone Tumors --General Classification pp. 119-124 --Common Benign Bone Tumors and Treatment pp. 181-206 Section: Malignant Bone Tumors --General Considerations pp. 227-232 --Chemotherapy pp. 239-244 --Common Malignant Bone Tumors pp. 265-298 Section: Soft Tissue Tumors --General Considerations pp. 499-508 --Diagnostic Strategies and Biopsy pp. 509-524 --Management pp. 525-576 Section: Carcinoma Metastatic to Bone --Evaluation pp. 621-624 COGNITIVE OUTCOMES After completing this rotation, residents will be able to understand: 1. Specific musculoskeletal topics a. Radiographic evaluation b. Tumor staging c. Biopsy d. Surgical treatment of benign bone tumors e. Surgical treatment of malignant bone tumors f. Benign soft tissue masses g. Malignant soft tissue masses h. Treatment of patients with metastatic disease i. Adjuvant treatments • Radiation therapy • Chemotherapy 2. Common tumor histology • H & E stains • Special stains • Immunohistic chemistry 3. Support and execute the preoperative preparation of each patient 4. Support and execute the postoperative care and follow up for each patient 5. Construct a sophisticated knowledge base (sufficient to teach others) in: a. preoperative preparation, especially in consideration of existing comorbid factors b. operative procedure including pertinent anatomy and technical considerations

c. cost-effective strategies for patient evaluation d. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. surgical decision-making principles 6. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 7. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Show the ability to work in a pediatric orthopaedic care team 5. Demonstrate reliability and responsibility for patient care 6. Communicate the details of patient progress and complications to attending in a timely fashion 7. Judge when to seek available assistance from attending 8. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique appropriate for each level under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of bone and soft tissue tumors of the extremities 4. Appreciate and understand various surgical procedures including: a. Biopsy - Needle - Incisional - Excisional b. Excision of Benign masses c. Curettage of benign bone tumors d. Bone grafting techniques e. Resection of bone and soft tissue sarcomas f. Complex reconstruction - Endoprosthesis - Bulk allografts g. Internal fixation/stabilization of impending pathologic fractures 5. Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a. Confirm and review pertinent history and physical findings with attending staff and other residents b. Review subjective and objective evidence of patient progress or complications with attending staff c. Review pertinent laboratory and imaging data with attending staff d. Educate medical students and peers in basic musculoskeletal oncology

BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY-3 Resident The PGY-3 resident will 1. Gather essential information from the parents. The resident will demonstrate an ability to perform an adequate musculoskeletal physical examination. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-3 resident will be able to formulate the treatment plan with the guidance of the faculty orthopaedic oncologist. The PGY-3 resident will become competent in preparing patients for surgery in the operating by assisting in patient set-up and draping in conjunction with the attending physician. 3. The PGY-3 resident will be able to assist the orthopaedic oncologist with a multitude of musculoskeletal oncology surgical procedures. 4. The PGY-3 resident will be able to satisfactorily manage post operative care in musculoskeletal oncology patients. 5. The PGY-3 resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. 6. The PGY-3 resident is expected to review data and prior treatment plans for patients scheduled for surgery, and write or dictate admission history and physicals and provide post operative notes and orders following surgery. 7. The PGY-3 resident will make daily rounds on patients in the hospital to keep accurate and timely notes, communicating and working closely with the faculty physician. 8. The PGY-3 resident must maintain good professional relations with all entities, internal staff and external health care professionals. They are expected to conduct themselves in a courteous and professional manner at all times. 9. The PGY-3 resident must attend all required educational meetings including tumor conference, journal club, and lectures as directed by the faculty orthopaedic oncologist. REQUIREMENTS Residents are to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in 1 full day or 2 half days of patient care clinics per week 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. organize M&M reports 10. provide a formal educational forum for medical students and junior staff at least once a week 11. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation

EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having faculty physician complete the Orthopaedic Department Resident Performance evaluation. 2. Evaluate residents’ teaching, time management skills, professionalism, communication skills, patient care, and medical knowledge by having peers complete an evaluation after each rotation. 3. Review faculty, and peer evaluations with the residents at least every six months with the Program Director. Disciplinary or construction actions will be discussed and approved by the Residency Program Director with recommendations from the Education Committee. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 4. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director and Medical Educator. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Private Practice Rotation Rotation Goals & Objectives PGY-4 GOAL: The Orthopaedic Private Practice Rotation is designed to provide the Orthopaedic Resident a broad exposure to General Orthopaedics as well experience in the organization, management and functioning of a private practice-like office. This is a unique opportunity to gain valuable insight to the way in which patients are managed in a health delivery system that emphasizes efficiency, technology, cooperation, patient education, compassion and empathy. The resident will experience the entire spectrum of orthopaedic care delivery, from initial evaluation, diagnosis, evaluative studies, determination of treatment plan, performance of therapeutic intervention, peri-operative care and post-operative follow-up and rehabilitation. EDUCATIONAL STRATEGY The duration of the Private Practice rotation is 10 weeks for each PGY-4 level resident. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Pages: Arthritis & Allied Conditions p. 2169 Koopman & Mreland, eds. Chapter 108 Management of Osteoarthritis of the Knee pp. 1 - 91 Fu & Browner, eds. AAOS Monograph Revision Total Hip Arthroplasty pp. 1 - 80 Paprosky, ed., AAOS Monograph Revision Total Knee Arthroplasty pp. 1 - 66 Whiteside, ed., AAOS Monograph COGNITIVE OUTCOMES After completing this rotation, residents will be able to: 1. Evaluate, diagnose, and manage patients with the following: - Knee osteoarthropathy - Hip osteoarthropathy - Meniscal injuries - Nonunion treatment - Shoulder impingement and rotator cuff tears 2. Support and execute the preoperative preparation of each patient

3. Support and execute the postoperative care and follow up for each patient 4. Construct a sophisticated knowledge base (sufficient to teach others) in: a. preoperative preparation, especially in consideration of existing comorbid factors b. operative procedure including pertinent anatomy and technical considerations c. cost-effective strategies for patient evaluation d. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. surgical decision-making principles 5. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 6. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1, Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4, Demonstrate reliability and responsibility for patient care 5. Communicate the details of patient progress and complications to attending in a timely fashion 6. Judge when to seek available assistance from attending 7. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique appropriate for level under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of the orthopaedic patient 4. Record and demonstrate competency in performing various surgical procedures including: a. knee arthroscopy & associated procedures b. total knee arthroplasty c. total hip arthroplasty d. unicompartmental knee arthroplasty e. fracture management in adults & children 5. Demonstrate teaching skills essential for creating an excellent learning environment including: a. Confirm and review pertinent history and physical findings with attending staff b. Review subjective and objective evidence of patient progress or complications with attending staff c. Review pertinent laboratory and imaging data with attending staff d. Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of orthopaedic patients

BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY-4 Resident The PGY-4 resident will 1. Gather essential information from the patient, available charts. The resident will demonstrate an ability to perform an adequate physical examination of the entire musculoskeletal system, specifically the upper and lower extremities, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-4 resident will be able to formulate the treatment plan for common musculoskeletal disorders such as sprains and strains, fractures, bone and joint infections, and complex infected nonunions and difficult knee deformities. 3. The PGY-4 resident will become competent in preparing patients for surgery in the operating room by assisting in patient set-up and draping in conjunction with the attending physician. 4. The PGY-4 resident will be able to perform simple orthopaedic surgical procedures such as tendon lengthenings, closed reductions of forearm and tibia fractures, drainage of joint infections. The PGY-4 will be able to perform the surgical exposure for many of the common procedures (proximal femoral osteotomy, open reduction of fractures, etc.). 5. The PGY-4 resident will be able to satisfactorily manage post operative care in patients undergoing standard orthopaedic procedures, such as osteotomies, tendon lengthening/transfer, closed or open treatment of fractures. 6. The PGY-4 resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. 7. The PGY-4 resident will continue to improve their skills in obtaining historical and physical examination information. They will be able to begin formulating differential diagnoses and treatment plans on their own and then present those to the attending staff. 8. The PGY-4 will become proficient in common surgical procedures, and begin to learn the techniques of more advanced skills, such as total joint replacement, revision total joint, knee arthroscopy, nonunion/malunion correction & treatment of infected nonunion, and complex/unusual fractures. REQUIREMENTS Residents are to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in 1 full day or 2 half days of patient care clinics per week 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. organize M&M reports 10. provide a formal educational forum for medical students and junior staff at least once a week 11. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation

EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attending complete the Orthopaedic Department Resident Performance evaluation. 2. Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 3. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Private Practice Rotation Scrub Policy Scrubs in the OR and on the floor for rounds ONLY if rounds are on an OR day & take place between cases. Otherwise, there are no scrubs in the office or around the hospital on non-operative days. Appropriate dress is clean & neat slacks, dress shoes (no athletic shoes), and a clean & neat shirt. We do not require neckties and white coats are completely optional.

Pediatric Orthopaedic Rotation Goals & Objectives GOAL: Orthopaedic surgery residents will develop the essential knowledge, attitudes, and skills in the diagnosis, operative care, and postoperative management of patients with pediatric orthopaedic conditions. The major thrust of the rotation is to allow residents to be involved in the evaluation and care of children with a wide range of musculoskeletal disorders as well as neuromuscular disorders with orthopaedic sequelae. In addition, each resident will be trained and educated in an office based pediatric orthopaedic practice, which includes routine lower extremity, hip, upper extremity, and spine deformity. Residents will understand the duties and responsibilities of each team member and function accordingly within this training schema. EDUCATIONAL STRATEGY The duration of the Riley Pediatric Orthopaedic rotation is 10 weeks for each PGY3, 4, and 5 level resident. Residents are assigned to one team. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Lovell and Winter 6th ed Lovell and Winter 6h ed Pages: Pages: Embryology and development 1-33 Congenital Scoliosis 763-795 Growth in Pediatric Orthop 35-65 Kyphosis 799-837 The Pediatric Ortho Exam 113-143 Spondylolysis and 839-870 Spondylolisthesis Genetic Aspects of Orthopaedic 146-250 Cervical Spine 872-919 Condition Syndromes of Orthopaedic 253-313 The Upper Limb 922-985 Importance Localized Disorders of Bone 316-356 Developmental Hip Dysplasia 987-1037 And Soft Tissue Osteomyelitis and Septic Arthritis 440-491 Legg-Perthes 1039-1083 Cerebral Palsy 552-603 SCFE 1085-1124 Myelomeningocele 605-647 Miscellaneous Hip Conditions 1126-1155 Other Neuromuscular Disorders 650-692 The Lower Extremity 1158-1211 Idiopathic Scoliosis 694-762 Leg Length Discrepancy 1214-1256 Childhood Limb Deficiency 1330-1381 Pediatric Foot 1259-1328 Pediatric Fractures 1431-1525 Child Abuse 1527-1545

COGNITIVE OUTCOMES After completing this rotation, residents will be able to: 1) Evaluate, diagnose, and manage patients with the following: a) common rotational and angular deformities b) common neuromuscular disorders such as cerebral palsy and myelodysplasia c) osteomyelitis and septic arthritis d) idiopathic, congenital and paralytic scoliosis e) kyphosis and spondlylolysis/spondylolisthesis f) developmental hip dysplasia, Legg-Perthes disease, and SCFE g) common congenital musculoskeletal deformities h) leg length discrepancy i) common fractures and the battered child 2) Support and execute the preoperative preparation of each patient 3) Support and execute the postoperative care and follow up for each patient 4) Construct a sophisticated knowledge base (sufficient to teach others) in: a) preoperative preparation, especially in consideration of existing comorbid factors b) operative procedure including pertinent anatomy and technical considerations c) cost-effective strategies for patient evaluation d) management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e) surgical decision-making principles 5) Evaluate periodical pediatric orthopaedic surgical literature related to the patients’ health problems 6) Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1) Put into practice self-directed learning habits 2) Demonstrate maturity and professional judgment in caring for patients 3) Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4) Show the ability to work in a pediatric orthopaedic care team 5) Demonstrate reliability and responsibility for patient care 6) Communicate the details of patient progress and complications to attending in a timely fashion 7) Judge when to seek available assistance from attending 8) Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1) Show appropriate written documentation skills, especially with consult information 2) Demonstrate surgical technique appropriate for each level under supervision of attending 3) Interpret radiologic studies that are common in the evaluation of the pediatric orthopaedic patient 4) Record and demonstrate competency in performing various surgical procedures including: a) pediatric fractures, both closed and open reductions b) pediatric congenital deformities (DDH, congenital foot/knee deformities)

c) pediatric hip disorders (Perthes disease, SCFE) d) surgical care of septic arthritis and osteomyelitis e) surgical procedures in neuromuscular disorders (myelodysplasia, cerebral palsy) f) spinal deformity surgery (scoliosis, kyphosis, spondylolysis/listhesis) g) complex hernia repairs 5) Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a) Confirm and review pertinent history and physical findings with other residents and attending staff b) Review subjective and objective evidence of patient progress or complications with other residents and attending staff c) Review pertinent laboratory and imaging data with other residents and attending staff d) Modify as needed, patient care plans developed by the junior resident e) Educate medical students in basic pediatric orthopaedic disorders, and the conduct of pre, intra, and postoperative care of pediatric orthopaedic patients BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY-3 Resident The PGY-3 resident will 1) Gather essential information from the child and parents, available charts. The resident will demonstrate an ability to perform an adequate physical examination of a child for the entire musculoskeletal system, specifically the spine, upper, and lower extremities, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2) After discussion with the attending staff, the PGY-3 resident will be able to formulate the treatment plan for children with common musculoskeletal disorders (eg. torsional/angular deformities, common congenital deformities [clubfoot, metatarsus adductus], common fractures, common bone and joint infections, and common acquired disorders [idiopathic scoliosis, developmental dysplasia of the hip, slipped capital femoral epiphysis]. 3) The PGY-3 resident will become competent in preparing patients for surgery in the operating by assisting in patient set-up and draping in conjunction with more senior residents and/or the attending physician. 4) The PGY-3 resident will be able to perform simple pediatric orthopaedic surgical procedures such as tendon lengthenings, closed reductions of forearm and tibia fractures, drainage of joint infections. The PGY-3 will be able to perform the surgical exposure for many of the common procedures (proximal femoral osteotomy, posterior spine, open reduction of fractures). 5) The PGY-3 resident will be able to satisfactorily manage post operative care in children undergoing standard pediatric orthopaedic procedures, such as spinal instrumentation and fusion (both posterior and anterior), osteotomies, tendon lengthening/transfer, closed or open treatment of fractures. 6) The PGY-3 resident will show appropriate respect and compassion to family needs concerning the child’s progress, complications, and future plans for rehabilitation.

PGY-4 Resident Having successfully completed the PGY-3 rotation, the 1. PGY-4 resident will continue to improve their skills in obtaining historical and physical examination information. They will be able to begin formulating differential diagnoses and treatment plans on their own and then present those to the attending staff. 2. PGY-4 resident will become involved in education of medical students and the PGY-3 resident. 3. The PGY-4 will become proficient in common surgical procedures, and begin to learn the techniques of more advanced skills, such as open reduction of developmental hip dislocations, spinal instrumentation, and complex/unusual fractures. PGY-5 Resident After successfully completing the PGY-3 and 4 rotations 1. The PGY-5 resident will successfully manage the Riley Inpatient Service by overseeing the PGY-3 and 4 residents. He/she will coordinate daily schedules for all residents and medical students on the rotation. He/she will create an environment of professional relationships with other medical services and personnel, and intervene when such an environment is in need of repair. He/she will ensure harmonious relations with the child and family. 2. The PGY-5 resident is responsible for monitoring complications and reporting them to the monthly Morbidity and Mortality meeting. 3. The PGY-5 resident will be able to independently evaluate children with musculoskeletal disorders, both simple and complex (cerebral palsy, myelodysplasia), formulate treatment plans, and carry out treatment, both operative and non-operative, in concert with the attending staff. REQUIREMENTS Residents are to assume the following responsibilities: 1) develop a personal program of self-study and professional growth 2) participate in 1 full day or 2 half days of patient care clinics per week 3) complete medical records promptly 4) document duty hours 5) document all procedures in the ACGME Surgical Operative Log 6) monitor themselves for fatigue 7) dress professionally, as each resident represents both the department and the attending physicians 8) participate in effective and compassionate patient care 9) organize M&M reports 10) provide a formal educational forum for medical students and junior staff at least once a week 11) complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1) Evaluate residents’ clinical performance and professionalism by having attendings complete the online Surgery Department Resident Performance evaluation. 2) Evaluate residents’ teaching, time management skills, professionalism, communication skills, patient care, and medical knowledge by having peers complete an evaluation after each rotation.

3) Review faculty, and peer evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 4) Review residents’ lists of procedures (SOL) at least every 6 months by Program Director and Medical Educator. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Pediatric Orthopaedic Rotation Scrub Policy During all clinic activities (private office and other specialty clinics [eg. CP, myelomeningocele, bone dysplasia, etc.]) the resident will be in professional street dress (eg. tie and clean shirt/slacks for men with dress shoes [not tennis shoes]); white coats do not need to be worn in clinic (unless required by the specific attending) as they often scare children, but the resident must be professionally dressed. Appropriate ID tags must always be worn. Scrubs are to be worn only in the OR, with the following exceptions: In the cast clinic with a white lab coat. In the rare circumstance that the resident will be seeing a patient in the clinic between OR cases, then coming down to the clinic in scrubs covered with a white lab coat is permissible. At the end of the OR day, the resident must discard dirty scrubs and change into professional street dress clothes. Also, scrubs must be changed after any case if they become contimanated by blood or other body fluids, or a major infection case.

Senior Elective Rotation You must pick up elective rotation forms from Donna Roberts (Residency Program Coordinator) to be completed prior to your elective rotation. The name of the rotation, accepting signature of the primary staff of the rotation, your expected goals and objectives while on the elective, and the signature of the Program Director are mandatory before the start of the rotation. You will not be allowed to participate in the rotation if you do not have all the necessary information complete and returned to Donna Roberts before the start of your rotation. Similarly, if you are not on the appropriate timeline for your Garceau-Wray research project, you will not be allowed to perform your Senior Elective rotation.

Spine Rotation Goals & Objectives One PGY-2 resident is assigned to a 10-week rotation on the Spine Service. The Chief-of- Service is a fellowship-trained orthopaedic spine surgeon faculty member. A multi-disciplinary group of spinal physicians completes the faculty team which includes a neurosurgeon and non-operative spine specialists. The resident will spend his time on the service interacting one-on-one with the faculty members and allowing continuity of patient care during the 10 week period. In a typical week, the resident will be a first-assistant in the operating room three full days, and evaluate patients in the office between one-and-a-half and two full days. The remaining time the resident will spend rounding on and providing post-operative care of inpatients, seeing inpatient consults, and preparing for resident conferences. The resident will spend the majority of his time at St. Vincent Hospital, but will typically spend between half day and one day per week at the Clarian North Hospital, and occasionally at Methodist Hospital. The vast majority of patients the residents are exposed to on the Spine Service are those with degenerative spinal disorders in the cervical, thoracic and lumbar spine, including spinal stenosis, herniated nucleus pulposus, cervical myelopathy, spondylolisthesis, and degenerative scoliosis. Spinal tumors, infections, and traumatic disorders are also encountered. The resident will be exposed to inflammatory disorders such as rheumatoid arthritis and ankylosing spondylitis as well as complex deformities of the occipitocervical and cervicothoracic junctions. Intradural abnormalities, including tumors and congenital abnormalities, will also be seen. Goals: Orthopaedic surgery residents will develop the essential knowledge, attitudes, and skills in the diagnosis, non-operative treatment, operative care, and postoperative management of patients with spinal disorders. The major thrust of the rotation is to allow residents to be involved in the evaluation and care of patients with a wide range of spinal disorders as well as neurological disorders with orthopaedic sequelae. In addition, each resident will be trained and educated in an office based spinal practice, which includes routine evaluation and diagnosis of myelopathy, radiculopathy, and spine deformity. Residents will understand the duties and responsibilities of each team member and function accordingly within this training schema. Objectives: PATIENT CARE In the out-patient office the resident will accompany the attending staff in seeing all the patients in the first two to four weeks of the rotation, and will learn to take a detailed and pertinent history, perform a pertinent spine examination including a detailed neurological examination, interpret plain radiographs, MRI, CT, and myelograms, formulate a differential diagnosis, order appropriate additional studies, arrive at a diagnosis, as well as formulate a general treatment plan. After the initial 2 to 4-week observational period, the resident will be allowed to see and work up patients of appropriate complexity and present the history, physical examination, and radiographic findings to the attending staff. The resident will then be asked to arrive at a diagnosis, or to specify additional diagnostic studies needed, and to present a treatment plan. The resident will participate in out-patient follow-up care and post-operative care in a similar fashion. In the operating room, the resident will function as the first assistant. Under direct, close supervision by the attending staff, the resident will learn to carry out posterior exposure of the spine on his side, to harvest autogenous iliac crest bone graft, to carry out the initial decompression of the spine appropriate for his technical skills, to assist in the preparation of the fusion bed and spinal instrumentation, and to close the wound in a meticulous fashion. The resident will learn the various

approaches to the spine including the anterior cervical Smith-Robinson approach, the transthoracic approach, the retroperitoneal approach, as well as the posterior approaches to the cervical, thoracic, and lumbar spine. The resident will learn and carry out the peri-operative care of the patient. He will make daily rounds on post-operative patients and discuss each patient with the attending staff at least once daily. He will carry out the peri-operative and post-operative care of the patients including prophylaxis of infection and thromboembolic diseases, management of medical conditions including effective communication with appropriate consultants, and discuss post-discharge disposition with social workers, allowing him to develop an awareness and responsiveness to the larger context of the healthcare delivery system. He will also learn the diagnosis and management of spinal emergencies such as cauda equina syndrome, epidural hematoma, and epidural abscess. EDUCATIONAL STRATEGY In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Lumbar Degenertive Pages Fritzell P, Hagg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group. Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter 1131-41 randomized study from the Swedish lumbar spine study group. Spine. 2002 Jun 1; 27(11) Fritzell P, Hagg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group. 2001 Volvo 2532-4 Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine. 2001 Dec 1; 26(23):2521-32; discussion Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. 1997 Volvo Award 2807-12 winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine. 1997 Dec 15;22(24) Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective 802-8 study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul; 73(6) Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: 102-8 the effects of fragment type and anular competence. J Bone Joint Surg Am. 2003 Jan; 85-A(1) Carragee EJ. Single-level posterolateral arthrodesis, with or without posterior decompression, for 1175-80 the treatment of isthmic spondylolisthesis in adults. A prospective, randomized study. J Bone Joint Surg Am. 1997 Aug; 79(8) Boden SD, Kang J, Sandhu H, Heller JG. Use of recombinant human bone morphogenetic 2662-73 protein-2 to achieve posterolateral lumbar spine fusion in humans: a prospective, randomized clinical pilot trial: 2002 Volvo Award in clinical studies. Spine. 2002 Dec 1; 27(23) Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of 403-8 the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am. 1990 Mar; 72(3) Borenstein DG, O'Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, 1306-11 Wiesel SW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: A seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep; 83-A (9) Cervical Degenerative Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Impact of smoking on the outcome 668-73 of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am. 2001 May; 83-A (5)

Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at 519-28 segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999 Apr; 81(4) Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis 941-51 for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am. 1998 Jul; 80(7) Vaccaro AR, Falatyn SP, Scuderi GJ, Eismont FJ, McGuire RA, Singh K, Garfin SR. Early failure of 410-5 long segment anterior cervical plate fixation. J Spinal Disord. 1998 Oct; 11(5) Wang JC, McDonough PW, Endow K, Kanim LE, Delamarter RB. The effect of cervical plating on 467-71 single-level anterior cervical discectomy and fusion. J Spinal Disord. 1999 Dec; 12(6) Dreyer SJ, Boden SD. Natural history of rheumatoid arthritis of the cervical spine. Clin Orthop. 98-106 1999 Sep; (366). Review Do Koh Y, Lim TH, Won You J, Eck J, An HS. A biomechanical comparison of modern anterior and 15-21 posterior plate fixation of the cervical spine. Spine. 2001 Jan 1; 26(1) Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of recurrent 2906-12 laryngeal nerve palsies during anterior cervical spine surgery. Spine. 2000 Nov 15; 25(22) DiAngelo DJ, Foley KT, Vossel KA, Rampersaud YR, Jansen TH. Anterior cervical plating reverses 783-95 load transfer through multilevel strut-grafts. Spine. 2000 Apr 1; 25(7) Brodke DS, Gollogly S, Alexander Mohr R, Nguyen BK, Dailey AT, Bachus aK. Dynamic cervical 1324-9 plates: biomechanical evaluation of load sharing and stiffness. Spine. 2001 Jun 15; 26(12) Trauma Wang JC, Hatch JD, Sandhu HS, Delamarter RB. Cervical flexion and extension radiographs in 111-6 acutely injured patients. Clin Orthop. 1999 Aug; (365) Brodke DS, Anderson PA, Newell DW, Grady MS, Chapman JR. Comparison of anterior and 229-35 posterior approaches in cervical spinal cord injuries. J Spinal Disord Tech. 2003 Jun; 16(3) Anderson PA, Bohlman HH. Anterior decompression and arthrodesis of the cervical spine: long- 683-92 term motor improvement. Part II--Improvement in complete traumatic quadriplegia. J Bone Joint Surg Am. 1992 Jun; 74(5) Bohlman HH, Anderson PA. Anterior decompression and arthrodesis of the cervical spine: long- 671-82 term motor improvement. Part I--Improvement in incomplete traumatic quadriparesis. J Bone Joint Surg Am. 1992 Jun; 74(5) Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic 1555-60 subluxation or dislocation of cervical facets. Case report. J Bone Joint Surg Am. 1991 Dec; 73(10) Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolumbar burst fractures. The clinical efficacy 955-70 and outcome of nonoperative management. Spine. 1993 Jun 15; 18(8) Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar "burst" fractures treated conservatively: a 33-8 long-term follow-up. Spine. 1988 Jan; 13(1) Pharmacological therapy after acute cervical spinal cord injury. Neurosurgery. 2002 Mar; 50(3 S63-72 Suppl). Review. MEDICAL KNOWLEDGE The resident will learn, through observation of and discussions with the attending staff , as well as through his reading (of required and recommended reading list), the diagnosis (including presentation, relevant history, physical examination findings, and interpretation of appropriate imaging studies), natural history, and treatment options (including non-operative and operative, as well as elaboration of the nature of operative treatment) of a wide variety of adult spinal disorders which encompass spinal stenosis, herniated nucleus pulposus, cervical spondylosis, spondylolisthesis, degenerative scoliosis as well as spinal tumors, infections, and traumatic disorders.

PRACTICE_BASED LEARNING AND IMPROVEMENT The resident will periodically be encouraged to conduct a literature search on an interesting topic encountered in clinical practice. The resident will also present complications on the Adult Spine Service at monthly Department Morbidity and Mortality Conference. As preparation for his presentation at the M&M Conference, the resident will conduct a literature search and gather the latest scientific findings pertaining to the topics of discussion. It is expected that he will critically analyze the findings in the literature and be able to apply the knowledge to patient management after discussion with the attending staff. INTERPERSONAL AND COMMUNICATION SKILLS PROFESSIONALISM SYSTEM-BASED PRACTICE Throughout the rotation, through close interaction with the resident, the attending staff will require that the resident possesses interpersonal and communication skills to interact effectively with patients, their families, and other health care workers in order to optimize patient care. The resident will also be held to a certain degree of professionalism in showing responsibility, diligence, respect of others, and responsiveness to the needs of the patients. Through his interactions with the attending staff, nurses and social workers, the resident will develop an awareness of and responsiveness to patient needs and cost-effective practice in the context of the complex health delivery system. COGNITIVE OUTCOMES After completing this rotation, the resident will be able to 1. Perform a thorough history and physicial exam of a patient with spinal pathology or complaints, including a comprehensive neurologic examination 2. Evaluate, diagnose, and manage patients with the following: - Degenerative conditions of the adult spine - Herniated Nucleus Pulposus - Spinal instability - Spinal trauma: lumbar, thoracic and cervical - Spinal stenosis - Spinal Infection – osteomyelitis, discitis, epidural abscess 3. Support and execute the preoperative preparation of patients undergoing spine surgery of the lumbar, thoracic or cervical spine; anterior or posterior 4. Support and execute the postoperative care and follow up for such patients, including identification and management of complications 5. Practice the principles of peri-operative patient protection and demonstrate an awareness of surgery associated safety issues 6. Construct a sophisticated knowledge base (sufficient to teach others, including education of patients) in: a. preoperative preparation, especially in consideration of existing comorbid factors b. operative procedure including pertinent anatomy and technical considerations c. cost-effective strategies for patient evaluation d. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. surgical decision-making principles

f. outcomes of spinal procedures, including spinal fusion, instrumentation, bone grafting and alternatives, decompression, and disc replacement 7. Evaluate periodical spine literature related to the patients’ health problems 8. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: - Put into practice self-directed learning habits - Demonstrate maturity and professional judgment in caring for patients - Demonstrate professional interpersonal skills with patients, family members, and other medical personnel - Show the ability to work in an orthopaedic care team - Demonstrate reliability and responsibility for patient care - Communicate the details of patient progress and complications to attending in a timely fashion - Judge when to seek available assistance from attending - Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique appropriate for each level under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of the pediatric orthopaedic patient 4. Record and demonstrate competency in performing or assisting various surgical procedures including: a) Spinal exposures b) Laminectomy and laminotomy c) Herniated disc removal d) Spinal fusion, including instrumentation e) Intertransverse fusion f) Placement of pedicle screws g) Placement of Halo jacket h) Placement of cervical tongs 5. Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a) Confirm and review pertinent history and physical findings with attending staff b) Review subjective and objective evidence of patient progress or complications with attending staff c) Review pertinent laboratory and imaging data with attending staff BASIC DUTIES, GOALS, AND OBJECTIVES The resident will 1. Gather essential information from the patient and available charts. The resident will demonstrate an ability to perform an adequate physical examination, including in depth neurologic exam. The

combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-2 resident will be able to formulate the treatment plan for patients with a. Degenerative conditions of the adult spine b. Herniated Nucleus Pulposus c. Spinal instability d. Spinal trauma: lumbar, thoracic and cervical e. Spinal stenosis f. Spinal Infection – osteomyelitis, discitis, epidural abscess 3. The resident will become competent in preparing patients for surgery in the operating room by assisting in patient set-up and draping in conjunction with the attending physician. 4. The resident will be able to perform simple orthopaedic surgical procedures such as placement of cervical tongs or halo. The PGY-2 will be able to perform the surgical exposure for many of the common procedures (bone grafting, posterior lumbar approach). 5. The resident will be able to satisfactorily manage post operative care in patients undergoing standard orthopaedic procedures a. Spinal exposures, anterior and posterior b. Laminectomy and laminotomy c. Herniated disc removal d. Spinal fusion, including instrumentation e. Intertransverse fusion f. Placement of pedicle screws g. Placement of Halo jacket h. Placement of cervical tongs 6. The PGY-2 resident will show appropriate respect and compassion to family needs concerning the patient’s progress, complications, and future plans for rehabilitation. REQUIREMENTS Residents are to assume the following responsibilities: - develop a personal program of self-study and professional growth - participate in 1 full day or 2 half days of patient care clinics per week - complete medical records promptly - document duty hours - document all procedures in the ACGME Surgical Operative Log - monitor themselves for fatigue - dress professionally, as each resident represents both the department and the attending physicians - participate in effective and compassionate patient care - organize M&M reports - provide a formal educational forum for medical students and junior staff at least once a week - complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION

- Evaluate residents’ clinical performance and professionalism by having attendings complete the Orthopaedic Surgery Department Resident Performance evaluation. - Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. - Review residents’ lists of procedures (SOL) at least every 6 months by Program Director. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Sports Medicine Rotation Goals and Objectives GOAL: The Orthopaedic Sports Medicine rotation is designed to provide the resident with an understanding of the evaluation and treatment of patients with sports related musculoskeletal injuries. The orthopaedic surgery resident will be educated in a sports oriented practice, which includes shoulder, knee, foot/ankle, wrist, elbow and spine injuries. Residents will gain skills and knowledge regarding the diagnosis, operative care and post-operative rehabilitation of patients with sports related injuries. Educational objectives will be accomplished through clinical experience and didactic lectures. EDUCATIONAL STRATEGY It is a ten-week course designed for the PGY-4 level resident. The resident will attend weekly didactic sessions including: lectures, radiology conferences, journal club and chapter review. Suggested reading assignments for the rotation: Delee & Drez Orthopaedic Sports Medicine, 2nd ed. Chapter 1 Basic Science and Injury of Muscle, Tendon, and Ligaments Section A & B ppg 1-49 Chapter 2 Basic Science and Injury of Muscle, Tendon, and Ligaments Section A-C, ppg. 67-119 Chapter 6 Surgical Principles Section E-G, ppg. 205-237 Chapter 13 The Female Athlete ppg 505-520 Chapter 16 Imaging of Sports-related Injuries, ppg 557-595 Chapter 17 section H Physeal Injuries in Young Athletes, ppg 712-729 Chapter 20 Cervical Spine, ppg. 791-827 Chapter 21 Shoulder Functional Anatomy and Biomechanics of the Adult Shoulder, Section A ppg 841-855, Section J Glenohumeral Instability in the Adult, ppg 1020-1033 Section K Superior Labral Injuries, ppg 1046-1062 Section L Rotator Cuff and Impingement ppg. 1065-1090 Section N Nerve lesion of the Shoulder, ppg 1154-1161 Chapter 23 Elbow Section C Throwing Injuries ppg 1236-1249 Chapter 28 Knee Section D Meniscal Injuries in the adult ppg 1668-1685 Section E Patellofemoral joint, ppg 1697 Section H Medial Ligament Injuries, ppg 1937 Section I Lateral and Posterior Instabilities of the Knee, ppg 1968

COGNITIVE AND PSYCHOMOTOR OUTCOMES 1. Demonstrate an understanding of the basic underlying scientific principles and theories pertinent to Sports Medicine. a. Pathophysiology and healing of musculoskeletal tissues b. Biomechanical considerations for the knee and shoulder 2. Gain in-depth understanding gross anatomy of the knee, shoulder a. Understand pathoanatomy of the most common knee, shoulder 3. Recognize the importance of epidemiology as well as some of the preventative issues in specific sports injuries 4. Identify important issues related to the female athlete 5. Develop clinical history taking skills with emphasis on sports-related injuries both chronic and acute in pediatric and adult patients 6. Develop basic physical examination techniques for both acute and chronic injuries of the knee and shoulder a. Recognize specific exam maneuvers of the knee and shoulder and identify the clinical significance and associated pathoanatomy 7. Demonstrate comprehensive history-taking and physical exam skills for the evaluation of knee and shoulder injuries 8. Become familiar with the clinical findings and diagnosis of glenohumeral instability 9. Develop diagnostic skills and management strategies for common knee maladies: a. Meniscus Injuries b. Patellar instability c. Articular Cartilage injuries d. Medial Ligament injuries e. Lateral collateral and posterolateral knee instability 10.Understand diagnosis and treatment strategies for acute and chronic ligamentous ankle injuries 11.Recognize the common knee and shoulder injuries seen in adolescent and pediatric sports medicine a. Discoid meniscus b. Physeal Injuries 12.Develop an understanding of normal radiographic anatomy of the knee and shoulder 13.Recognize normal MRI anatomy of the shoulder and knee a. Identify pathoanatomy (MRI and Roentengrams) of the knee, shoulder and foot/ankle in common sports-related injuries 14.Gain an understanding of the assessment of on-field sports injuries with particular emphasis on closed head trauma and cervical injuries 15.Understand the non-operative treatment of common knee and shoulder sports injuries both acute and chronic 16.Identify surgical indications for common shoulder and knee sports-related injuries acute and chronic a. Rotator cuff injuries b. Glenohumeral instability c. ACL injuries d. PCL Tears e. Meniscal Injuries

f. Extensor alignment 17.Gain exposure to some of the reconstructive techniques for common knee and shoulder injuries (ACL reconstruction, rotator cuff repair, shoulder instability 18.Gain appreciation of basic arthroscopic knee and shoulder techniques 19.Resident will demonstrate basic skills for arthroscopic knee and shoulder a. Set-up b. Portal placement 20.Gain a general understanding of the post-operative rehabilitation for the most common Knee and shoulder surgeries a. ACL Reconstruction b. Meniscal surgery, repair and debridement c. Rotator Cuff Repair d. Glenohumeral stabilization BASIC DUTIES, GOALS, AND OBJECTIVES PGY-4 Resident 1. Residents are assigned to specific sports medicine faculty for a focus of study of a specific body part (i.e. shoulder, knee). 2. The resident will accompany the staff during office/clinic and surgery for a “one-on-one” learning experience. 3. Residents will rotate with specific faculty lasting approximately 4-5 weeks to ensure a continuity of care of patients. 4. Residents will conduct comprehensive history and physical examinations on patients with sports-related musculoskeletal injuries. 5. Based upon preliminary information, the resident will work with the faculty to make decisions about diagnostic and treatment approaches. The resident will begin formulating differential diagnoses and treatment plans on their own and then present those to the attending staff. 6. While on the orthopaedic sports medicine rotation, the resident will be engaged in all facets of patient care including: initial encounter assessment (on-field and clinic), peri-operative and post-operative management. 7. The PGY-4 resident will develop a basic arthroscopic skill set for knee and shoulder surgery (set-up, portal placement, basic diagnostic evaluation. 8. PGY-4 Residents must maintain good professional relations with ancillary staff and external health care professionals. REQUIREMENTS Residents are to assume the following responsibilities: 1. Develop self-study program 2. Participate in office and operative days with the assigned faculty 3. Document duty hours 4. Document all procedures in the ACGME Surgical Operative Log 5. Dress professionally 6. Participate in effective and compassionate patient care 7. Complete evaluation forms for rotation and for documents requested at the conclusion of each rotation

EVALUATION The resident will be evaluated based upon professionalism, communication skills, patient care, and medical knowledge. An evaluation process will take place with each faculty member involved with the rotating resident. Faculty Supervision The resident will perform a primary assessment of patients within the clinic setting. Both the faculty and resident work together to assimilate the patient data and develop an appropriate treatment plan. The resident’s ability to synthesize patient data and formulate a rational treatment plan is continually assessed by the faculty. The resident will assume progressive operative responsibility according to their level of experience and skill. The degree of supervision will vary with the level of training and knowledge of the individual resident’s experience, ability and technical skills.

Trauma Rotation Goals and Objectives PGY-5, PGY-4, PGY-3, PGY-2 Wishard Hospital is the Level I Trauma Center associated with Indiana University Medical School and is home to the second busiest Emergency Department in the U.S. This rotation provides the residents with both a busy and complex trauma experience, as well as a wide variety of general orthopaedic problems. At present, over 1000 surgeries are performed annually with 300 weekly clinic visits. At present, there are three General Orthopaedic Clinics weekly, along with a large Adult Trauma Clinic. Subspecialty clinics in Pediatric Trauma, Hand, Shoulder and Arthritis/Arthroplasty also exist. The overall leadership of the center is provided by Dr. Jeff Anglen, an Orthopaedic Traumatologist who staffs the majority of the complex trauma cases, as well as traumatic reconstructions. In addition, Dr. Brian Mullis is a fellowship trained orthopaedic traumatologist working mostly at Wishard beginning in September 2006. Expertise in subspecialty areas for clinical and surgical experience is provided by Dr. Alexander Mih (Hand) along with one fellow from the Indiana Hand Center, Dr. Andrew Parr (Arthroplasty), Dr. Steven Trippel (Arthritis), Dr. Randall Loder and Dr. John Lubicky (Pediatric Trauma and Pediatric Orthopaedics), Dr. Daniel Wurtz (Tumor and General Orthopaedics) and Dr. Gregory Gilot (Shoulder), and Dr. Dominique Nickson (Foot and Ankle). The Wishard team comprises one resident from each of the PGY-2, 3, 4 and 5 levels. The PGY-5 serves as leader for the team. In all, each resident will complete a total of four, 10-week rotations at Wishard Hospital during their residency. Additionally, one to four medical students are normally rotating at Wishard. The surgical experience currently consists of approximately 50% acute trauma, 25% general orthopaedics (including total joint arthroplasty, arthroscopy and foot and ankle), 5% hand surgery (both trauma and nontraumatic disorders), 15% trauma reconstruction (non-unions, malunions and osteomyelitis) and 5% amputations. The trauma experience provides both excellent volume and complexity of cases, including a large number of peri-articular fractures (supracondylar femur, tibial plateau and pilon), pelvic and acetabular fractures, complex upper extremity trauma, foot trauma, multiply injured patients and a unique experience in complex soft tissue injury treatment. EDUCATIONAL STRATEGY The duration of the Wishard Orthopaedic rotation is 10 weeks for each PGY2, 3, 4, and 5 level resident. Residents are assigned to one team. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: 1. Textbooks a. PGY2&3 i. Skeletal Trauma, edited by Browner, Jupiter, Levine and Trafton, WB Saunders Co., Philadelphia, most recent edition ii. Fractures in Adults and Children edited by Rockwood, Green and Bucholz, Lippincott Co., most recent edition

iii. AO Principles of Fracture Management, edited by Ruedi and Murphey, AO Publishing, Davos, most recent edition iv. Surgical Exposures in Orthopaedics, Hoppenfeld b. PGY4&5 i. Orthopaedic Knowledge Update – Trauma, AAOS, most recent edition ii. Fractures of the Acetabulum, Judet and Letournel, Springer-Verlag iii. Rationale of Operative Fracture treatment, Shatzker and Tile, Springer-Verlag iv. Planning and Reduction Technique in Fracture Surgery, Mast, Jakob, Ganz, springer-Verlag 2. Journals a. Journal of Orthopaedic Trauma (each month) b. Journal of bone and Joint Surgery (selected articles) c. Journal of Trauma, Infection and Critical Care (selected articles) d. Journal of the AAOS (selected articles) 3. Other a. Orthopaedic Knowledge Online – Trauma topics b. OTA website – resident lectures c. Collected trauma articles from JAAOS COGNITIVE OUTCOMES 1. After completing this rotation, residents will be able to: a. Evaluate, diagnose, and manage patients with the following: b. Common fractures of the spine, pelvis and extremities c. Open wounds d. Acute and chronic musculoskeletal infection e. Posttraumatic complications such as nonunion, delayed union, malunion, arthritis f. Common general orthopaedic complaints in an urban low income 2. Support and execute the preoperative preparation of each patient 3. Support and execute the postoperative care and follow up for each patient 4. Construct a sophisticated knowledge base (sufficient to teach others) in: a. Preoperative preparation, especially in consideration of existing comorbid factors b. Operative procedure including pertinent anatomy and technical considerations c. Cost-effective strategies for patient evaluation d. Management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure e. Surgical decision-making principles 5. Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 6. Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Show the ability to work in a orthopaedic care team 5. Demonstrate reliability and responsibility for patient care

6. Communicate the details of patient progress and complications to attending in a timely fashion 7. Judge when to seek available assistance from attending 8. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1) Show appropriate written documentation skills, especially with consult information 2) Demonstrate surgical technique appropriate for each level under supervision of attending 3) Interpret radiologic studies that are common in the evaluation of the pediatric orthopaedic patient 4) Record and demonstrate competency in performing various surgical procedures including: a) fractures, both closed and open reductions b) nonunion or malunion c) infection, including septic arthritis and osteomyelitis d) common general orthopaedic procedures such as arthroscopy, arthroplasty, etc. 5) Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a) Confirm and review pertinent history and physical findings with other residents and attending staff b) Review subjective and objective evidence of patient progress or complications with other residents and attending staff c) Review pertinent laboratory and imaging data with other residents and attending staff d) Modify as needed, patient care plans developed by the junior resident e) Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of orthopaedic patients BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR Goals and Objectives for the PGY-2 Resident 1. The PGY-2 resident will gather essential information from patients, families and other members of the trauma team, as well as information from charts, plain radiographs, CT scans, MRI and other investigations to allow in understanding the patient’s needs for orthopaedic care. 2. The PGY-2 resident will demonstrate the ability to perform adequate physical examination of all joints of the body, as well as detailed examination of extremity neurological and vascular function. Complete evaluation of the trauma patient, including spine examination, evaluation of soft tissue wounds and open fractures, and evaluation of pelvic stability is required in both pediatric and adult patients. 3. The PGY-2 resident will formulate a treatment plan for common orthopaedic problems including osteoarthritis of the knee and hip, meniscal disorders and ligament injuries of the knee, and common hand disorders, including carpal tunnel syndrome, trigger fingers, tendon ruptures and infection. The resident will be expected to obtain the appropriate history and perform an accurate physical examination of the above conditions.

4. The PGY-2 resident will become competent in preparing the trauma patient for surgery. This will include appropriate preoperative laboratory evaluation, assessment of transfusion needs, evaluation of the patient’s appropriateness for positioning (for example, patients with concomitant C-spine injury to be positioned lateral or prone), and assessment of nutritional status. The resident will also become competent in positioning patients for fracture care, including prone and lateral decubitus positioning. 5. The PGY-2 resident will be able to perform closed reduction (including administration of a hematoma block where appropriate) of distal radius fractures and ankle fractures. In the pediatric population, closed reduction of forearm and tibia fractures will also be expected with supervision from senior residents and staff. 6. The PGY-2 resident will prepare a written pre-operative plan for all operative cases that they attend which will include templating. This will be done with the assistance of senior residents and staff 7. The PGY-2 resident will be able to perform simple operative techniques including suturing, operation of drills, insertion of screws. 8. The PGY-2 resident will be able to understand the principles of 2-stage management of complex periarticular fractures and be able to apply both knee spanning and ankle spanning external fixation. 9. The PGY-2 resident will be able to satisfactorily manage the post operative care of the trauma patient, with the assistance of senior members of the team. This will include evaluations of traumatic wounds for infection, surveillance for compartment syndrome, accurate and detailed neurological and vascular examinations, and evaluations of laboratory values. 10.The PGY-2 resident will be expected to achieve the score of 50% correct answers on the trauma portion of the OITE. Goals and Objectives for the PGY-3 Resident In addition to satisfactory completion of all of the above PGY-2 rotation objectives: 1. The PGY-3 resident will formulate a treatment plan for common traumatic injuries including fractures of the distal radius, both bone forearm, olecranon, humerus, femur (neck, intertrochanteric, shaft and supracondylar regions), and tibia (plateau, shaft and plafond regions). This will include the preparation of a preoperative plan (both diagrams and written surgical plan) for all trauma cases that are booked 24 hours in advance. For cases proceeding to the OR with less than 24 hours notice, the PGY-3 resident will provide a verbal plan during the morning planning conference on the day of surgery. 2. The PGY-3 resident will be able to perform operative management (including ORIF and IM nailing) of fractures of the ankle, tibial shaft, femoral shaft, intertrochanteric femur, humeral shaft and both bone forearm. The resident will also be able to appropriately debride traumatic wounds (a key learning point on this rotation). The resident will be able to perform spit thickness skin grafting.

3. The PGY-3 resident will function as liaison to the General Surgery Trauma Team and will be able to appropriately manage complex orthopaedic issues in the multiply injured patient (with staff guidance). For example, the PGY-3 resident will understand the principles of anticoagulation in the trauma patient. 4. The PGY-3 resident will be understand and implement appropriate post operative rehabilitation in patients with traumatic injuries. 5. The PGY-3 resident will be expected to achieve the score of 60% correct answers on the trauma portion of the OITE. Goals and Objectives for the PGY-4 Resident In addition to satisfactory completion of all of the above PGY-3 rotation objectives: 1. The PGY-4 resident will formulate a treatment plan for complex orthopaedic trauma patients including the multiply injured patient, complex peri-articular fractures (including timing of staged procedures), acetabular fractures, complex foot fractures etc. 2. The PGY-4 resident will be able to perform operative management of tibial plateau fractures, simple pilon fractures, distal humerus fractures and complex distal radius fractures. The resident will also develop the ability to manage complex soft tissue wounds including de- gloving injuries, massive soft tissue loss and the mangled extremity. 3. The PGY-4 resident will be able to independently plan the post operative rehabilitation plan for all trauma patients 4. The PGY-4 resident will be expected to achieve the score of 70% correct answers on the trauma portion of the OITE. Goals and Objectives for the PGY-5 Resident In addition to satisfactory completion of all of the above PGY-4 rotation objectives: 1. The PGY-5 resident will provide leadership for the team including running of the morning planning conference, ensuring appropriate resident coverage for all clinical activities each day, overseeing the on-ward patient care and providing liaison with staff regarding all of the above. 2. The PGY-5 resident will formulate a treatment plan for the most complex trauma patients including multiply injured patients, pelvic ring fractures, complex acetabular and foot fractures as well as the mangled extremity. The treatment plan will include, not only an operative plan, but will encompass all aspects of the patients care including pre-operative and post-operative management. In other words, the resident will provide a comprehensive plan for all aspects of the trauma patient care from admission to discharge. 3. The PGY-5 resident will be completely able to perform all surgical approaches for fracture care of any bone, with the exception of the spine and the anterior approach to the acetabulum. In addition to all previously described surgical procedures, the PGY-5 resident will be able to perform ORIF of the posterior wall of the acetabulum, calcaneus, talus, Lisfranc joint,

supracondylar humerus and the radial head. The resident will also demonstrate mastery of advanced trauma techniques including minimally invasive/percutaneus plating, handling of traumatized soft tissues and indirect reduction. The resident will also have command of an array of soft tissue management strategies and understand their indications including use of antibiotic beads, composite bone grafting, the “Wound Vac” system and STSG. 4. The PGY-5 resident will keep track of all complications occurring on the service and will present all of these, along with an appropriate review of the literature, twice during the 10 week rotation. 5. The PGY-5 resident will be responsible for the selection and presentation of cases at the weekly Fracture Conference and will be able to lead the discussion on the chosen topic. 6. The PGY-5 resident will be expected to achieve the score of 80% correct answers on the trauma portion of the OITE. The above objectives collectively address the General Competencies of Patient Care, Medical Knowledge and Practice Based Learning. The remaining competencies are addressed as follows: Interpersonal and Communication Skills The residents play an intricate part in the daily patient management, from admission through the ER, to daily rounds to follow up care in the clinic. The residents also interact both formally (at weekly Interdisciplinary Planning Conference) and informally with a wide variety of subspecialties and para- medical personal. Superb communication skills are expected as the Wishard service is extremely busy, patients are complex, multiple social issues complicate planning and patients are frequently wholly unprepared for their traumatic injuries. A further challenge exists at Wishard, which serves as the County Hospital providing care to the indigent. Particular sensitivity to the needs of the less fortunate are required and expected. An array of language barriers are also frequently encountered and require the effective use of translators. The resident is closely evaluated on his/her ability to communicate effectively and respectfully with patients, staff and colleagues. Professionalism Each resident is expected to behave at all times in a manner appropriate for a health care professional. This requires appropriate personal behavior including promptness, courtesy to all patients, staff and other physicians, appropriate phone etiquette, and modestly. The residents are also required to dress appropriately for the clinic in a professional manner. All residents are expected to attend to medical records documentation in a very timely fashion and all operative reports must be dictated within 24 hours of the procedure. Systems Based Practice The residents on the trauma service are required to become proficient in the operation of several form of information technology. The “Gopher” computer system is used for all patient data from obtaining laboratory values to researching past medical records. The residents will become proficient at the interpretation of the digitalized radiographic images on the PACS system. The residents will be familiar with the dictation system for all reports including clinic notes, discharge summaries and operative notes. HIPPA guidelines will be followed at all times.

REQUIREMENTS Residents are to assume the following responsibilities: 2. develop a personal program of self-study and professional growth 3. participate in 1 full day or 2 half days of patient care clinics per week 4. complete medical records promptly 5. document duty hours 6. document all procedures in the ACGME Surgical Operative Log 7. monitor themselves for fatigue 8. dress professionally, as each resident represents both the department and the attending physicians 9. participate in effective and compassionate patient care 10. organize M&M reports 11. provide a formal educational forum for medical students and junior staff at least once a week 12. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attendings complete the online Surgery Department Resident Performance evaluation. 2. Evaluate residents’ teaching, time management skills, professionalism, communication skills, patient care, and medical knowledge by having peers complete an evaluation after each rotation. 3. Review faculty, and peer evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 4. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director and Medical Educator. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Trauma Rotation Scrub Policy Pants and tie (and equivalent for women) to be worn in clinics, unless the resident is likely to be needed in the OR or ED. If scrubs are worn, a white coat is to be worn over scrubs throughout the hospital (Clinic, ED, floor, etc.).

Upper Extremity Rotation PGY-5 GOAL: The upper extremity rotation is a comprehensive course designed to introduce orthopaedic surgery residents into all aspects of the evaluation and treatment of patients with problems involving the upper extremity. This includes the brachial plexus, shoulder, upper arm, elbow, forearm, wrist and hand. The rotation will include the principles of diagnosis, the treatment of all disorders involving the upper extremity including congenital, degenerative, traumatic and overuse syndromes. This course is designed as a ten-week rotation for residents at the PGY-3 level. The course will also allow for attendance at the numerous upper extremity conferences that currently take place. EDUCATIONAL STRATEGY The duration of the Upper Extremity rotation is 10 weeks for each PGY-5 level resident. In addition to partaking in this rotation residents participate in teaching conferences. Suggested reading assignments to improve patient care and knowledge base for this rotation: Thumb Carpometacarpal Arthrosis Reconstruction of Distal Radioulnar Joint Instability Steven D. Young, MD and Elizabeth A. Mikola, MD Mark H. Henry, MD, Dean W. Smith, MD and Maroos V. Masson, MD Nerve Conduction Studies in Hand Surgery Low Ulnar Nerve Palsy David J. Slutsky, MD, FRCS(C) Charles A. Goldfarb, MD and Peter J. Stern, MD Dupuytren’s Disease Obstetric Brachial Plexus Injuries Thomas B. Hughes, Jr., MD, Anthony Mechrefe, MD, J. Mohammad M. Al-Qattan, FRCSC William Littler, MD and Edward Akelman, MD Metacarpal Fractures Congenital Hand Anomalies: Principles of Management Loryn P. Weinstein, MD and Douglas P. Hanel, MD Leung Kim Hung, MBBS, Mch(Ortho), FRCS Ed Ortho, FHKAM(Orth), Ping-Chung Leung, DSc, MBBS, MS, FRACS,FRCS (Edin), FHKCOS, FHKAM(Orth), and Margaret-Wan Na Wong, MBBS, FRCS(Ed), FCSHK, FHKCOS, FHKAM(Orth) Fractures of the Carpal Bones Excluding the Scaphoid Ganglion Cysts of the Wrist Muhir A. Shah, MD and Steven F. Viegas, MD Phil Minotti, MD and John S. Taras, MD Flexor Tendon Repair Proximal Row Carpectomy John Gray Seiler III, MD James H. Calandruccio, MD Nonobstetric Brachial Plexus Injuries Syndactyly IMatthew M. Tomaino, MD Scott H. Kozin, MD Scapholunate Instability Scott W. Wolfe, MD COGNITIVE OUTCOMES After completing this rotation, residents will be able to: 1) Evaluate, diagnose, and manage patients with the following: - Peripheral nerve compression - Hand/wrist ganglia

- Degenerative disease of basilar TMB joint - Hand and wrist fractures - Wrist degenerative disease - Wrist ligament injury - Flexor tendon injury, extensor tendon injury - Brachial plexus injuries 2) Support and execute the preoperative preparation of each patient 3) Support and execute the postoperative care and follow up for each patient 4) Construct a sophisticated knowledge base (sufficient to teach others) in: a) preoperative preparation, especially in consideration of existing comorbid factors b) operative procedure including pertinent anatomy and technical considerations c) cost-effective strategies for patient evaluation a. management of post-op care considering comorbid factors, basic disease process, and conduct of the procedure b. surgical decision-making principles 5) Evaluate periodical orthopaedic surgical literature related to the patients’ health problems 6) Demonstrate the ability to execute care for patients on the service on a day-to-day basis AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1) Put into practice self-directed learning habits 2) Demonstrate maturity and professional judgment in caring for patients 3) Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4) Show the ability to work in an orthopaedic care team 5) Demonstrate reliability and responsibility for patient care 6) Communicate the details of patient progress and complications to attending in a timely fashion 7) Judge when to seek available assistance from attending 8) Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1) Show appropriate written documentation skills, especially with consult information 2) Demonstrate surgical technique under supervision of attending 3) Interpret radiologic studies that are common in the evaluation of the orthopaedic patient 4) Record and demonstrate competency in performing various surgical procedures including: a) mass excision b) fracture fixation c) management and treatment of compressive neuropathy d) degenerative conditions e) joint replacement 5) Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a) Confirm and review pertinent history and physical findings with attending staff b) Review subjective and objective evidence of patient progress or complications with attending staff

c) Review pertinent laboratory and imaging data with attending staff d) Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of pediatric orthopaedic patients BASIC DUTIES, GOALS, AND OBJECTIVES 1) The PGY-5 resident will successfully manage the Upper Extremity Inpatient Service. He/she will create an environment of professional relationships with other medical services and personnel, and intervene when such an environment is in need of repair. He/she will ensure harmonious relations with the patient and family. 2) The PGY-5 resident is responsible for monitoring complications and reporting them to the monthly Morbidity and Mortality meeting. 3) The PGY-5 resident will be able to independently evaluate patients with common upper extremity problems such as fracture, compressive neuropathy, degenerative disease and congenital abnormality, formulate treatment plans, and carry out treatment, both operative and non-operative, in concert with the attending staff. REQUIREMENTS Residents are to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in 1 full day or 2 half days of patient care clinics per week 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. organize M&M reports 10. provide a formal educational forum for medical students and junior staff at least once a week 11. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attending complete the Orthopaedic Department Resident Performance evaluation. 2. Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 3. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of

patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

Upper Extremity Rotation Scrub Policy Residents should wear a tie with or without white coat while seeing patients in the office. OR attire should not be worn outside of the immediate OR area except in emergent circumstances.

VA Rotation Goals & Objectives PGY 2, 3 & 5 GOAL: The VA Hospital associated with Indiana University Medical School affords orthopaedic residents the opportunity to manage a large number of adult patients with multiple types of orthopaedic problems. Currently, approximately 650 to 700 orthopaedic surgeries per year are performed and 250-300 patients are seen in the clinic per week. Two large General Orthopaedic clinics occur weekly, and there are subspecialty clinics devoted to hand surgery, and foot and ankle surgery that meet from weekly to monthly. The overall leadership is provided by Dr. Mark Webster who staffs most of the cases. Staffing is also done by Dr. Russell Meldrum, Dr. Stephen Trippel, Dr. Drew Parr and Dr. Dominique Nickson. There is one resident from the PGY-2 level, one resident from the PGY-3 level, and one from the PGY- 5 level. In addition, through most of the year we have two to four medical students rotating through the service. There is a large surgical experience in total joint arthroplasty including large numbers of hips and knees and a reasonable number of shoulder replacements. In addition, there is a reasonable experience in revision surgery in all these areas. There is additional large experience in shoulder surgery and knee arthroscopy mainly for meniscal type lesions as well as extremity and diaphyseal trauma. EDUCATIONAL STRATEGY The acquisition of knowledge is mainly resident driven and is mainly in preparation for clinic and surgical cases. To do this the resident will demonstrate an ability to know what entails and perform adequate physical examination of shoulders, knees, hips, feet, and hands after evaluating multiple patients in the General Orthopaedic Clinic and specialty clinics and presenting his findings to the attending staff. SUGGESTED READING ASSIGNMENTS Surgery of the Knee, Third Edition, Vol. 1, The Adult Hip, Volume 1, Chapter 75 Chapter 51, p. 829 Pages: Pages: History and Physical Examination of the Hip Ch. 22, p. 315 Basic Biomechanics p. 215 Arthroscopic Meniscal Repair Ch. 25, Radiographic Evaluation of Ch. 23, p. 333 p 521 the Hip Nonoperative Treatment of Knee Arthritis Ch. 28, Surgical Parts of the Hip Ch. 42, p. 663 p. 565 Medial and Lateral Ligament Injuries of the Ch. 32, Arthrodesis Ch. 45, p. 749 Knee p. 651 Anterior Cruciate Ligament Reconstructive Ch. 33, Osteotomy, An Overview Ch. 46, p. 761 with Patellar Tendon Graft p.657 Anterior Cruciate Ligament Reconstruction Ch. 34, Proximal Femoral Ch. 47, pl. 775 with Bone–Patella Tendon-Bone Autograft: p. 665 Osteotomy

Indications, Technique, Complications, and Management Disorders of the Patellofemoral Joint Ch. 46, Overview of Total Hip Ch. 51, p. p. 913 Arthroplasty Unicompartmental Total Knee Arthroplasty Ch. 75, Preoperative Planning Ch. 58, p. 925 p. 1621 Results of Posterior Cruciate-Preserving Ch. 76, General Principles of Ch. 59, p. 951 Total Knee Arthroplasty p. 1629 Surgical Technique Total Knee Arthroplasty with Posterior Ch. 77, Cruciate Ligament Substitution p. 1660 The Shoulder, Vol. 1 Pages: Clinical Evalulation of Ch. 4, p. 149 Shoulder Problems Biomechanics of the Ch. 6, p. 208 Shoulder Fractures of the Proximal Ch. 9, p. 270 Humerus Disorders of the AC Joint Ch. 12, p. 413 Subacromial Impingement Ch. 15, p. 623 The Shoulder and Supports Ch. 26,p. 961 COGNITIVE OUTCOMES The resident will be able to: 1. formulate the treatment plan for patients with common shoulder problems (impingement, AC degeneration, rotator cuff tears) 2. knee disorders (meniscal injuries, patellofemoral disorders, and various arthritides) 3. hip disorders (all hip fractures, arthritides of the hip) and 4. common hand disorders (carpal tunnel, simple fractures, infections), After evaluating patients with these conditions in the clinic or in the Emergency Room and discussing with various staff members. 1. The resident will become confident in preparing patients in the operating room for total joint arthroplasty, shoulder surgery, and knee arthroscopy by observing senior residents and staff, and then doing preparations themselves. 2. During the rotation the resident will plan and research the upcoming cases to be done and assigned commensurate to the level of training. This will include the relevant procedure, their techniques, indications and contraindications. The Veterans administration hospital system affords each of the residents the opportunity to be proficient residents are required to be proficient with the computerized methods for lab retrieval, note taking, physician orders imaging retrial in computer intranet that interfaces with many of the VA web based systems serving several clinics and hospital in our “VISN” area that covers central Indiana and Illinois. The resident will review the established surgical computer database verifying accuracy and inputting follow up data concerning joint arthroplasties and fracture cases.

AFFECTIVE OUTCOMES After completing this rotation, residents will be able to: 1. Put into practice self-directed learning habits 2. Demonstrate maturity and professional judgment in caring for patients 3. Demonstrate professional interpersonal skills with patients, family members, and other medical personnel 4. Show the ability to work in an orthopaedic care team 5. Demonstrate reliability and responsibility for patient care 6. Communicate the details of patient progress and complications to attending in a timely fashion 7. Judge when to seek available assistance from attending 8. Counsel as to the risks and benefits of surgery as well as expectations and alternatives to surgery PSYCHOMOTOR OUTCOMES After completing this rotation, residents will be able to: 1. Show appropriate written documentation skills, especially with consult information 2. Demonstrate surgical technique appropriate for each level under supervision of attending 3. Interpret radiologic studies that are common in the evaluation of the orthopaedic patient 4. Record and demonstrate competency in performing various surgical procedures including: a. fractures, both closed and open reductions b. hip disorders c. surgical care of septic arthritis and osteomyelitis 5. Demonstrate teaching skills essential for creating an excellent learning environment for the team including: a. Confirm and review pertinent history and physical findings with other residents and attending staff b. Review subjective and objective evidence of patient progress or complications with other residents and attending staff c. Review pertinent laboratory and imaging data with other residents and attending staff d. Modify as needed, patient care plans developed by the junior resident e. Educate medical students in basic orthopaedic disorders, and the conduct of pre, intra, and postoperative care of orthopaedic patients BASIC DUTIES, GOALS, AND OBJECTIVES BY PG YEAR PGY- 2 Resident will 1. Gather essential information from the patient, available charts. The resident will demonstrate an ability to perform an adequate physical examination of the patient, including observation of gait. The combination of the history and physical examination information will then allow the resident to present his/her findings to the attending staff. 2. After discussion with the attending staff, the PGY-2 resident will be able to formulate the treatment plan. 3. The PGY-2 resident will become competent in preparing patients for surgery in the operating room by assisting in patient set-up and draping in conjunction with more senior residents and/or the attending physician. 4. The PGY-2 resident will be able to perform simple orthopaedic surgical procedures. The PGY-2 will be able to perform the surgical exposure for many of the common procedures.

5. The PGY-2 resident will be able to satisfactorily manage post operative care in patients undergoing orthopaedic procedures. 6. The PGY-2 resident will show appropriate respect and compassion to the patient and families concerning progress, complications, and future plans for rehabilitation. PGY- 3 Resident will Having successfully completed the PGY-2 rotation, the 1. PGY-3 resident will continue to improve their skills in obtaining historical and physical examination information. They will be able to begin formulating differential diagnoses and treatment plans on their own and then present those to the attending staff. 2. PGY-3 resident will become involved in education of medical students and the PGY-2 resident. 3. The PGY-3 will become proficient in common surgical procedures, and begin to learn the techniques of more advanced skills. PGY-5 Resident will After successfully completing the PGY-2 and 3 rotations 1. The PGY-5 resident will successfully manage the VA Orthopaedic Service by overseeing the PGY-2 and 3 residents. He/she will coordinate daily schedules for all residents and medical students on the rotation. He/she will create an environment of professional relationships with other medical services and personnel, and intervene when such an environment is in need of repair. He/she will ensure harmonious relations with the patients and families. 2. The PGY-5 resident is responsible for monitoring complications and reporting them to the monthly Morbidity and Mortality meeting. 3. The PGY-5 resident will be able to independently formulate treatment plans, and carry out treatment, both operative and non-operative, in concert with the attending staff. REQUIREMENTS Residents are to assume the following responsibilities: 1. develop a personal program of self-study and professional growth 2. participate in 1 full day or 2 half days of patient care clinics per week 3. complete medical records promptly 4. document duty hours 5. document all procedures in the ACGME Surgical Operative Log 6. monitor themselves for fatigue 7. dress professionally, as each resident represents both the department and the attending physicians 8. participate in effective and compassionate patient care 9. organize M&M reports 10. provide a formal educational forum for medical students and junior staff at least once a week 11. complete evaluation forms for rotation and for documents requested at the conclusion of each rotation EVALUATION 1. Evaluate residents’ clinical performance and professionalism by having attendings complete the Orthopaedic Surgery Department Resident Performance evaluation.

2. Review faculty evaluations with the residents at least every six months with the Program Director. Residents receiving multiple or repetitive check marks indicating problem areas must undergo remediation. 3. Review residents’ lists of procedures (SOL) at least every 6 months by Program Director. Chain of Command and Faculty Supervision: Patient care is provided using an academic model with a resident team comprised of junior level residents and medical students led by a chief resident. The team cares for all patients, making daily rounds both independently and with faculty supervision. Residents perform primary assessment of patients prior to surgery and assume progressive operative responsibility according to their level of experience and skill. Delegation of responsibility is made by the responsible attending faculty and chief resident. The degree of supervision varies with the level of training and knowledge of the individual resident’s experience, ability, and technical skills. Senior residents may act as teaching assistants to junior residents for certain types of cases; however, attending faculty are always present and/or immediately available at each institution including nights, weekends, and holidays based on 24-hour on-call schedules. Faculty supervision is required for all operative cases. The attending faculty is ultimately responsible for both the legal and ethical decision-making and the overall care and for supervision of the residents. Although sometimes difficult to master, faculty should strive to balance supervision in a manner that does not conflict with development of resident confidence, accountability, and independent decision-making.

V.A. Rotation Scrub Policy It is OK for the residents to wear scrubs at the VA for clinic, in the OR and for rounds.

Administrative Procedures

Professional Demeanor and Appearance It is expected that the demeanor and personal appearance of the resident will reflect quality professionalism and pride in all the roles in which the resident finds him/herself. In addition to the resident’s clinical skills and technical abilities, the manner in which he/she “presents” to other people is the crucial element in earning the confidence and respect that is so important to successful patient and professional relationships. The following practices should be observed: Dress • Dress clothes (tie for males) must be worn in clinic at all times. Bloody athletic shoes are not considered acceptable attire. • O.R. dress code will be strictly adhered to. Conduct • Attendance is expected at all scheduled conferences and clinics unless specifically excused by the Chief Resident or Staff. • Hospital rules for smoking will be observed. In addition, simple courtesies such as no gum chewing or smoking during patient contact or while presenting are observed. • Everyone with whom the resident comes in contact is to be treated courteously. Do not respond to irritating behavior with an angry response; nothing positive is accomplished. Rather, submit the problem areas to the Chief resident, Staff, or Chairman as appropriate. • Do not take up personal vendettas with any office, position, or person. Be honest and candid and use sound judgment and discretion. When we fail in our interpersonal contacts, the best remedy is to seek forgiveness. It is professional and reflects mature character to say “I’m sorry”. • Be especially courteous to nurses and ancillary personnel.

Department Social Events Garceau-Wray Lectureship Held the first part of June, always on a Thursday and Friday, with the Garceau-Wray dinner on Friday night. The Garceau-Wray dinner is an adult only event. Attire for both the lectures and the dinner is business; dress pants, dress, or skirt, jacket and tie for the gentlemen. The lectures and the dinner on Friday night are mandatory events for all residents. Spouses are welcome. Christmas Holiday Party For all faculty, residents, office staff and hospital staff associated with orthopaedics. Held the second or third Sunday evening in December from 6:00-10:00 PM. The Christmas Holiday Party is an adult only event. Attire for the Christmas Holiday Party is Christmas casual. Annual Summer BBQ The annual summer BBQ is held to honor the incoming interns. Usually held the last weekend in June. The annual summer BBQ is a family event with children welcome. The attire for the summer BBQ is casual. RSVP When you receive an invitation which includes a contact to RSVP, whether a personal or a business invitation, a response to that RSVP is expected. The initials “RSVP” stand for the French term “répondez s’il vous plait”, or “Please respond”. It means the host or hostess needs to know how many people are coming. Whenever possible, please adhere to RSVP deadlines. Usually deadlines are created for catering needs and your host/hostess is on a deadline as well.

Rules and Regulations All residents are expected to conduct themselves in a manner which reflects a high standard of performance and conforms to high standards of conduct. Below are examples of misconduct which will subject a resident to disciplinary action. This is not intended to be a complete list, but to be a guide to conduct which may result in disciplinary action, up to and including discharge: 1. Physical or verbal abuse of any patient, employee, or visitor. 2. Use or possession of intoxicants or illegal drugs on Medical Center premises or reporting for work under the influence of intoxicants or illegal drugs. 3. Possession of weapons of any kind unless authorized by the Medical Center Vice Chancellor. 4. Gambling or being present where gambling is in process or being in possession of gambling devices or equipment on Medical Center premises. 5. Being engaged in immoral or indecent conduct on the Medical Center premises. 6. Taking property of any person or of the Medical Center without authorization. 7. Falsification of institutional records, such as employment application, medical records, expense vouchers or time records. 8. Disclosing confidential information concerning patients, employees, or the institution. 9. Fighting, creating a disturbance, or engaging in other acts constituting disorderly conduct such as horseplay, scuffling, wrestling, throwing things, attempting to injure others, practical joking, unnecessary noise, shouting, using profane, threatening, or abusive language to others, and acting in a disorderly manner. 10. Walking off the job. 11. Conduct detrimental to patient care or general safety. 12. Distributing written or printed matter of any kind, posting or delivering notices, signs, or writing in any form on the premises without permission of the Vice Chancellor of the Medical Center. 13. Refusal to follow the instructions of a supervisor. 14. Refusal of a request to security personnel to open all packages, purses, luggage, briefcases and/or any other form of container in their possession while on or upon leaving these premises. 15. Sleeping, wasting time, or leaving your assigned work area during working hours without permission of your supervisor. 16. Failure to report to work or notify department, late arrival at place of work, or leaving work early without authorization of supervisor. 17. Violation of department work rules or procedures. 18. Failure to wear name tag in clearly visible manner while on duty. 19. Unauthorized use or abuse of Medical Center equipment, materials, or vehicles. 20. Violating Medical Center parking rules and regulations. 21. Smoking in unauthorized areas. 22. Soliciting contributions of any kind unless authorized by the Vice Chancellor. 23. Soliciting loans from patients, visitors, or employees. 24. Excessive absenteeism (numerous, happening at short intervals, often, or constantly repeated), or unexcused absenteeism.

Putting the Principles of Good Practice for Residents’ Teaching Into Action Good Practice… Emphasizes the need for a solid foundation of knowledge in a given discipline and explains how it relates to knowledge in other disciplines. Is knowledgeable of current medical literature and able to cite it when appropriate. Is aware of standard practice and routinely explains any deviations. Shares knowledge of available resources for assistance in the clinical care of patients. Explains the appropriate process in obtaining consults and etiquette in providing consults. Establishes and communicates high expectations for teachers and learners. Participates in a defined orientation process for students and residents new to the service or discipline. Goals for each rotation are communicated both verbally and in writing. Evaluation methods are discussed prior to the evaluation process. Unwritten expectations, such as outside readings during “down time”, should be communicated at the beginning of the rotation rather than at evaluation time. Attendance and punctuality issues should be clearly communicated the first day. Establishes and communicates clear student objectives for knowledge, skills, and attitudes on teaching rounds, in lectures, clinics, tutorials, and other teaching moments. Discusses written objectives for the month or rotation. Prepares lectures with good audiovisual support and handouts. Actively employs adult learning principles in rounding, clinics, and tutorials. Adults prefer to participate in assessing their learning needs. Pretests are helpful. Adults want to use what they learn as soon as possible. Adults are interested in concepts and applications that can be linked to existing knowledge and experience. Adults want a problem-solving approach. Case reviews and case studies are useful. Adults prefer measures of self-progress over competition with others. Self-assessments can be encouraged as an adjunct to more formal evaluation. Models the behavior of treating others (patients, students, healthcare team members) with compassion, dignity, and respect. Refers to patients by name, not diagnosis, eg. the gall bladder in room 405. Calls patients and healthcare team members by their proper, not familiar, names unless agreed to by both parties. Employs three characteristics of friendship that are important to learning: Friends treat each other with courtesy. Friends share humor and laughter. Friends talk to each other. Corrects students’ and other residents’ knowledge, behavior, and skills without using personally demeaning remarks or name-calling.

Recognizes that repeated threats of failure or punishment create antagonism. Provides adequate time for teaching and learning activities through accessibility and through willingness to clarify what is being taught. Is a careful listener. Uses clarifying questions, rather than probing ones, in the hospital setting. Uses discussion to cross-check findings, symptoms, differential diagnosis, etc. Limits hallway lectures to brief, relevant case-related issues. Encourages problem-solving skills by using open-ended questions, especially in clinic settings. Uses honest questions, not trickery, that allow for analysis and application of clinical data. Does not provide “over-helping” behaviors that complete a procedure for students rather than with them. Encourages learning beyond a specific activity by recommending additional reading, identifying faculty resources, and encouraging discussion. Identifies reading as the cornerstone of self-directed learning. Uses skills in questioning, listening, and responding in formal and informal discussion groups rather than giving mini-lectures. Matches students who have particular areas of interest with like-minded faculty to motivate additional learning. Role-modes effective use of resources and strong continuing education habits. Provides prompt, evaluative feedback on student performance which is based on measurable changes in students’ knowledge, skills, and attitudes. Is descriptive rather than judgmental. Is specific rather than general. Is well timed. Focused on behavior rather than person. Contains positives as well as suggestions for change.

Involuntary Termination The rules and regulations of the Indiana University Medical Center Employees Handbook which outlines grounds for dismissal also applies to the Orthopaedic Resident. Among those grounds for dismissal, the resident should make particular note of the following: 1. Neglect of duties 2. Incompetency 3. Insubordination 4. Unprofessional conduct 5. Frequent tardiness or absenteeism 6. Discourtesy 7. Disregard for established organization and Department procedures 8. Neglect of personal appearance, dress, or hygiene In the event that a resident shows disregard for Indiana University Medical Center or Department rules, the Chairman of the Department will schedule a disciplinary conference with the resident and place a written record of the infraction in the Department’s files. The Chairman may place the resident on probation, if he determines the situation warrants such action. When dismissal is considered, a committee will address the issue and render the final decision.

ACGME Policy on “Moonlighting” by GME Resident ACGME Approved June 27, 2000 Characteristically the physician in the United States accepts the responsibility for his or her patients regardless of time or calendar. If the physician may be unavailable, arrangements are made for appropriate coverage. It is in this philosophical context that graduate medical education (GME) carries the same connotation of total engagement of the resident for the care of his or her patients and the attendant dedication to the learning of the skills, knowledge and professional behaviors of the educational program. Obviously, finite limits of the work schedule must be observed to provide for study, assimilation of knowledge and appropriate rest and recreation for good mental and physical health. Further, recognizing that the physician with a well-balanced life style may well provide more for his or her patients, these elements must be incorporated as well. All of this suggests that while the physician resident may be totally dedicated to the care of his/her patients and to the learning opportunity, there are realistic limits that must be observed. Thus, the Residency Review Committees have attempted in different ways to recognize prudent limits on work requirements so that the learning objectives are not compromised. In recent years, an additional burden has been placed on some residents. The high cost of education in general and medical education in particular has forced many medical school graduates to borrow large sums of money to complete their undergraduate and MD degree programs. Increasingly, the available loan programs do not defer payments after medical school and those that do add even more burdensome interest. Resident stipends are often not sufficient to cover the cost of living and loan repayments. Thus, residents may seek opportunities to earn additional money during residency to assist in educational loan repayments. The circumstance of working as a physician outside of one’s authorized training program is called “moonlighting”. Moonlighting has been discouraged in the past for several reasons. First, it clearly competes with the opportunity to achieve the full measure of the educational objectives of the residency. Not only does the added time burden take away from study, it reduces rest and the ability for a more balanced lifestyle. Nevertheless, many residents find the need for money to be compelling, and wish to use their time away from their training program to meet financial obligations. First and foremost, the moonlighting workload must not interfere with the ability of the resident to achieve the goals and objectives of their GME program. The Program Director should monitor resident performance to assure that factors such as resident fatigue are not contributing to diminished learning or performance, or detracting from patient safety. The Program Director may also choose to monitor the number of hours and the nature of the workload of residents engaging in moonlighting experiences. Residents must not be required to engage in “moonlighting”. All residents engaged in moonlighting must be licensed for unsupervised medical practice in the state where the moonlighting occurs. It is the responsibility of the institution hiring the resident to moonlight to determine whether such licensure is in place, adequate liability coverage is provided, and whether the resident has the appropriate training and skills to carry out assigned duties. The Program Director should acknowledge in writing that s/he is aware that the resident is moonlighting, and this information should be part of the resident’s folder.

Department of Orthopaedic Surgery Policy on Moonlighting To: All Orthopaedic Residents cc: All Orthopaedic Faculty From: Randall T. Loder, M.D. Interim Chair, Department of Orthopaedic Surgery Date: June 22, 2004 Re: Moonlighting The primary objective of a residency is to ensure proper training, both technical and academic, in the field of study. All other activities must keep the primary goal in mind: competency in orthopaedic surgery and the ability to pass the ABOS examinations. The ACGME official policy is that moonlighting is discouraged. Moonlighting results in less time available for study needed to become a competent orthopaedic surgeon and rest necessary to maintain a balanced lifestyle. After considerable thought and discussion, the following policy regarding resident moonlighting in the orthopaedic surgery program at Indiana University will be invoked effective July 1, 2004. This is in addition to the Moonlighting Policy of the Committee on Graduate Medical Education of Indiana University School of Medicine (attached). 1. All moonlighting must be requested in writing and approved ahead of time by the Program Director. 2. Only residents in good standing may moonlight; those on probation are forbidden from moonlighting 3. Each resident may moonlight the maximum of one Saturday morning per month at the Compensation and Pension clinic associated with the Veterans Administration Hospital 4. Moonlighting beyond the VA Compensation and Pension clinic will be subject to the following rules: a. Only PGY3 through PG5 residents participate. b. The resident must have achieved a score on the preceding years OITE of 75th percentile or greater. c. It must be requested in writing and approved by the Program Director ahead of time. 5. All moonlighting in IUMC associated facilities applies to the 80 hour work week limit. Thus the combined hours from the standard orthopaedic rotations and moonlighting must not exceed this 80 hour limit. 6. Any moonlighting that will potentially go beyond the 80 hour work week limit must be cancelled. 7. The Program Director may relinquish any and all moonlighting privileges from any resident at any time. I know that this policy may be controversial. However, it is in the best interests of the Residency Program.

Moonlighting and Professional Liability If you are getting paid for moonlighting (any pay outside your monthly salary from IU), your moonlighting activities are not covered by your IU liability coverage. If you are getting paid for moonlighting (any pay outside your monthly salary from IU) you must have a permanent Indiana medical license, not a temporary residency permit. If you prescribe medication to anyone outside of your clinic, OR, ward duties (i.e. a friend, a child of a friend, your neighbor, etc.) you are not covered by your IU liability coverage. Moonlighting (even at VA, Wishard or Clarian facilities) and prescribing medicine as outlined above are considered “outside the scope of your training program” activity and you would have no professional liability coverage should a claim be filed.

Vacation/Time Away Policy A vacation request form must be obtained from Donna Roberts (Residency Program Coordinator), completed by you, and signed off on by the faculty chief of the rotation you are requesting time off from and the Program Director. No vacation requests will be approved for the Saturday of the Orthopaedic Intraining Examination. Only one week of vacation per 10-week rotation will be allowed unless prior approval is given by the Program Director and rotation Chief. The vacation “allowance” is: PGY-5, 4, 3 4 weeks PGY-2 3 weeks PGY-1 3 weeks, but is handled through General Surgery No vacation will be allowed during June or July. The IU House Staff Handbook denotes the number of vacation weeks per year depending upon the level of resident. Please be reminded that these are 7 day weeks, not 9 day. Thus it can be expected that you will need to work on one of the weekends surrounding the 7 day vacation time slot. Finally, all residents will and must be present through June 30 of the year. Senior residents will not be allowed to depart before June 30 of the graduation year. All residents are allotted certain time for standard courses in addition to vacation. These include 1) the AO skills course for the PGY-2; 2) the prosthetic course for the PGY-3 or 4; 3) and the AAOS Annual meeting or (but not both) a review course lasting the same number of days as the AAOS annual meeting for the PGY-5. All other time away must be approved in writing by the Program Director before departure, and will be counted as vacation time unless the Program Director deems otherwise. Thus, interviews for fellowships, jobs, or attendance at other courses is considered vacation. All requests for vacation or time away (including standard courses) must be submitted on the Vacation/Time Away Request sheet, which can be obtained from Donna Roberts. Oral requests for time off will not be accepted. Your time off is not approved until your form is submitted, signed by both the rotation Chief and the Program Director, and a copy is placed into your mailbox.

Salary Stipends for 2009-2010 for Levels 1 through 9 are listed below: Level Annual Monthly Level Annual Monthly PGY 1 $46,146 $3,845.50 PGY 6 $51,646 $4,303.83 PGY 2 $46,846 $3,903.83 PGY 7 $53,346 $4,445.50 PGY 3 $47,746 $3,978.83 PGY 8 $55,246 $4,603.83 PGY 4 $48,846 $4,070.50 PGY 9 $57,346 $4,778.83 PGY 5 $50,146 $4,178.83 PGY 10 $59,646 $4,970.50 Stipends are subject to change on July 1 of each fiscal year. All residents will receive an IU paycheck even when rotating to affiliated hospitals and off-site electives. Checks are issued monthly on the last business day of the month. No advance pay can be made. As an IU employee, you are required to have direct bank deposit. This is a simple, dependent, convenient, and safe method and must be used by all IU employees. Forms to start, change, or stop direct bank deposit are available in the Office of Graduate Medical Education or may be printed from the house staff web site at http://housestaff.iusm.iu.edu/forms/direct_deposit1.pdf. If you wish your check to be deposited to your checking account, the form must be accompanied by a voided check or deposit slip. If you wish your check to be deposited to your savings account, a deposit slip is needed. You will receive a Direct Deposit Pay Advice each month which details all withholdings from your gross pay. The Pay Advice will be distributed by the department office. Federal, State, and County Income Tax, and Social Security Tax will be withheld from your pay. In a few instances (fellows), where a portion of the pay is from non-taxable grants, income taxes will not be withheld, and you are advised to file a Declaration of Estimated Tax, State and Federal, to cover the balance.

Ethical Relationships with the Orthopaedic Industry Residents are expected to know the guidelines published by the AAOS, AMA, and AdvaMed (Appendice 6, 7, and 8), and that their relationships with companies and company representatives should be governed by accepted principles of medical ethics. The abovementioned guidelines can also be found at the following web addresses: http://www.ama-assn.org/ama/pub/category/4001.html http://www3.aaos.org/member/profcomp/SOPConflictsIndustry.pdf http://www.advamed.org/NR/rdonlyres/FA437A5F-4C75-43B2-A900- C9470BA8DFA7/0/coe_with_faqs_41505.pdf

Types of Evaluation Resident Evaluation An evaluation is completed by the attending physician with whom the resident worked. This evaluation is to be discussed between the attending physician and resident, and then signed by the resident at the end of this discussion. This form is filed in the resident’s file at the end of each rotation. Contracts are renewed annually. Evaluations are an integral part of the decision-making process of renewing contracts. Each resident’s progress is reviewed semi-annually by the Chairman and Program Director. Rotation Evaluation Residents are required to complete an evaluation form at the conclusion of each rotation. Topic Evaluation Residents and faculty are required to evaluate the quality of each lecture given by either faculty or residents during the mandatory Wednesday morning Grand Rounds lectures. In addition, the attendings will, on a daily basis, submit evaluations of the resident’s individual performances on individual cases, as well as in the clinic and/or rounds.

Resident Evaluation RESIDENT EVALUATION: Resident evaluations are in comparison with a completely trained and competent orthopaedic surgeon. KNOWLEDGE OF BASIC SCIENCES AS THEY RELATE TO ORTHOPAEDICS This factor is concerned with the resident’s knowledge of Anatomy, Bacteriology, Biochemistry, Physiology, Pathology, Biophysics, and Biomechanics that is necessary to adequately diagnose and treat orthopaedic patients. The ineffective resident does not The effective resident routinely know surgical anatomy of cases is well prepared at surgery with assigned, does not show evidence a knowledge of Anatomy and of understanding of patho-mechanics Pathology of a given case. He/she in trauma and does not show evidence understands the mechanisms of of understanding of basic Bacteriology, injury of most fractures and is Physiology, and Pathology in patient aware of the affects of disease management. He/she lacks understanding and trauma on the physiology of aseptic technique and appropriate of his/her patients. He/she utilizes selection and use of antibiotics. appropriate antibiotics, medications, and treatment adjuncts. He/she demonstrates a good understanding of aseptic technique. KNOWLEDGE OF CLINICAL ORTHOPAEDICS This factor is concerned with the resident’s knowledge of clinical entities, methods of treatment, and expected results in Trauma, Adult and Reconstructive Orthopaedics, Children’s Orthopaedics and Rehabilitation. The ineffective resident show a lack of The effective resident shows knowledge of awareness of musculo- evidence of knowledge of the skeletal conditions affecting patients. literature, methods of manage- He/she is not aware of treatment alternatives ment, and the use of prostheses, and methods. orthoses and other appliances. He/she is aware of the advantages and disadvantages of various treatment alternatives.

INFORMATION GATHERING This factor is concerned with the resident’s willingness, ability, and skill in gathering information necessary for diagnosis. The ineffective resident limits his/her The effective resident routinely interview and physical examination takes a comprehensive initial to the area of complaint and fails history and physical examination. to pursue alternative hypotheses. He/she records the information received in a systematic fashion He/she frequently uses therapy to and pays careful attention to substantiate clinical impressions. progress notes. He/she is aware of information other than the medical and indicates this by initiating further procedures and questions. PROBLEM-SOLVING This factor is concerned with the resident’s ability and skill in using information gained to develop a diagnosis and support clinical activity. The ineffective resident has an incomplete The effective resident realizes the comprehension of the implications of the importance of unexpected findings data he/she has collected. and seeks to determine their implications. He/she is unable to interpret unexpected results and often ignores them. He/she understands the nature of probability and uses this to He/she makes decisions on the basis of illuminate his/her experience. experience, disregarding the context in which that experience was gained. He/she takes all the data into account before reaching a His/her thinking is rigid and decision, and routinely tests unimaginative, including his/her alternative hypotheses. recognition of associated problems. CLINICAL JUDGMENT This factor is concerned with the resident’s ability to use sound judgment in planning for and carrying out treatment. The ineffective resident is overly concerned The effective resident is familiar with treatment techniques at the expense with the uses and limitations of the of overall goals. procedures he attempts. He/she recognizes his/her own capabilities He/she often delegates pre and post operative and uses procedures which care to others. correspond to them. He/she plans treatment without sufficient He/she considers simple procedures familiarity with the procedures he/she selects. first.

His/her treatment choice is rigid – using a set His/her clinical judgment encompasses formula for treating each clinical problem information beyond the pathologic. or using a favorite technique when more effective ones are available. He/she demonstrates regard for patient needs, desires, and life conditions. He/she is flexible enough to modify his/her treatment plans when the situation warrants. SURGICAL TECHNIQUE This factor is concerned with the resident’s ability and skill in carrying out operative procedures. The ineffective resident has insufficient The effective resident handles skill for the procedures he attempts. issues gently, uses careful hemostasis, and makes proper and adequate His/her overall handling of instruments and exposure of the Operating field. tissue lack finesse. He/she carefully attends to details His/her operating time is often prolonged such as sterilization of instruments through unfamiliarity with procedures or and proper choice of same. inadequate planning. He/she make proper application of He/she takes unnecessary operative risks fixation devices or prostheses and or terminates operation before maximum makes proper closure of wounds. results are achieved. He/she carefully monitors his/her patient during operative procedures. He applies appropriate dressings, splints, and casts. RELATING TO PATIENT This factor is concerned with the resident’s effectiveness in working with patients. The ineffective resident does not The effective resident’s manner communicate with his/her patients, either elicits patient confidence and through aloofness, indifference, or the cooperation and relieves anxiety. pressure of time. He/she is interested in his/her He/she has difficulty understanding patient’s well-being and patient needs. demonstrates this without becoming emotionally involved. He/she is unable to evoke patient confidence, tending even to alarm them. He/she is honest with the patient and his/her family. He/she reacts negatively to hostility or other emotional displays. Patients like him/her and readily feel they can ask questions and

discuss problems with him/her. CONTINUING RESPONSIBILITY This factor is concerned with the resident’s willingness to accept the responsibility for long-term patient care. The ineffective resident either loses The effective resident is able and interest after initial treatment or does willing to work with the patient to not take the time for adequate follow- achieve maximum rehabilitation. up. He/she motivates the patient to strive for his own rehabilitation. He/she becomes discouraged with slow progress and cannot cope with a poor He/she monitors patient’s progress prognosis. He/she is unable to altering therapy or treatment as communicate realistic expectations to indicated. patients. He/she understands the roles of His/her utilization of support personnel various allied health professions is either inadequate or he/she expects and makes maximum use of assistance beyond their capabilities and their assistance. training. He/she maintains a positive and persistent attitude toward recovery. EMERGENCY CARE This factor is concerned with the resident’s ability to act effectively in emergency situations in the operating room or the emergency room. The ineffective resident panics easily The effective resident quickly and makes inappropriate use of time assesses the situation, pays available. attention to lifesaving procedures and demonstrates understanding He/she becomes confused under of triage concepts. pressure and has difficulty establishing priorities. He/she is unable to delegate He/she is able to obtain and aspects of care to others. organize assistance of others. He/she is careless about applying He/she is able and willing to make protective measures. decision alone if necessary. He/she is unable to make decision alone. He/she is aware of consequences of delay.

RELATING TO COLLEAGUES This factor is concerned with the resident’s ability to work effectively with his colleagues and other members of the health team. The ineffective resident has difficulty The effective resident relates well relating to others and lacks the ability to others and communicates easily, either to give or take gracefully. working well in a team situation. He/she tends to be tactless and inconsiderate He/she seeks consultation when and does not evoke the confidence and appropriate and respects others’ cooperation of those with whom he/she views. works. He/she demonstrates self-control. He/she habitually gives unsolicited advice and in an offensive manner. He/she gives credit to others for their contributions and creates an He/she is unwilling to make referrals or atmosphere of working together – seek consultation and fails to support his/ not working for. her colleagues in their contacts with his patients. MORAL AND ETHICAL VALUES This factor is concerned with the residents attitudes and standards as an individual. The ineffective resident attempts to cover The effective resident’s conduct up his errors. reflects kindness, respect, honesty, and humility. He/she is frequently absent from assigned duty or unavailable when needed. He/she reports facts accurately, including his own errors. He/she has unethical contacts with non- medical professions and allows his personal He/she respects the confidences finances to unduly influence treatment. of colleagues and patients. He/she discusses medical mismanagement He/she respects the property of with patients. others. He/she recognizes his/her own professional capabilities and limitations. OVERALL COMPETENCE This factor is concerned with your judgment of the resident’s overall competence as an orthopaedic surgeon, taking into account factors 1 through 11. UNSATISFACTORY MARGINAL SATISFACTORY EXCELLENT

Indiana University School of Medicine Orthopaedic Surgery Training Program Resident Evaluation of Competencies Resident Name Faculty Evaluator Rotation/Dates 4 = Exceeds Expectations 3 = Meets Expectations 2 = Needs Improvement 1 = Unsatisfactory N/E= Not Evaluated FACTORS 4 3 2 1 N/E A. Patient Care (1) Judgment: Common sense, decisiveness, ability to draw sound conclusions, willingness to admit mistakes. Regard for patient’s needs and life Conditions. (2) Caring: Compassionate, appropriate and effective care of patients for the treatment of health problems and the promotion of health. (3) Communication: Gather essential and accurate information about patients – work with healthcare professionals to provide patient focused care B. Medical Knowledge (1) Intellectual Ability: Retention, comprehension, abstraction, discrimination, logical thinking. (2) Knowledge of anatomy, physiology, pathology, and mechanics of cases. (3) Conference Performance: Punctuality, organization, preparation. Shows knowledge of current literature and treatments. (4) Decision Making: Makes informed decisions about diagnostic-therapeutic treatment based on patient info, preferences, up-to-date scientific evidence and clinical judgment. Develop and carry out patient management plans. Demonstrate investigatory and analytic thinking approach to clinical situations. C. Practice-Based Learning and Improvement (1) Motivation: Exhibits active and aggressive attitude toward learning (2) Knowledge of Field: Shows evidence of the literature, methods of management, advantages and disadvantages of alternative treatments of their own patient care. Appraisal and assimilation of scientific evidence and improvements in patient care. (3) Leadership: Ability to elicit cooperation from nursing staff, technicians, and orderlies in the discharge of their functions in patient care. (4) Research Aptitude: Curiosity, creativity, ability to evaluate and analyze data. Utilization of resources. Independent work. (5) Work Habits: Initiative, amount of prodding or supervision needed, responsibility, quality, amount.

FACTORS 4 3 2 1 N/E (6) Relating to students: Accepts role of teacher. Explains and elaborates. Recognized student’s interests and needs. (7) Use information technology to management information – access on-line medical info to support their own education. D. Interpersonal and Communication Skills (1) Communication Skills – Oral Clarity of expression, articulateness, grammar. Skills that allow for effective information exchange with patients, their families and other health professionals. (2) Communication Skills: Written Must observe and document observations accurately and in good time. Progress, operative, and discharge notes should be written completely and promptly. (3) Relating to Patients: Interested, honest, and understanding. Explains clearly and to the patient’s satisfaction details related to diagnosis, proposed treatment, and its implications. E. Professionalism (1) Concern for Others: Sensitivity to and consideration of others, tactfulness. Committed to ethical principles and sensitivity to a diverse patient population (culture, age, gender, disabilities). (2) Reliability: Acceptance of responsibility, punctuality, availability. (3) Integrity: Honesty, discretion, accountability to patients, society, and the profession; a commitment to excellence and on-going professional development. (4) Appearance: Poise, alertness, cleanliness, appropriateness of dress. (5) Ethical principles: A commitment to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices. (6) Professional Promise: Desirability of letting this person treat you or your family. F. Systems-Based Practice (1) Resourcefulness: Management of available resources. Understands roles of support personnel and makes maximum use of their assistance. Resourcefulness in obtaining information about patients. (2) System of Health Care: Ability to demonstrate an awareness and responsiveness to the large context and system of health care. The ability to effectively call on system resources to provide care for optimal value. Advocate for quality patient care and help patients deal with system complexities. G. Surgical Skills Psychomotor skill level for year in training. Dexterity, thoroughness, efficiency of effort

FACTORS 4 3 2 1 N/E Other Factors Emotional Stability and Stress Management: Performance in emergency situations, response to opposition or frustration, mood stability, control. Stamina: Physical endurance, perseverance, health. Overall Rating: Additional Comments: ______________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Evaluator Signature: ______________________________ Date: ___________________ Resident Signature: ________________________________________________________

EVALUATION OF SERVICE SERVICE: DATE: PATIENT SELECTION FOR SURGERY: Never Appropriate Usually Inappropriate Usually Appropriate Always Appropriate 1 2 3 4 PATIENT VARIETY: Too Narrow Narrow Just Right Too Broad 1 2 3 4 ATTENDING AVAILABILITY TO ME: Never Available Seldom available Usually Available Always Available 1 2 3 4 ATTENDING SUPERVISION OF MY ACTIVITIES: To Little About right Just right Too much 1 2 3 4 CONFERENCES - NUMBER: To Few About right Just right Too many 1 2 3 4 QUALITY: Bad Below Average Average Above Average 1 2 3 4 Please complete the sections below. This will help us improve and/or expand your rotations COMMENTS: SUGGESTIONS ON AREAS THAT NEEDS IMPROVEMENT:

HOUSESTAFF EVALUATION OF FACULTY The teaching abilities of our faculty are an important component of their responsibilities. As such, we vitally need your judgment as to the teaching you received. The information you provide to us will be anonymous. In addition, individual faculty will only receive a composite score on a yearly basis. Thus, you should not have any fear of a faculty member linking you as an individual to a negative assessment. Thank you in advance for filling out this form. Name of Faculty being evaluated: , M.D. 1. The attending was interested in teaching and consistently available for consultation. A B C D E Strongly Agree Agree Strongly Disagree 2. The attending made me feel like a welcome and important member of the team. A B C D E Strongly Agree Agree Strongly Disagree 3. The attending was able to cover patient care issues while simultaneously highlighting important teaching points about each case. A B C D E Strongly Agree Agree Strongly Disagree 4. The attending was able to speed up or slow down surgery and clinic as necessary to efficiently and effectively cover both patient care and teaching points. A B C D E Strongly Agree Agree Strongly Disagree 5. The attending presented information in an organized manner, used examples for clarification, and summarized important take-home points. A B C D E Strongly Agree Agree Strongly Disagree 6. The attending asked me questions in order to assess my understanding and ability to apply information to my patients. A B C D E Strongly Agree Agree Strongly Disagree 7. The attending allowed me to participate in surgical care at my level of ability. A B C D E Strongly Agree Agree Strongly Disagree 8. The attending provided me with feedback about both correct and incorrect performance and guidance about how to improve throughout the rotation. A B C D E Strongly Agree Agree Strongly Disagree 9. The attending was a good role model both as a physician and as a person. A B C D E Strongly Agree Agree Strongly Disagree

10. The attending stimulated me to want to learn more about my patients and their problems. A B C D E Strongly Agree Agree Strongly Disagree 11. Overall, this attending was: A. One of the best B. Above average C. Average D. Below average E. One of the worst Comments: Please write any additional comments about the strengths and weaknesses of this faculty member. All comments will be appreciated.

Education

Minimum Educational Requirements for Board Certification The Board has established the following minimum education requirements for certification. These requirements should not be interpreted as restricting programs to minimum standards. Throughout these rules, the term “accredited” denotes approval by the Accreditation Council for Graduate Medical Education. A. Time requirements 1. Five years (60 months) of accredited post-doctoral residency are required. 2. Prior to July 1, 2000, four of these years (48 months) must be served in a program whose curriculum is determined by the Director of an accredited orthopaedic surgery residency. Three of these years (36 months) must be served in an accredited orthopaedic surgery residency program. One year (12 months) may be served in an accredited graduate medical program whose educational content is determined by the Director of an accredited orthopaedic surgery residency program. Beginning on July 1, 2000, one year (12 months) must be served in an accredited graduate medical education program whose curriculum fulfills the content requirements for the PGY-1 (see B.1.) and is determined or approved by the Director of an accredited orthopaedic surgery residency program. An additional four years (48 months) must be served in an accredited orthopaedic surgery residency program whose curriculum is determined by the Director of the accredited orthopaedic surgery residency. 1. Each program may provide individual sick leave and vacation times for the resident in accordance with overall institutional policy. However, one year of credit must include at least 46 weeks of full-time orthopaedic education. Vacation or leave time may not be accumulated to reduce the five-year requirement. 2. Program Directors may retain a resident for as long as needed beyond the minimum required time to ensure the necessary degree of competence in orthopaedic surgery. According to the current Special Requirements of the Residency Review Committee for Orthopaedic Surgery, the committee must be notified of such retention. This information must also be provided to the Board on the Record of Residency Assignment form. B. Content requirements 1. Requirements for post graduate year one. Prior to July 1, 2000, a minimum of nine months during the PGY-1 must be based in clinical services other than orthopaedics. This requirement may be fulfilled by a year of accredited

residency in any broad based program involving patient care. Beginning July 1, 2000, the residency Program Director should be responsible for the design, implementation, and oversight of the PGY-1. The PGY-1 must include: a. A minimum of six months of structured education in surgery to include multisystem trauma, plastic surgery/burn care, intensive care, and vascular surgery. b. A minimum of one month of structured education in at least three of the following – emergency medicine, medical/cardiac intensive care, internal medicine, neurology, neurological surgery, rheumatology, anesthesiology, musculoskeletal imaging, and rehabilitation. c. A maximum of three months of orthopaedic surgery. 2. Orthopaedic requirements beyond the PGY-1. a. Minimum distribution. Orthopaedic education must be broadly representative of the entire field of orthopaedic surgery. The minimum distribution of educational experience must include: (1) 12 months of adult orthopaedics (2) 12 months of fractures/trauma (3) Six months of children’s orthopaedics (4) Six months of basic science and/or clinical specialties Experience may be received in two or more subject areas concurrently. Concurrent or integrated programs must allocate time by proportion of experience. b. Scope. Orthopaedic education must provide experience with all of the following: (1) Children’s orthopaedics. The educational experience in children’s orthopaedics must be obtained either in an accredited position in the specific residency program in which the resident is enrolled or in a children’s hospital in an assigned accredited residency. (2) Anatomic areas. All aspects of diagnosis and care od disorders affecting the bones, joints, and soft tissues of the upper and lower extremities, including the hand and foot; the entire spine, including intervertebral discs; and the bony pelvis. (3) Acute and chronic care. Diagnosis and care, both operative and nonoperative, of acute trauma (including athletic injuries), infectious disease, neurovascular impairment, and chronic orthopaedic problems including reconstructive surgery, neuromuscular disease, metabolic bone disease, benign and malignant tumors, and rehabilitation.

(4) Related clinical subjects. Musculoskeletal imaging procedures, use and interpretation of clinical laboratory tests, prosthetics, orthotics, physical modalities and exercises, and neurological and rheumatological disorders. (5) Research. Exposure to clinical and/or laboratory research. (6) Basic science. Instruction in anatomy, biochemistry, biomaterials, biomechanics, microbiology, pathology, pharmacology, physiology, and other basic sciences related to orthopaedic surgery. The resident must have the opportunity to apply these basic sciences to all phases of orthopaedic surgery. c. Options. Twelve months of the four required years under the direction of the orthopaedic surgery residency Program Director may be spent on services consisting partially or entirely of: (1) Additional experience in general adult or children’s orthopaedics or fractures/trauma. (2) An orthopaedic clinical specialty. (3) Orthopaedics-related research. (4) Experience in an accredited graduate medical educational program whose educational content is pre-approved by the Director of the orthopaedic surgery residency program. C. Accreditation requirements 1. The educational experience in orthopaedic surgery obtained in the United States must be in an approved position in programs accredited by the Residency Review Committee for Orthopaedic Surgery and by the Accreditation Council for Graduate Medical Education.

Meetings and Courses/Procedure Financial assistance is provided to residents in good standing to attend the meetings listed below. Residents in good standing who have papers accepted for presentations at other meetings may also receive financial assistance. Specific courses, on and off campus, are available. PGY-2 Fracture Course for Residents PGY-3 Prosthetics/Orthotics Course – Chicago, IL PGY-4 Any one meeting their Garceau-Wray presentation has been accepted PGY-5 AAOS Annual Meeting and Courses or an Orthopaedic Board Review Course Funds for resident travel will be subject to change depending upon the Department’s finances.

Resident Course Policy All course literature needs to be sent to Donna Roberts, the Residency Program Coordinator, to be distributed to the Program Director and Chairman. The Program Director and Chairman will decide whether the course would educationally benefit the resident. If it is decided that the course would be of benefit to the residents, the Program Director will decide which residents to send based on a schedule of courses attended, so that the residents are given a fair opportunity to attend courses. Courses that the program will consider are: • University Courses • AAOS Courses • Subspecialty Society Courses (POSNA, OTA, etc.) • AO Courses • Independent Educational Foundation Courses The program will assist with requests for educational grants, etc. for these courses. These courses are in addition to the Fracture Management Course for the PGY-2 residents, the Orthotics/Prosthetics Course for the PGY-3 residents and the AAOS or Board Review Course for the PGY-5 residents. ** The program will not assist with any courses which the resident schedules directly with the industry sponsor

Conferences • While at the Hand Center, the resident is expected to attend Fracture Conference with Dr. Fischer. These will be held in the Boardroom on the 2nd floor Monday mornings at 7:00 AM.

Travel Procedures • Meetings which the residents choose to attend should be coordinated through Donna. • RE: Airline Tickets – these arrangements must be made at least 21 days in advance to insure the lowest priced airfare available! Receipts must be obtained for all expenses for which reimbursement is desired, including those expenses covered by a travel advance. Receipts, as well as travel mileage, should be turned in to Donna immediately upon return from the trip. Illegible receipts will not secure a reimbursement of your funds. • Reimbursable Items: Transportation to and from course location (city) Taxi/shuttle from airport to hotel and from hotel to airport Course registration/tuition Airport parking Hotel room charges (maximum of $137.50 per night) plus any taxes $44.00 per diem • A Travel Form requesting administrative leave must be completed. Foreign travel forms (outside the Continental U.S.) must be completed 45 days in advance. • You must also notify the attending staff on your service of the dates you will be away!

Library The Orthopaedic Library is located in Clinical Building 600 adjacent to the Chairman’s office. This library includes a number of textbook and journal resources. In addition, the library includes a desktop PC with internet connection to multiple online databases, to include MEDLINE. Orthopaedic residents and faculty have the full use of the Ruth Lilly Medical Library positioned on the IUPUI campus and situated within easy walking distance of hospitals and clinics. The Ruth Lilly Medical Library is a wonderful source of information with a very complete list of reference journals and readily available assistance from experienced librarians. In addition, the residents have campus-wide access to the Ruth Lilly Medical Library via the internet through which many journals can be accessed online and printed off readily using a .pdf file.

Skills Laboratory The Department of Orthopaedic Surgery is presently organizing a skills laboratory. This Skills Lab will include a sawbones area with various internal and external fixation systems for the ongoing training of residents in the field of orthopaedic traumatology. It will house arthroscopy equipment with anatomic practice models to gain technical experience and to enhance arthroscopy skills.

Gross Anatomy Laboratory Gross Anatomy Lab is held the second and fourth Thursday of each month. The second Thursday is a didactic session held in the Clinical Building Conference Room 627. The fourth Thursday is a dissection session held in Wile Hall on the Methodist Campus, Basement, Room WG 16.

Appendices

Research Research Section: A. Research Mission Indiana University Department of Orthopaedic Surgery Vision: The Indiana University Department of Orthopaedic Surgery is committed to providing the enabling technology that will revolutionize the treatment of musculoskeletal ailments and the practice of orthopaedic surgery. Mission Statement: The faculty and staff of the Department of Orthopaedic Surgery strive to change the practice of orthopaedic surgery and treatment. We will focus on the needs of the patient. We will improve patient quality of life by providing effective orthopaedic treatments for debilitating skeletal diseases such as osteoarthritis and osteoporosis, rapidly translate the latest technologies in genomics and bioinformatics into clinical tools that can be used to improve patient outcomes, reduce patient discomfort associated with orthopaedic surgery by developing minimally- invasive surgical procedures, and reduce patient hospitalization by pioneering new and effective outpatient procedures to replace traditional surgeries requiring hospital stays. Research Objectives: The faculty, staff and residents of the Department of Orthopaedic Surgery conduct research that will form the basis for new and revolutionary orthopaedic treatments. Our efforts broach the topics of genetics, genomics, molecular biology, electrophysiology, cellular biomechanics, high resolution imaging, biomaterials, and engineering design. B. Resident Research Project Each resident is expected to design, complete, and present a research project over the course of their training, which will culminate in a research presentation at the annual Garceau-Wray Lectureships of their PGY-4 year. Any resident who does not produce a research project for presentation at the annual Garceau-Wray Lectureships, will not be allowed to graduate the program. If a resident fails to meet any required research deadlines, they will lose any and all future sponsorship for meetings and courses. Any meetings or courses attended will be at your own expense, including using available vacation time.

B.2. Choosing a Faculty Mentor and Research Project Please review faculty research interests in Section III of this manual. Meet with faculty members. Please phone, email or meet in person. Review faculty research publications using Medline (Medical Library) or PubMed (http:// www.ncbi.nlm.nih.gov/PubMed/). B.3. Research Facilities All research facilities within the Department will be made available for resident research. These include: Cell and Molecular Biology: Facilities are available in IB 355 and IB 357 for cell culture and most modern molecular biology techniques. Contact Dr. Randall Duncan. Cartilage Cell and Molecular Biology. Facilities are available in CL 379-390. Contact Dr. Stephen Trippel. Tissue Histology: Facilities for preparation and microscopy of samples from bone and connective tissue are available in MS 5045G. Contact Dr. David Burr. Biomechanics: Facilities for mechanical testing of specimens, including MTS machines, are available in MS 264 and SL 025. Contact Dr. Charles Turner. Bone Densitometry and CT Imaging: Facilities for high resolution imaging of tissues and measurement of bone mineral density in experimental samples are located in MS 264. Contact Dr. Charles Turner.

DEPARTMENT OF ORTHOPAEDIC SURGERY RESIDENT RESEARCH PROGRAM PROJECT TIMELINE PGY-2 Explore research options Turn in project title/topic and name of faculty mentor – Due Date: March 30th (Action: E-mail confirmation sent back to resident and mentor; Attachment: outline to be followed for proposal development) PGY-3 Develop research idea and explore literature Turn in formal research proposal – Due Date: September 30th (Action: Research Committee will Review/Comment on proposal with feedback to resident and mentor Attachment: Instructions for obtaining IRB approval, if applicable) Obtain IRB approval by March 30th PGY-4 Data collection and analysis Progress report to include project title, mentor and description of research project to date – Due Date: September 30th Extended abstract - two pages, single spaced, 12-point font with all tables and figures appended – Due Date: May 1st Presentation of completed project at annual Garceau-Wray meeting PGY-5 Publication-ready manuscript – Due Date: December 31st All research materials should be turned in to Donna Roberts via electronic mail danders@iupui.edu

Revised: March 2007

USMLE Part 3 All residents will be expected to have taken and passed the USMLE Part 3 examination by the end of their PGY-2 year, but it is strongly suggested they take the examination during their PGY-1 year.

Personal Information for House Staff

INTRODUCTION________________________________________________ Indiana University School of Medicine sponsors graduate medical education training in approximately seventy residency and fellowship programs. The training of house staff occurs at several hospital sites. Most of the training occurs at Methodist, IU, and Riley Hospitals of Clarian Health Partners, Wishard Hospital of Wishard Health Services, Richard L. Roudebush VA Medical Center (VAMC), and Larue D. Carter Memorial Hospital. In addition, training occurs at St. Vincent Hospital & Health Care Center, Community Hospitals of Indianapolis, Inc., and the Rehabilitation Hospital of Indiana. Prestigious centers of excellence are part of IU's residency/fellowship programs. These include the Krannert Institute of Cardiology, the Regenstrief Institute, the Walther Oncology Research Center, the Wells Center for Pediatric Research, the IU Cancer Center, the Diabetes Research and Training Center, and many other research- sponsored centers. The School of Medicine presides over the educational programs in each of the hospitals whose medical staff includes members of the IU School of Medicine faculty. This makes possible student and house staff training throughout all the hospitals and clinics. The training programs provide a balance of primary, secondary, tertiary, and inpatient quartiary care; ambulatory care; emergency care; and community health. THE OFFICE FOR HOUSE STAFF AFFAIRS___________________________ 1120 South Drive * Fesler Hall, Room 224 * Indianapolis, Indiana 46202-5114 Phone Number: 274-8282 * Fax Number: 278-3909 * Email: houstaff@iupui.edu. The primary function of this office is to provide an organized administrative system to oversee all residency programs sponsored by the IU School of Medicine. The office, under the direction of the Associate Dean for Graduate Medical Education, has the authority and the responsibility for the educational quality, oversight and administration of the GME training programs. The office also serves as a human resource office for house staff. It facilitates the completion of the necessary forms for payroll, federal and state taxes, health and dental insurance, disability and life insurance, liability insurance, parking decals, etc. The office processes loan deferments and letters of verification of employment. Administrative assistance is given to department chairs and program directors with Accreditation Council for Graduate Medical Education (ACGME) applications, National Resident Matching Program (NRMP), appointments, payroll, and contracts. IMPORTANT: If your home address changes during the course of your training, please notify the Office of Graduate Medical Education.

Department Personnel: Vacant Associate Dean 317/274-5261 Nancy J. Baxter Director 317/274-8282 Nancy A. Bechtel Associate Director 317/274-8282 Carol Robinson Office Manager 317/274-8281 Joann Bright Executive Secretary 317/274-5261 Brenda Leveque Administrative Accounts Coordinator 317/274-5435 Emilie Leveque Payroll-Personnel Coordinator 317/274-4085 Linda A. Bratcher Internal Review Coordinator 317/274-1252

STATEMENT OF HOUSE STAFF RESPONSIBILITIES_____________________ House staff responsibilities include the following: • Provide initial medical care to assigned patients in ambulatory/outpatient or inpatient settings appropriate to the resident's experience and ability. Patient care responsibilities assigned to residents will be commensurate with their level of training, according to ACGME Special Requirements for the training program, and the judgment of the program director and the attending physician. • Where appropriate, formulate a plan of care based on a thorough assessment of the patient's history, current condition, and needs. • Write orders for the implementation of the plan of care. • Coordinate consultations with physicians and other members of the multi disciplinary health team. • Facilitate communications regarding the plan of care with the patient, family, attending physician(s), and any other involved member(s) of the health team. • Perform and/or assist in procedures according to the level of delegation appropriate to the resident's experience and ability. • Adhere to the duty hour regulations and policies of the School and submit hours worked as mandated by the School and/or program. • Participate in education, research, and patient care experiences required by the particular program within which he/she is a trainee. • Supervise and teach other house staff and medical students as appropriate. • Adhere to the affiliated hospitals' policies and procedures for the medical staffs including the "Bylaws, Rules, and Regulations for the Medical Staff" of each hospital and the School of Medicine "Personal Information for House Staff." • Before rotating to another assignment, complete and sign all medical records, charts, and reports assigned to him/her in a timely fashion. • Participate in institutional orientations, relevant committees, projects, and other leadership assignments and activities involving the clinical staff. • Demonstrate the knowledge and skills necessary to provide care, based on physical, socioeconomic, psychosocial, educational, safety and related criteria, appropriate to the age of patients served in the assigned service area. • Reflect a fundamental concern with and respect for patients' rights. • Develop an understanding of ethical and medical/legal issues surrounding patient care, hospitals' policies governing these issues, and structures available to support ethical decision making. • Sensitive to and apply cost containment strategies while caring for patients. • Conduct him/herself professionally, ethically, and personally in a manner consistent with the standards and aims of the medical staff of the affiliated hospitals and the School of Medicine.

• Develop and participate in a personal program of self study and professional growth with guidance from the teaching staff. • Participate in the evaluation of the program and its faculty. Non-Academic Criteria (Technical Standards) for House Staff_____________ In accordance with the ADA and the Rehabilitation Act of 1974, IU School of Medicine provides reasonable accommodations to qualified individuals with a disability. The Graduate Medical Education Committee (GMEC) has specified the following non- academic criteria ("technical standards") that all residents/fellows are expected to meet in order to participate in the medical education program and the practice of medicine. As appropriate, individual training programs may add more specific standards to these criteria. 1. Observation: The resident/fellow must be able to participate actively in all demonstrations and laboratory exercises in the basic medical sciences and to assess and comprehend the condition of all patients assigned to him or her for examination, diagnosis, and treatment. Such observation and information acquisition usually requires the functional use of visual, auditory, and somatic sensation. 2. Communication: The resident/fellow must be able to communicate effectively and sensitively with patients in order to elicit information; describe changes in mood, activity, and posture; assess non-verbal communications; and effectively and efficiently transmit information to patients, fellow house staff, students, faculty, staff, and all members of the health care team. Communication skills include speaking, reading, and writing, as well as the observation skills described above. 3. Motor: The resident/fellow must have sufficient motor function to elicit information from patients by palpation, auscultation, percussion, and other diagnostic maneuvers; be able to perform basic laboratory tests; possess all skills necessary to carry out diagnostic procedures; and be able to execute motor movements reasonably required to provide general care and emergency treatment to patients. 4. Intellectual-Conceptual, Integrative, and Quantitative Abilities: The resident/fellow must be able to measure, calculate, reason, analyze, and synthesize. Problem solving, the critical skill demanded of physicians, requires all of these intellectual abilities. In addition, the resident/fellow must be able to comprehend three- dimensional relationships and to understand the spatial relationships of structures. The resident/fellow must have the capacity to perform these problem-solving skills in a timely fashion. 5. Behavioral and Social Attributes: The resident/fellow must possess the emotional health required for full utilization of his or her intellectual abilities, the

exercise of good judgment, the prompt completion of all responsibilities attendant to the diagnosis and care of patients, and the development of mature, sensitive, and effective relationships with patients and others. Residents/fellows must also be able to tolerate taxing workloads, function effectively under stress, adapt to a changing environment, display flexibility, and learn to function in the face of uncertainties inherent in the clinical problems of many patients. Compassion, integrity, concern for others, commitment, and motivation are personal qualities that each resident/fellow should possess. QUALIFICATION REQUIREMENTS__________________________________ No resident will be able to begin a training program or receive any benefits without having met these requirements which include: SIGNED CONTRACT AND PATENT AGREEMENT The term of your appointment is for one year. Reappointment to subsequent years will be dependent upon satisfactory progress in education and satisfactory performance of all duties. It is the University's responsibility to see that advancements of intellectual property at the University are administered for the best interests of the public and in such a way as to bring credit to the University and to fulfill the University's contractual obligations to others. Therefore, it is the policy of Indiana University that all employees sign a patent agreement to achieve that end. INDIANA SCHOOL OF MEDICINE HONOR CODE All house staff members must sign an honor code. This is a promise to uphold the highest standards of ethical and compassionate behavior while training at the School of Medicine. It is also an agreement to strive to uphold the spirit and letter of this honor code during your years at Indiana University School of Medicine, and throughout your career in the health professions, by following the tenets of honesty, integrity and respect. The purpose of the honor code is to create a professional environment that fosters excellence, abhors intolerance, and values each individual's unique contribution to the learning community. SIGNED STATEMENT OF PRINCIPLES All house staff members must sign the Indiana University School of Medicine Statement of Principles. This statement is a promise to uphold the highest standards of ethical and compassionate behavior while training at the School of Medicine. It is also an agreement to strive to uphold the spirit and letter of this honor code during your years at Indiana University School of Medicine, and throughout your career in the health

professions, by following the tenets of honesty, integrity and respect. The purpose of the honor code is to create a professional environment that fosters excellence, abhors intolerance, and values each individual's unique contribution to the learning community. CRIMINAL BACKGROUND CHECK Appointments are contingent on the University's verification of credentials and other information required by Indiana state law. Likewise, appointments are also contingent on the completion of a criminal history check. IU has established a background check process that consists of two parts: the appointee will be required to complete a self- disclosure questionnaire and a consent form prior to the beginning of training. A formal background check will be conducted which will include criminal history, sex and violent offender registries. MOTOR VEHICLE RECORD CHECK POLICY In order to drive on university business, you must maintain an acceptable driving record. If you will be driving a university vehicle or your own vehicle on university business more than once a month, you will be required to authorize a review of your driving record. An annual motor vehicle record check will be conducted by the Office of Risk Management; you may request a copy of this check. If your driving record falls below an acceptable level, your authorization to drive on university business will be suspended until your driving record improves. MEDICAL or DENTAL SCHOOL DIPLOMA A copy of the medical or dental school diploma must be submitted prior to the beginning of training. EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG) CERTIFICATE All International Medical Graduates (IMG) must submit a valid unexpired ECFMG certificate. LICENSURE TO PRACTICE MEDICINE OR DENTISTRY IN INDIANA All physicians and dentists must have a "Permanent License" or a "Temporary Medical Permit" in force throughout the entire training period as is required by the Health Professions Bureau of the State of Indiana. It is the house officer's obligation to maintain current registration. A copy of the updated license or temporary medical permit must be provided to the Office of Graduate Medical Education each year prior to expiration of the current license/permit.

IMPORTANT: If your home address changes during the course of your training, it is your legal obligation to notify the Health Professions Bureau. Address: 402 West Washington Street, Room 041, Indianapolis, IN 46204; Phone Number: 232-2960. HEALTH SCREENING Prior to the beginning of training, house staff members are required to complete and return the Occupational Health Services form. An annual PPD screening and immunization review prior to reappointment on July 1 is also required. Anyone failing to comply with these requirements will not be able to begin training or will be placed on an Administrative Leave of Absence without pay. The hepatitis B vaccine, although not required, is strongly recommended as a protection to the house staff and the patient population. The Occupational and Student Health Services Department is located in Coleman Hall, First Floor; Phone Number is 274-5887. The department provides annual PPD screenings and hepatitis B vaccines at reduced costs. Workmen's compensation claims will be processed at no cost to the house staff member. I-9 FORM - DOCUMENTATION OF IDENTITY AND RIGHT TO WORK The Immigration and Control Act of 1986 and the Immigration Act of 1990 states that all employees, citizens and noncitizens, must complete an I-9 form at the time of hire, which is the actual beginning of employment. This information will be used as a basis for determining eligibility of an employee to work in the United States. Documents must be presented that establish identity (e.g., driver's license or U.S. passport) and employment eligibility (e.g., social security card). IMGs on a J-1 visa must present an unexpired foreign passport, I-94 card indicating J-1 D/S (Duration of Status), and DS2019 from ECFMG showing expiration date, the institution, and training program. IMGs on a J-2 visa must present Employment Authorization Document Form I-688B issued by Immigration and Naturalization Service (INS). SCHOOL OF MEDICINE COMPLIANCE PROGRAM AND HEALTH INFORMATION PRIVACY AWARENESS ACT(HIPAA) All new house staff will participate in the IU School of Medicine General Compliance and HIPAA Training program at the house staff orientation. This is a mandatory program and includes the following modules: 1) General compliance training; 2) General insurance information and Medicare-specific rules/regulations; 3) Introduction to CPT and ICD-9 coding; and 4) Introduction to evaluation and management documentation guidelines and teaching physician guidelines. Failure to complete this compliance program at the orientation will result in the postponement of training or in immediate suspension from the training program.

LOCATION OF RESIDENCE House staff must reside within a reasonable distance of IU School of Medicine and the affiliated hospitals so as to provide patients with continuity and quality care. The determination of reasonable distance may vary depending upon the specialty of the house staff member. VISAS Visas that permit graduate medical education training: J-1 sponsored by ECFMG J-2 accompanied with Employment Authorization Form I-688B F-1 for one year of residency BENEFITS_____________________________________________________ HEALTH INSURANCE Health insurance is provided to the house staff by the affiliated hospitals through the School of Medicine Office of Graduate Medical Education. You will be responsible for any co-payments required by the plan at the time of service. Courtesy discounts are not permitted for inpatient or outpatient hospital charges which are not covered by insurance. The plan year runs from July through the following June. If you marry or have a child, you must complete a new form to add the dependent(s) to your insurance within thirty days of the event. If you do not complete an enrollment form within thirty days of the event, you will be required to wait until the next open enrollment period to obtain benefits for your spouse or child. Proof of dependent coverage must be submitted to the Office of Graduate Medical Education within 30 days from the effective date (i.e. marriage certificate, birth certificate, etc). Coverage will end on the last day of eligibility; for example, midnight on the last day of active, full-time employment. The main components of the M-Plan Health Network are explained below. Please refer to the enrollment packets for a more detailed explanation of the plan's benefits. • M-Plan Health Network: M-Plan provides you with health care services through different Health Networks of doctors and hospitals in Indiana. The M-Plan Physician Directory is available on line at www.mplan.com. The directory contains a listing of each M-Plan Health Network, its primary care and specialty physicians, office locations, and the hospital(s) you will be admitted to if inpatient services are necessary. You and each of your family members will need to choose one of the M-Plan Health Networks identified in the Physician Directory. Then, you and each of your

family members will need to choose a primary care physician with the Health Network you've selected. Your primary care physician's office needs to be located within fifty miles of your home. The primary care physician you select will work with you to coordinate your health services. You may change Health Networks only during an open enrollment period. However, you and your family members may change primary care physicians within the Health Network you selected at any time during the plan year. With any M-Plan Health Network you select, you will be able to see the same primary care physician for office visits. To receive specialty services, you will need to obtain a referral from your primary care physician. M-Plan members are offered a selection of convenient pharmacies for filling prescriptions. A list of pharmacies is also located on the M-Plan website. You will have two levels of co-payments: generic and brand name. For up to a thirty-day supply of a brand name drug, you will pay a higher amount of co-payment than for a generic drug. If a brand name drug is requested when a generic equivalent is available, it will not be covered. The vision program is through Vision Service Plan (VSP). VSP has an extensive statewide network of doctors who provide quality eye care and materials. When you are seen by a participating doctor from VSP's list, your plan covers an eye examination, less any applicable co-payment. You may also purchase eyeglass frames and lenses at a discount. If you have questions about M-Plan, its providers, or your specific benefits, please contact the Member Services Representatives. They can also help you with any concerns regarding eligibility, membership cards or other specific situations. The Member Services Representatives can be reached from 8am to 5:30pm, Monday through Friday. Phone numbers: 317-571-5320 or toll-free 1-800-816-7526. If additional health care options become available, you will receive a detailed description of the plans prior to open enrollment. DENTAL INSURANCE You have a choice of two dental care plans: CIGNA Dental Health Maintenance Organization (DHMO) and CIGNA Preferred Provider Organization (PPO). You will be allowed to enroll in one of these plans at the beginning of your training. Please refer to the enrollment packet for a detailed explanation of each of the plans. If you decide not to enroll, you must wait until the next open enrollment period to receive this benefit. Also, you may change plans only during open enrollment.

• DHMO: This program emphasizes diagnostic and preventive services and offers quality services and benefits through a network of participating dental locations. With the DHMO there are no deductibles or claim forms. You will receive services at no charge for x-rays, routine cleanings, topical fluoride, oral exams, and local anesthesia. All other procedures are covered at substantial savings to you. Please refer to your Fee Overview which shows the exact amount you pay for other procedures. • PPO: This is a traditional plan that provides reimbursement for dental services from a network of participating providers, or at a lower benefit, outside the network from any licensed dentist of your choice. You are required to pay the dentist for normal charges and then file a claim for reimbursement. Under this program, you have an annual deductible of $50 for a single plan and $150 for a family plan. There is also an annual benefit maximum amount of $500 per person per plan year. DOMESTIC PARTNERS BENEFITS The IU School of Medicine provides the benefits listed below for qualified domestic partners and qualified children of domestic partners. • Medical and dental coverage • Fee courtesy • Life and Accidental Death and Dismemberment Insurance To take advantage of these benefits for a same-sex domestic partner and any associated child(ren), a house staff member will first need to register the domestic partnership with the IU Office of Graduate Medical Education by completing an Affidavit of Domestic Partnership form and submitting the required supporting documentation. After completing that process, a house staff member would follow the normal benefit enrollment provisions for the domestic partnership. OPEN ENROLLMENT Open enrollment occurs annually from mid-April to mid-May. Changes made during open enrollment will be effective from July 1 through the following June 30. During open enrollment, you have the opportunity to change to one of the other available health or dental plans or choose a different M-Plan Health Network. You may change your primary care physician at any time during the plan year. If you had a qualifying event during the past year but did not add your spouse or child to your health plan within thirty days of the event, you may add the individual during the open enrollment period. No individual may be eligible for benefits both as a house staff member and as a dependent or as a dependent of more than one house staff member.

COBRA CONTINUATION COVERAGE You and/or your dependents may continue coverage under your group health plan for up to eighteen months after termination of employment. This is called COBRA continuation coverage. You will be notified that you have the right to continue coverage and you will have sixty days to respond. If you elect to continue coverage, the total cost is your responsibility. IU School of Medicine will not supplement the cost. There will be no interruption in benefits if your election form is completed within the specified time and you have paid all premiums due within 45 days of the date you complete your election form. Premiums are calculated at the Group Plan rates. It is important that the Office of Graduate Medical Education has a current address on file for you in order to insure that all information related to COBRA is received by you in a timely manner. If you choose not to continue coverage, your group health insurance will end at your termination date. MENTAL HEALTH REFERRAL, EVALUATION, AND TREATMENT RESOURCES Indiana University School of Medicine provides free and confidential counseling services to the medical students and house staff. Information can be obtained by calling Counseling Services at 317-278-4750 or visiting their website at http://msaa.iusm.iu.edu/counser.htm. Services available are: individual, couples and family, and group counseling, consultation, programming, and emergency intervention. Typical concerns presented for counseling include adjustment, alcohol or drug-related difficulties, anxiety/stress management, body image, depression, disordered eating, emotional response to physician responsibilities, harassment, individual differences, relationship difficulties, self-esteem, sexuality, sexual victimization, and suicidal thoughts. At times, students and house staff may require mental health evaluation and/ or long-term counseling. These individuals are referred to mental health professionals both on and off campus who provide these services. The Office of Counseling Services may assist, organize, and/or present educational programs depending on advance notice and availability. All individuals will be treated with respect regardless of age, color, counseling concern, ethnicity, gender, marital/parental status, national origin, race, religion, physical ability, sexual orientation, or veteran status. Counseling is confidential in accordance with state laws and ethical guidelines. Counseling records are maintained in files separate from the student/house staff files and cannot be accessed by faculty, staff, administrators, parents or other student/house staff without the individual's written permission. Students and house staff may schedule an appointment by calling Counseling Services. A meeting with the counselor should be available within one week. Walk-in and evening appointments are welcomed depending on counselor availability. When an emergency occurs after regular business hours call 911 or the Access Center for Clarian Health, 24 hour a day, 7 days a week at (317)962-2622.

Mandated psychiatric or substance abuse evaluations may be requested by a residency training director or the Dean's Office when there is concern that a resident's performance may be impaired by psychiatric illness or substance abuse. Results of a mandated evaluation are reported to the residency training director and to the Director for Graduate Medical Education. The results of such evaluations are circulated as narrowly as possible consistent with the need to establish fitness to continue in training. Refusal to cooperate with a mandated psychiatric or substance abuse evaluation may be considered grounds for administrative dismissal from the training program. Additional coverage for mental health services is available through M-Plan. PHYSICIAN ASSISTANCE PROGRAM IU School of Medicine has contracted with the Indiana State Medical Association Physician Assistance Commission (ISMA-PAC) to coordinate efforts in identifying and assisting IUSM physicians with illnesses impairing their ability to practice medicine. These illnesses may include chemical dependency, psychiatric illnesses, and/or physical illnesses. The IU Committee and the liaison with ISMA Commission were created to assist in the identification, treatment, and rehabilitation of an impaired member of the medical staff and house staff. This committee's charge is to serve all physicians who provide care at Clarian Methodist, IU, Riley, VAMC, and Wishard Hospitals be they faculty, staff, or resident physicians. If intervention is deemed appropriate, it is undertaken in a confidential, positive, supportive manner, consistent with the laws of the State of Indiana, with the goals of recovery and rehabilitation foremost in mind. For confidential assistance, contact: Candace Backer, ISMA Physician Assistance Coordinator, 322 Canal Walk, Indianapolis, IN 46202; Phone: 317-261-2060 or 1-800-257-4762. DISABILITY INSURANCE The long-term disability insurance, provided at no cost to house staff members, is administered by Northwestern Mutual Life Insurance Company, Policy Number L661073. Please refer to the brochure which explains this benefit in detail. The plan pays 66-2/3% of basic monthly earnings not to exceed the maximum monthly benefit of $2,500. The elimination period is 90 days. The benefit period is to age 65 if under age 60; if more than 60 years of age, the benefit duration decreases accordingly. After the first 12 months of disability yearly benefit increases will be determined by multiplying the benefit amount by an indexing factor based on Consumer Price Index (CPI). There is a preexisting condition exclusion of 3/12 months. The plan also contains a survivor's benefit if a claimant should die. The lump-sum equivalent of three monthly benefits will be paid to the spouse or child. When your training is complete, you may continue to purchase coverage at group rates based upon your stipend during the last

full month of training for as long as you remain employed in the health sciences. You can visit the disability plan website at www.iudisability.com for details on a voluntary option to purchase individual disability coverage under special discounted pricing. In addition to information on your coverage options, you can also request a cost quote for coverage at this website. If you have any questions regarding coverage, please contact Lee Moore (558-1012) or John Haffner (873-6060). LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Basic Life and Accidental Death & Dismemberment insurance is provided to the house staff at no cost through CIGNA Life Insurance, Policy Number FLX-960485. Proof of good health is not required. In the event of death of the employee, the plan pays $20,000 to the named beneficiary. All employees must have a current beneficiary designation card on file with the House Staff Office that is signed and dated. Coverage is effective on the first day of full-time employment with the University; there are no waiting periods to satisfy. Please consult your "Certificate of Coverage" for specific details of the program including Waiver of Premium and Conversion Privileges. If you have any questions, please contact the Graduate Medical Education Office at 317/274-8282. MEDICAL MALPRACTICE LIABILITY INSURANCE The School of Medicine provides, or arranges to provide through its affiliate hospitals, medical malpractice liability insurance coverage for house staff only while acting in the scope and course of approved training. Insurance coverage extends to claims made during and after the training period if based on acts or omissions which took place during the training period. Coverage limits for house staff are in accordance with the Indiana Medical Malpractice Act, as amended from time to time. The School of Medicine provides medical malpractice liability insurance coverage for house staff outside an approved affiliate hospital ONLY WITH THE PRIOR WRITTEN APPROVAL OF THE PROGRAM DIRECTOR AND ASSOCIATE DEAN FOR GRADUATE MEDICAL EDUCATION. Rotations or electives outside the State of Indiana are also subject to prior written approval of the Program Director and Associate Dean for Graduate Medical Education. Coverage limits for out of state rotations may be difficult to obtain unless the institution in which the rotation occurs provides the insurance. This may limit the availability of such rotations. The School of Medicine DOES NOT provide insurance coverage for house staff engaged in moonlighting activities. For additional information or questions about insurance coverage, contact the Office of Graduate Medical Education at 274-8282.

UNIFORMS AND IU SCHOOL OF MEDICINE PHOTO IDs The standard uniform is a white lab coat with IU School of Medicine embroidered on it. Lab coats and laundering are usually provided by each program. Ask your Chief Resident about specific departmental requirements regarding dress codes. The IU School of Medicine Photo ID card is required for all house staff. The cost of the ID card is $10, paid to Card Services. No other hospital specific identification will be necessary when on rotation at the affiliated hospitals. You may also add funds to the card if you wish to use it as a debit card at the campus locations that accept it. You may use your Photo ID for a library card, campus photocopy card, physical education recreational sports card, vending machine card, food services card, and bookstore card. Photo IDs are available at two locations: University College Room 127, Mondays and Wednesdays, 10 am - 1 pm and 2 - 7 pm; Tuesdays and Thursdays, 8 am - 1 pm and 2 - 5 pm; and Fridays 10 am - 4 pm, and the Union Building UN115, Monday through Friday 8 am - 4:45pm. You will need to bring a photo ID with you to obtain an IUSOM Photo ID card. In order to gain admittance into Clarian IU and Riley Hospitals and any IUSOM building after 8pm and on holidays and weekends, you must have a security access card. Your department will assist you in obtaining this card. VEHICLE REGISTRATION-PARKING All affiliated hospitals offer preferential parking stickers or cards to the house staff at no charge. For Clarian IU and Riley Hospitals, register at IUPUI Parking Services Office located in the Vermont Street Garage. IUPUI stickers expire on June 30 of each year and must be renewed prior to July 1. IUPUI parking allows for "A" surface parking or garage parking, but not both. Residents on rotation at Clarian Methodist Hospital should park in Parking Garage #1, located on the Northeast corner of 16th and Senate. For your convenience, it is recommended that you obtain a Parking Card ($15 deposit). Your IUSM ID badge will still be able to be used if you do not obtain a parking card - Just show it to the parking attendant when leaving and you will not be charged for parking. If you park in any other garage on the Methodist campus, you will be expected to pay the customary parking charges. At Wishard, you will receive a parking decal from your Chief Resident at the beginning of each rotation. If you have any problems, go to the Human Resources Office on the second floor of the Ott Building. You will need your IUSM photo ID and security access card in order for them to issue you a parking decal. At VAMC register at the Police and Security Office, C-2107. Take care of parking registration on the first day of rotation at each affiliated hospital.

LIVING QUARTERS Each affiliated hospital will provide suitable on-call quarters. OSHA AND CDC RECOMMENDATIONS It is the policy of the School of Medicine that training for universal precautions is mandatory for all house staff prior to the commencement of training. Compliance is also required with OSHA and CDC recommendations which assumes that every direct contact with a patient's blood and other body substances is infectious and requires the use of protective equipment. The affiliated hospitals agree to provide, and make readily available, personal protective equipment to include gloves, face protection (masks and goggles), and cover gowns. In the event of a contamination incident the house staff member should call pager number 312-OUCH (312-6824) and follow the instructions given. Other numbers that may be useful if questions or concerns arise regarding infection control, needle sticks or OSHA requirements are the following: Clarian: 962-2157 Wishard: 630-7574 VAMC: 554-0000, Ext. 3387 IUSM Occupational and Student Health Services: 274-5887 DINING FACILITIES-MEALS ON CALL Residents are provided meals when on call at each of the affiliated hospitals. Fellows rarely are on call; therefore, meals are not provided to fellows. House staff are expected to pay for meals when not on call. In addition to the Student Union Cafeteria and snack bar, cafeterias are available at each hospital listed below. Similarly, all the hospitals have vending machines open 24 hours a day. • Clarian IU, Riley, and Methodist Hospitals: Electronic meal cards are issued through your department. The card works as a debit card to purchase food in the Clarian IU Hospital Cafeteria and Quick Serve, Clarian Riley Hospital Cafeteria and the Methodist Hospital Cafeteria. Points will be deposited into your account based on the number of on-call times you are scheduled for each month. Two tickets are issued for week night call to use for the evening meal and breakfast the next morning. For weekend and holiday call, three tickets are issued for lunch, dinner, and breakfast the following morning. The value of each meal ticket is $4.25. Any cost in excess of this amount must be paid by the individual. If you lose your card, please inform your department secretary in order for the card to be deactivated and a new one issued. There will be a $5.00 charge to replace the card. Each time you use the gold card, your receipt will tell you how many points still remain in your account. Each point represents one penny to the system. During the month, it will be possible to add or subtract meals to your

account if rotation changes have occurred. Please contact the department secretary who will submit the appropriate form to Nutrition and Dietetics. Points will be zeroed out twice a year: on December 31 and on June 30. Clarian IU Hospital Patio View Cafeteria Breakfast 6:30 am-10:00 am Lunch 11:00 am- 2:00 pm Grill Service 2:00 pm- 4:30 pm Dinner 4:30 pm- 7:00 pm Grill Service 7:00 pm-11:00 pm Late Night Dinner 12:00 am- 3:00 am 1st Floor Quick Serve Monday-Friday 6:30 am- 1:30 pm Clarian Riley Hospital Cafeteria Monday-Friday Breakfast 6:30 am-10:00 am Lunch 11:00 am- 2:00 pm Dinner 4:00 pm- 7:00 pm Saturday and Sunday Lunch 11:00 am- 2:00 pm Dinner 4:00 pm- 7:00 pm Riley Deli & Pizza Station Monday - Friday 7:00 am- 4:00 pm 7:00 pm-12:00 am

McDonald's Sunday - Saturday 5:00 am- 3:00 am Clarian Methodist Hospital: Beacon Cafeteria Full Breakfast 6:00 am- 9:30 am Continental Breakfast 9:30 am-10:45 am Lunch 10:45 am- 1:30 pm Limited Selections & Grill Items 1:30 pm- 4:30 pm Dinner 4:30 pm- 7:30 pm Limited Selections & Grill Items 7:30 pm- 12:30 am Late Night Dinner 2:00 am- 3:30 am Continental Breakfast 4:30 am- 6:00 am • Wishard Hospital: Meal tickets will be distributed to residents when on call. Tickets will not exceed the dollar value printed on each color coded, pre- numbered ticket. Food items costing in excess of the value must be taxed at 6% and the difference collected from the ticket holder in cash at the time of the purchase. Each clinical service is responsible for the distribution of tickets to its own house staff members. Two tickets for week night call (evening and breakfast the next morning) and weekends and holidays (lunch, dinner, and breakfast). Cafeteria Breakfast 6:00 am-9:00 am Coffee Service 9:00 am-10:00 am

Lunch 11:00 am- 2:30 pm Dinner 4:00 pm- 7:00 pm Late Dinner 9:30 pm - 11:30 pm Early Breakfast 12:00 am - 1:30 am • VAMC: House staff assigned as "Officer of the Day" (OD) are authorized to receive the evening meal, a snack with the evening meal, and breakfast (following morning) Monday through Friday. Three meals and a snack are provided Saturday, Sunday, and federal holidays (noon, evening, snack and breakfast the following morning). House staff must be scheduled on duty at VAMC and have a signed meal ticket to be eligible to receive these meals. If you are unable to pick up a tray in the evening, call #2814, give your name and service, and a tray will be held for you until 7 pm. If house staff are unable to get their meals at the times noted, a frozen dinner, bread, milk, and fruit (evening meal) and milk, fruit, and cereal (breakfast meal) will be provided in Room C-5126 (medicine) and C-4078 (surgery and anesthesiology). House staff must sign their name, service, type of meal, and the date on the frozen meal sheet hanging on the refrigerator. This will permit Nutrition and Food Services to track food items to ensure that ample supplies of dinners are available. In addition, other food items, e.g., bagels and cream cheese, yogurt and fruit, will also be located in these two rooms throughout the day. On-call meals from Dietetics: Monday - Friday Breakfast 6:30 am- 8:30 am Dinner & Snack 4:30 pm- 6:30 pm Sat., Sun., and federal holidays Breakfast 6:30 am- 8:30 am Lunch 11:30 am- 1:00 pm Dinner & Snack 4:30 pm- 6:30 pm FEE COURTESY INFORMATION Summary of House Staff fee courtesy benefits: House Staff Member - Covered tuition paid at 100% up to a dollar limit* per semester; based on 100% of three credit/audit hours and 50% for another three credit/audit hours, at the Indiana resident undergraduate, graduate, or professional rate.

Spouse/Domestic Partner Fee Courtesy - covered tuition paid at 100% up to a dollar limit* per semester; dollar limit based on 50% of three credit/audit hours at the Indiana resident undergraduate rate. Dependent Child Fee Courtesy - 50% of Indiana resident undergraduate rate, up to a maximum of 140 credit hours towards the first baccalaureate degree. *Dollar limits will vary based on tuition rates at each campus, and will increase from year to year based on tuition rates approved by the Board of Trustees. Covered tuition does not include special fees such as those for laboratories, applied music, student teaching, dissertation research fees, facility fees, etc. Please refer to the Fee Courtesy Application for more detailed information regarding this benefit. Applications for fee courtesy are available at the Office of Graduate Medical Education, Fesler Hall, Rm. 224 and on-line at http://housestaff.iusm.iu.edu/ . Applications must be submitted to the Office of Graduate Medical Education. BANKING SERVICES Membership to the Indiana Federal Credit Union is available to the house staff. The Credit Union offers a number of services including savings, no-charge interest-bearing checking, a variety of loans, and payroll deduction. The dividend rate on regular savings, money market and checking accounts is very competitive. A $50 deposit is required. The facility is located on the first floor of the Student Union Building, next to the bookstore. Phone Number: 636-8479. ATMs are located at all affiliated hospitals and many buildings on the IUPUI campus. Preferred Private Banking Programs are offered by Key Bank National Association, National City Bank of Indiana, and Bank One. They will provide banking services as well as assistance with student loan payments and other financial needs. FITNESS FACILITIES Swimming, indoor track and workout equipment are available to house staff at a reduced rate at the Natatorium (274-3518) and the National Institute for Fitness and Sport (NIFS)(274-3432). Residents/fellows are also allowed to use the fitness centers located at Clarian Methodist and Clarian IU Hospitals. The fee for using the centers is $20/month. The centers are open 24 hours/day, 7 days/week. The Methodist center is located in Building E and the phone number is 962-8104. The IU center is located in the basement of the out patient center and the phone number is 274-0341. The VAMC exercise room is located in room C-B008 (Basement - C wing). Access is through a key pad. Residents go to VAMC Employee Health to sign a waiver and than

will be given the key pad access code. Employee Health is located in room C-2106 (2nd floor - C wing). COMMUNICATIONS_____________________________________________ MAIL Each department has its own arrangements for house staff mail. Check with your department or Chief Resident as to where to pick up your mail. When possible, personal mail should be delivered to your home address. The Campus Post Office is located in the Post Office Building, Room 100, between the Clinical Building and Long Hospital. E-MAIL House staff members will be given an E-mail account through their departments. The E- mail application used by Indiana University and Clarian is OUTLOOK. This is a versatile desktop information manager application which helps you communicate with other people, schedule and keep track of appointments, meetings, and tasks, and organize information. The Office of Graduate Medical Education sends out important notices and communications via the house staff list serve. It is important that you access your email frequently so you do not miss these important emails. IUSM WEBSITE The IU School of Medicine website is: http://www.medicine.iu.edu. The House Staff have an intranet site for convenient access to forms and information. It also has a polling section for voicing your concerns and suggestions. The URL for this site is http:// housestaff.iusm.iu.edu. PAGERS Clarian Methodist, IU, and Riley Hospitals, Wishard Hospital, and VAMC all use a unified paging network which allows house staff and medical staff to be reached at any of the above hospitals as well as Larue Carter Hospital, St. Vincent Hospital, Community Hospital, hospitals outside of the Indianapolis area, and the beltway facilities. The commercial vendor is SBC. You will receive a pager when you begin your training and should be able to use the same pager number throughout your training. You will be required to sign an Equipment Agreement with the School before receiving the pager. You are responsible for the pager; if it is lost, stolen, or damaged, you must pay the insurance deductible prior to replacement of the pager.

MISCELLANEOUS SERVICES_______________________________________ HOUSE STAFF FORUM This organization was established in October, 1998, to provide the house staff with assurance of an educational environment in which they may raise and resolve issues without fear of intimidation or retaliation. The Forum provides the house staff with an organizational system to communicate and exchange information on their working environment and their educational programs. A house staff representative is elected from each parent program annually. Any resident in the parent program or a fellow in an appropriate subspecialty program may be elected to represent the parent program. The representative must be willing to attend and participate in meetings, provide information, and disseminate information to the other house staff. The House Staff Forum meets quarterly and on an as-needed-basis. Officers for the Forum are chosen by the program representatives. NOTARY PUBLIC SERVICE Services of a Notary Public are available for official documents at no charge in the Administration Office at Wishard Hospital, the Information Desk (front lobby) of IU Hospital, and the Details Clerk (Ext. 2386) at VAMC. The Dean's Office in Fesler Hall 224 and several departmental offices also have notary services available. PHYSICIAN ID NUMBER At the beginning of your training, you will be assigned a Physician ID number for use at the IU School of Medicine affiliated hospitals. The purpose of the Physician ID number is to provide a common access number for the computer systems at each hospital, in particular the medical records and dictation systems. This number will be associated with house staff who continue as faculty/medical staff members in the future. The numbers are essentially the same; however, each hospital has a unique difference as shown below: Clarian Methodist, IU, and Riley 01234 Wishard 1234-1 VAMC VA1234

Clarian Methodist, IU, and Riley Hospitals' number is a five-digit number (Example: 01234); Wishard's number is the four numbers plus a check digit (Example: 1234-1); VAMC's number is the four numbers preceded by VA (Example: VA1234) or followed by VA (Example: 1234VA). In order to access any of the hospitals' systems, each institution will assign you an initial password. You will have the capability of changing this password and making it the same across all institutions. In order to receive your password and initiate logon into the systems, you must complete and sign a confidentiality letter at each institution. Please contact the Office of Graduate Medical Education if you do not receive a Physician ID number at the beginning of your training. DEA NUMBERS If you have your own DEA number, please use it when writing prescriptions at the affiliated hospitals. Otherwise, medical and dental residents may write prescriptions using the DEA number of the hospital pharmacy where you are working. These prescriptions can only be filled at the hospital's pharmacy. They are not valid for outside pharmacies, i.e. Osco, CVS, etc. The hospital DEA #s are: Clarian Methodist BC 5175535 Clarian IU BC5175561 Clarian Riley BC 5175511 Wishard AW6812398 VAMC Your Social Security Number Your patient and the pharmacist must deal with multiple state and federal laws, regulations, and insurance requirements. The pharmacist cannot dispense medications until all the information on the prescription form is complete. To produce a legal prescription you must enter the following items: • Your full name - printed legibly. • The hospital name and address, including the city. • Your DEA number - permanent number if issued, or Hospital DEA number plus the last five digits of your Social Security number. • Your Indiana license number. • The correct quantity box must be marked on Indiana Security prescription blanks for controlled drugs.

Please enter your DEA and license number on the form as a matter of routine. These are required by insurance companies and Indiana Medicaid as prescriber identifications for controlled as well as noncontrolled drug orders. Prescriptions cannot be dispensed without these numbers if the patient has insurance. LONG DISTANCE TELEPHONE CALLS It is not appropriate to make a personal long distance telephone call and charge it to any of the hospitals. Contact the operator in the specific hospital and arrange to have the call charged to your home. Do not direct-dial from the phone in a patient's room as this results in double-billing to the patient. • At Clarian IU and Riley Hospitals, you will be given a long-distance authorization code. You will be required to enter this code whenever you make a long distance call from the IUPUI telephone system or when accessing the system remotely. The authorization code is to be used for Clarian IU and Riley Hospitals' patient- related business only. All personal/unauthorized calls will be billed to the individual who places the call. The authorization code is strictly confidential and is not to be given to anyone! If the authorization code is lost or misplaced, please notify the House Staff Office (274-8282) immediately. The lost number will be deactivated and a new one issued. Please use SUVON (State University Network) whenever possible because of the reduced cost. The long-distance authorization code will remain the same throughout your training. • At Clarian Methodist Hospital long distance calls can be placed from designated phones. Contact the program secretary or Chief Resident to assist you. • At VAMC there are codes used to place long distance calls; you must ask one of the secretaries or ward clerks to place the call on an FTS line (similar to a WATS line). • At WISHARD, it is usually unnecessary to place long-distance calls, but if needed, check with the department chief, or in an emergency, ask the Wishard operator to assist you. MEDICAL LIBRARIES The Indiana University School of Medicine Ruth Lilly Medical Library, established in 1908, is located in the Medical Research and Library Building. The hours are: Monday-Friday 7:30 am-midnight Saturday 8:00 am- midnight Sunday Noon - midnight

You may call the Library at 274-7182 for further information; the Web site is: http://www.medlib.iupui.edu. Your IUSM ID card can be used as a library card for borrowing books. The library has approximately 1,900 current journals and 245,000 physical volumes. There are reference services, computer-search services (BRS, OCLC, SDC, and MEDLINE), interlibrary loan service, and photocopiers (5 cents per exposure) available for your use. Clarian Medical Library is located in the Outpatient Surgery Center, Room D1422. The hours are: Monday-Thursday 8:00 am-5:30 pm and Friday 8:00 am-4:30 pm. The library has a collection of 3,000 books and 530 active journal subscriptions. Computer access to medical databases is available via the OVID Web and Internet access. Microsoft Office Suite, photocopiers, audio visual equipment are also available. After hours access requires a security card. For additional information call 962-8021. FAX 962-8397. E-mail http://www.clarian.org/health_care_professionals/Libraries/ClarianLib/ default.asp VAMC Health Sciences Library is located in Room A-2009. The hours are: Monday-Friday 7:30 am-5:00 pm. There are approximately 4,500 bound journals, 3,200 books, 1,500 audio visual programs, and subscriptions to 600 journals. Also available are reference service, interlibrary loan service, and computer-searching service (MEDLINE, BRS and CD-ROM end user searching). For additional information call 554-0000, ext. 2333. Wishard Professional Library is located in the Ott Building, Main Floor. The hours are Monday-Friday 8:00 am-4:30 pm. Telephone 630-7654 for further information. Wishard Media Services is also located in the Ott Building, Third Floor. The hours are: Monday- Friday 8:00 am-4:30 pm. Telephone 630-7657. Library/Media Services information for Wishard is subject to change. MEDICAL SOCIETIES AND ASSOCIATIONS House staff members are encouraged to consider membership in the Marion County Medical Society, Indiana State Medical Association, and the American Medical Association. While here in training, it is easy to find four faculty members to sponsor your application. Since transfer to any other county medical society can be done by an endorsement letter, it may make future membership easy anywhere in the U.S. without having to find local physicians to sponsor you in an unfamiliar town. Residents and fellows get a bargain rate per year for all three; new members receive the Marion County Society Bulletin, the Indiana State Medical Journal, J.A.M.A., and a choice of one of several specialty journals. (The individual subscription rates for these are more than the dues.) SECURITY AND ESCORT SERVICE

• Escort services are available at all hospitals; call the hospital where you are working for escort services to you car or another hospital. The numbers for each facility are listed: IU Hospital 962-8000 Riley Hospital 962-8000 Methodist Hospital 962-8000 Wishard Hospital 630-7071 VAMC 554-0063 IUPUI 274-SAFE • Security will try to be there within ten to fifteen minutes. • Emergency parking is available for house staff at the following hospital garages for up to four hours at a time. House Staff must show their "A" permit when leaving the garage. University Out-Patient Parking Riley Out-Patient Parking Wilson Street Garage VAMC - Will identify two spaces next to Emergency Room entrance for emergency parking for house staff. • If called to campus for an emergency, house staff may also park in the Police Parking lot across from University Hospital; however, the car must be moved as early as possible the next morning. • IUPUI will provide backup escort services for all facilities; when calling for assistance, house staff should identify themselves as a house staff member. • House staff should not call in advance and ask security to meet them at their car; too much can happen between the time a call is placed and the time you arrive on campus pulling security away from other urgent tasks. • Instead, house staff should pull up to an Emergency Phone; call the police and wait there for them; the police will wait while you park your car and then will escort you to the hospital. POLICIES AND PROCEDURES______________________________________ House staff must abide by the policies and procedures of the affiliated hospitals where they are working. HONOR CODE

Embarking on a career in the life sciences and health care professions means accepting the responsibilities and unique privileges of these professions. These include self- monitoring and self-governance, and the responsibilities for these professional duties begin the moment that an individual starts medical school or graduate school. I understand that it is a great honor and privilege to study and work in the health care profession. As a member of the Indiana University School of Medicine community, I promise to uphold the highest standards of ethical and compassionate behavior while learning, caring for others, performing research, and/or participating in educational activities. I do so according to the following tenets that will guide me through my career. I will strive to uphold the spirit and the letter of this code during my years at Indiana University School of Medicine and throughout my career in the health professions. Honesty • I will maintain the highest standards of honesty. • If engaged in research, I will conduct these activities in an unbiased manner, report the results truthfully, and credit ideas developed and worked on by others. • If engaged in patient care, I will be considerate and truthful, and will accurately report all historical and physical findings, test results, and other pertinent information. Integrity • I will conduct myself professionally. • I will take responsibility for what I say and do. • I will recognize my own limitations and will seek help when appropriate. Respect • I will respect the dignity of others, treating them with civility and understanding. • I will contribute to creating a safe and supportive atmosphere for teaching and learning. • I will regard privacy and confidentiality as core obligations. • I will not tolerate discrimination. Expectations of the University and your colleagues Indiana University School of Medicine promises to create a professional environment that fosters excellence, abhors intolerance, and values each individual's unique contribution to our learning community. DUTY HOURS and THE WORKING ENVIRONMENT

Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident. The duty hour policy applies to all participating hospitals where training of residents occurs. 1. Duty Hours a. Duty hours are defined as all clinical and academic activities related to the residency program, i.e., 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. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, 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. 2. On-Call Activities 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 work day when residents are required to be immediately available in the assigned institution. a. In-house call must occur no more frequently than every third night, averaged over a four-week period. b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain

continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements. c. No new patients, as defined in Specialty and Subspecialty RRC Program Requirements, may be accepted after 24 hours of continuous duty. d. At-home call (pager call) is defined as call taken from outside the assigned institution. • The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. • When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit. • The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. 3. Moonlighting a. Because residency education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program. b. The program director must comply with the sponsoring institution's written policies and procedures regarding moonlighting, in compliance with the ACGME Institutional Requirements (See IUSM Moonlighting Policy). c. Moonlighting that occurs within the residency program and/or the sponsoring institution or the non-hospital sponsor's primary clinical site(s), i.e., internal moonlighting, must be counted toward the 80-hour weekly limit on duty hours. 4. Oversight a. Each program must have written policies and procedures consistent with the ACGME Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the residents and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service. All institutions that participate in the training of residents will be included in the monitoring process.

b. All ACGME-accredited programs will be required to complete the following information: o The ACGME WebADS annual update of the duty hour regulations (six questions relating to the numeric components of the standards). o For the first quarter of each academic year a summary document of the results of the program's monitoring activity for a four-week period consisting of a single rotation during that quarter submitted to the Office of Graduate Medical Education. o A copy of the program's duty hour's policy and an example of the method used to monitor the duty hours must be attached to the summary document. o An affirmation by the residents that they have seen the program's duty hour's policy must be contained in each program's duty hours monitoring method. o The summary document must include an explanation of how any non- compliance will be immediately remedied. c. GMEC will be presented with a report of all programs' duty hours summary documents. o Any program director who does not sufficiently and adequately address, in the summary document, all non-compliance issues will be requested to repeat the monitoring process in the next quarter and to submit a summary document for that quarter. If compliance issues remain, the program director must appear before GMEC with a plan of action to come into immediate compliance. o Any program director who does not submit a summary document of the results of the program's monitoring activity for the four-week period during the first quarter will be expected to repeat the monitoring process in the second quarter and to submit a summary document for that quarter. If the program director fails to submit a summary report of the second quarter monitoring process, the GMEC will request that the program director appear before the GMEC with an explanation as to why a summary report was not submitted and when the summary report will be submitted. o Any issues of non-compliance that are due to excessive service demands and that have not been successfully addressed by the program in cooperation with the affiliated hospital will be referred to the GMEC Task Force on Duty Hours for resolution. o The Duty Hours Task Force will report back to GMEC on its activities and the status of the non-compliance issue.

d. Faculty and residents must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract its potential negative effects. e. Residents who have observed violations and non-compliance with the duty hour regulations should report the violations to the Teacher/Learner Advocacy Committee (TLAC). The TLAC can be contacted through email at tlac@iupui.edu or visit their website at http://msa.iusm.iu.edu/tlaccommittee.htm. This committee will follow its standard procedures in investigating the allegations and report their findings to the Associate Dean for Graduate Medical Education. f. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care. 5. Requests for Duty Hour Exceptions The Graduate Medical Education Committee (GMEC) may grant exceptions for up to 10% of the 80-hour limit, to individual programs based on a sound educational rationale. The IUSM Policy and Procedures for Requesting Duty Hour Exceptions must be followed. MOONLIGHTING AND OTHER PROFESSIONAL ACTIVITIES OUTSIDE THE SCOPE OF THE RESIDENCY TRAINING POLICY Moonlighting is defined as any professional activity arranged by an individual resident/fellow, which is outside the course and scope of the approved residency/fellowship program, whether or not the resident receives additional compensation IU School of Medicine believes that moonlighting, either internal or external, by house officers is inconsistent with the educational objectives of house officer training and may not provide sufficient time for rest and relaxation to promote the resident's educational experience and safe patient care. Therefore, program directors must closely monitor all moonlighting activities keeping in mind the duty hour regulations which limit the house staff to 80 hours per week. Internal moonlighting must be counted toward the 80-hour weekly limit (See IUSM Policy on Resident Duty Hours and the Working Environment). All residency/fellowship training programs must have a written policy that addresses professional activities outside the educational program to include moonlighting. The policy must specify that house officers must not be required to engage in moonlighting. All house officers engaged in moonlighting must be licensed for unsupervised medical practice in the State of Indiana. It is the responsibility of the institution hiring the house officer to moonlight to determine whether such licensure is in place, adequate liability coverage is provided, and whether the house officer has the appropriate training and

skills to carry out assigned duties. If a house officer engages in employment outside the training program, Indiana University, the Schools of Medicine or Dentistry, any of the affiliated hospitals, or their insurers will have no responsibility for acts or omissions occurring outside the jurisdiction of the hospitals or the training program assignments. The program director must be fully informed about any moonlighting activity on the part of the house officer. Moonlighting activities and schedules must be submitted in writing, in advance, to the program director. If a program specific form is not available for this purpose, the IUSM Moonlighting Activity Form should be used. The program director must acknowledge that s/he is aware that the house officer is moonlighting by signing the moonlighting form and placing this form in the house officer's folder. The program director may or may not determine that the activity is detrimental to the house officer's progress in the training program. House officers engaging in moonlighting activities that have not been approved by the program director risk dismissal from the program. If it comes to the program director's attention that a house officer's moonlighting schedule coincides with the training program assignments, the house officer may be subject to disciplinary action, up to, and including termination (See Procedures for Grievance, Discipline and Termination in the Personal Information for House Staff handbook). If it is determined that the moonlighting activity is interfering with the training of the house officer, the program director may ask the house officer to reduce or terminate his/her moonlighting activity. House staff members on H-1B visas may accept moonlighting employment only if the employer for the moonlighting employment obtains approval for the concurrent employment from the INS by filing a new H-1B petition for concurrent employment for the house staff member. House staff members on J-1 visas many not engage in moonlighting in the United States. The J-1 visa only gives permission for the house officer to undergo medical training in the United States. LEAVE OF ABSENCE The IU School of Medicine Leave of Absence Policy for House Staff was developed to serve the best interests of the individual resident, the resident's colleagues, and to meet the resident's program goals as well as the goals of the School of Medicine. The education of the residents is of primary concern; patient care is not to be jeopardized, nor the education of medical students hampered. • Key Provisions: The School of Medicine provides eligible house staff two types of leaves of absence, a standard leave of absence, and a family/medical leave of

absence in accordance with the Family and Medical Leave Act of 1993 (FMLA). Generally, full-time house staff may be granted up to six weeks paid leave with full benefits for bona fide events including: Short-term disability or sick leave, and parental leave. The department chair/program director will determine what constitutes a bona fide leave and the length of leave on a case-by-case basis. Eligible house staff (house staff who have worked for the School of Medicine at least twelve months and at least 1250 hours during the twelve-month period prior to the first day of leave.) are entitled by law to a maximum of twelve weeks of FMLA leave (up to six weeks paid and six weeks unpaid) with full benefits for the following qualifying events: Birth of a child or care for the newborn; placement with the employee of a child for adoption or foster care; the need for the house staff member to care for a spouse, child, or parent with a serious health condition; a serious health condition that renders the house staff member unable to perform the functions of the job. All requests for leaves of absence will be made in writing to the department chair/program director at least thirty days in advance, or as soon as reasonably practicable. In addition, all requests for leaves of absence require the final approval of the Associate Dean for Graduate Medical Education. Vacation time must be taken as part of the School of Medicine leave and counted against the six weeks paid leave; this applies to the FMLA leave as well. • American Boards: In order to meet the educational requirements for each resident, it is necessary to consult the American Boards of each specialty to determine the maximum leave allowed for a resident to remain Board eligible. Some Boards clearly state the maximum time allowed for leaves; some have no specific policy; while others defer to the program director. Therefore, each Board must be consulted in order to determine if makeup time is required. • Make-Up Time: For a leave of absence that extends beyond the maximum allowed by the specialty Board, the department has the responsibility to see that the best interest of the educational program, as well as the interest of the resident is served. In order to assure the highest quality education, the department may decide that making up absent time would not be

satisfactory. The program director will ultimately decide how to resolve these situations. However, potential problems involving makeup time do not grant the program director the authority to deny FMLA leave to someone lawfully entitled to it. Any makeup time that is required will be scheduled with an effort to best accommodate the needs of the resident, but makeup time cannot be guaranteed. When makeup time is scheduled, the resident ordinarily will be required to make up the absent time in excess of six weeks (or the maximum allowed by the specialty Board) at the end of the academic year in which the absence occurred. This makeup time will necessarily delay the beginning of each of the resident's subsequent academic years by an amount equal to the makeup time. In effect, the resident's senior year will extend beyond June 30 by an amount equal to the makeup time. Any required makeup time will be paid and all fringe benefits provided. • Vacations: In addition to approved leaves of absence, a resident could be absent as a result of a vacation, a death in the family, military duty, or other personal reasons. Vacations of three calendar weeks (21 days) are granted each year for Levels I and II, and four calendar weeks (28 days) for Levels III and above. Vacation need not be taken at one time but must be taken during an academic year and cannot be accumulated. No payment will be made for unused vacation at the completion of training. Programs may place limits on the times of the year when vacation can be taken. Vacation time must be taken as part of the School of Medicine leave and counted against the six weeks paid leave; this applies to the FMLA leave as well. • Educational Seminars: If a department chair specifies certain seminars, meetings, or courses as part of the educational experience, residents at Level II or higher may be granted a few days' leave with pay. If a house officer wishes to attend a meeting, symposium, etc., which is not on the specified list, this should be done as part of annual vacation time. All educational leaves are at the discretion of the department chair and no additional pay or compensating time off will be granted. Each program determines whether expenses will be provided for attending medical conferences. • Additional Provisions: If a leave extends past six weeks in the first twelve months of a resident/fellow appointment or twelve weeks for all other appointments, health benefits may be

provided at the house staff member's expense and with the approval of the School of Medicine. This document is not intended to cover all of the provisions of the FMLA. Some of the key requirements of the FMLA are listed that will have the most significant impact on personnel practices for house staff. If more information is required, please contact the Office of Graduate Medical Education. • Short Tours of Military Duty: A house staff member will receive fifteen days of paid leave for military training in the National Guard or military reserves in any one military year (October 1 to September 30). Available vacation time may be taken to receive pay for military training that exceeds fifteen days. All fringe benefits will continue to be provided for up to six weeks of military leave. Written military orders must be submitted to the program director as soon as possible to allow for revision of the rotation and on-call schedules. • Extended Active Military Duty: A house staff member inducted to active military duty through Selective Service, voluntary enlistment, or called through membership in the National Guard or military reserves will be granted leave without pay. All fringe benefits will be discontinued. A military leave of absence may extend to four years. An additional year of leave may be taken at the request of or for the convenience of the federal government, even if the additional year is voluntary. Upon return from military leave of absence, the house staff member may be reinstated in his/her former position, provided the house staff member is honorably discharged. Military leaves may result in extension of training periods based on the requirements of specialty boards. COMPLETION OF TRAINING When your training is completed, be sure your department and the Office of Graduate Medical Education know your forwarding address. Fringe benefits, particularly professional liability and health insurance, will end at the training-end date. An appropriate certificate of training will be provided upon satisfactory completion of the education and training program. If you transfer, e.g., from General Surgery to Neurosurgery, ask the department to order your certificate in General Surgery at the

time of transfer. If training is all in one department, certificates will be ordered at the final completion date, including regular and sub-specialty titles and dates. In requesting certificates from your department, check to be sure that your name is spelled exactly as you wish, and that dates are correct. CERTIFICATION FOR ACTIVE BOARD STATUS On an annual basis, the program director must complete the appropriate ABMS tracking and evaluation form for each resident as required by the specialty Board. The program director has the final responsibility and authority to certify the individual house officer's satisfactory completion of training. Verification by a department chair/program director that the individual served the prescribed number of years is not the same as certifying the individual's satisfactory completion of training. Notification: If a department chair/program director is not going to certify/recommend an individual's satisfactory completion of training, he should notify the individual as early as possible. Included in the notification should be a recommendation for remedial training if this is appropriate. The Associate Dean for Graduate Medical Education will be notified at the time the decision is made and the resident or applicant notified. Included with the notification to the Associate Dean for Graduate Medical Education will be supporting documentation. Appeal: The resident may seek an informal discussion regarding this noncertification with the Associate Dean for Graduate Medical Education. The Associate Dean for Graduate Medical Education will limit his/her findings to verifying that the individual has been notified and that the documents support the decision not to certify. If such documentation is available and supports the decision, the decision of the chair will be final. If in the judgment of the Associate Dean for Graduate Medical Education, the documentation does not support such a decision, then a remedial plan agreed to by both parties will be required. The Associate Dean for Graduate Medical Education will advise the Dean of any adverse actions resulting in denial of certification. ZERO TOLERANCE POLICY FOR UNPROFESSIONAL OR ABUSIVE BEHAVIOR AND SEXUAL HARASSMENT POLICY Background Medical students and house staff often believe they are abused or sexually harassed in the setting of medical education. Because the relationship between faculty and students or house staff is hierarchical, it remains the ethical responsibility of the faculty to assure that students and house staff are professionally mentored and respectfully treated.

GMEC believes that all patients, ancillary support personnel, co-workers and students are entitled to equitable, respectful, and professional interaction. Also, that professionalism is best learned through a mentoring process between the faculty and students. Policy IU School of Medicine does not tolerate abusive behavior or sexual harassment by and to house staff members and investigates every complaint in a timely manner and provides proper remediation when abuse or harassment is determined. Criticism of performance will be discussed in private with the student or resident/fellow. Discussions about patient care with consulting medical staff among house staff or students will be carried out in a civil tone and volume. Shouting, cursing, name calling, or personal attacks have no place in such discussions. When physically present in the hospitals, professional conversation and interactions are critical to patient care and to the functions of the hospitals. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, constitute sexual harassment when: • Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's employment or academic achievement; • Submission to or rejection of such conduct by an individual is used as the basis for employment or academic decisions affecting such individuals; or • Such conduct has the purpose or effect of unreasonably interfering with an individual's work or academic performance or creating an intimidating, hostile, or offensive working or learning environment. * Complaint Procedures Individuals who believe that they have been abused or sexually harassed should notify either their department chair, program director, or the Associate Dean for Graduate Medical Education. Complaint procedures will include the following principles: • Efforts will be made to restrict information regarding complaints to the complainant, the accused party, and those persons directly involved in processing the matter. • The Associate Dean for Graduate Medical Education will advise and consult with either or both parties to the complaint. • If necessary, a formal investigation of the complaint will be conducted by the Associate Dean for Graduate Medical Education or his/her designee. • Investigations will be conducted promptly and thoroughly and the outcome will be reported to both parties involved. • If a complaint is found to be valid, corrective action, up to and including termination of the offender, will be taken through appropriate channels of the

Graduate Medical Education Office. The corrective action will reflect the severity and persistence of the abuse or harassment, as well as the effectiveness of any previous remedial action. • The GME Office will make follow-up inquiries to ensure the abuse or harassment has not resumed and the complainant has not suffered retaliation. • Appeal will be open to either the complainant or the accused party. • The Affirmative Action Office will serve as a resource with regard to interpretation of sexual harassment guidelines. *Equal Employment Opportunity Commission "Guidelines on Discrimination Because of Sex" (29CFR 1604.011) define sexual harassment and consider it a violation of Title VII of the Civil Rights Act of 1964. RELATIONS WITH COLLEAGUES POLICY The University's educational mission is promoted by professionalism in faculty/house staff/ student/staff relationships. Professionalism is fostered by an atmosphere of mutual trust and respect. Actions of house staff members that harm this atmosphere undermine professionalism and hinder fulfillment of the School's educational mission. Trust and respect are diminished when those in positions of authority abuse or appear to abuse their power. Those who abuse their power in such a context violate their duty to the academic community. House staff members exercise power over other house staff, students, and staff whether in providing praise or criticism, evaluations, recommendations for their further studies or future employment, or conferring other benefits. All amorous or sexual relationships among house staff members, between house staff and students, or house staff and personnel staff are unacceptable when the house staff member has any professional responsibilities for the other. Such situations greatly increase the possibility that house staff members will abuse power and this abuse may lead to sexual exploitation. Voluntary consent by the other in such a relationship is suspect, given the fundamental asymmetric nature of the relationship. Moreover, other house staff, students, and staff may be affected by such unprofessional behavior because it places the house staff member in a position to favor or advance one person's interest at the expense of others and implicitly makes obtaining benefits contingent on amorous or sexual favors. Therefore, the School will view such relationships as a violation of this policy if house staff members engage in amorous or sexual relations with other house staff members, students, or staff for whom they have professional responsibility even when both parties have consented or appear to have consented to the relationship. Should a house staff member find him/herself in a supervisory relationship with someone he/she has already had a relationship with, he/she should notify his/her supervisor immediately and ask for reassignment.

Any concerned person may initiate complaints about alleged violations of this policy. Such complaints should be brought to the attention of the department chair, program director, or Director of Graduate Medical Education or designee. Sanctions appropriate to the offense will be applied by the Associate Dean for Graduate Medical Education or designee. Possible sanctions may include, but are not limited to, reprimand, consideration in promotion decisions, termination of employment, and immediate dismissal. House staff members disciplined or terminated on grounds of violation of this policy shall have such rights as are provided by the "Procedures for Discipline and Termination of House Staff." THE TEACHER LEARNER ADVOCACY COMMITTEE PROCESS FOR RESOLVING CONFLICTS Introduction Students, residents, graduate students, or fellows with legitimate complaints or conflicts about the learning environment should be able to make non-capricious, good faith complaints, without fear of retaliation. Because of the potential jeopardy to the reputation of the individual(s) involved, the reporting of complaints and the procedures for investigating them should be handled with care to preserve confidentiality to the maximum extent possible consistent with the goals of objectively investigating and resolving such complaints. It should be understood, however, that a guarantee of absolute confidentiality is not possible. To contact the TLAC about a situation that has impact on your learning environment, you can send an email to: tlac@iupui.edu. Visit: http://msa.iusm.iu.edu/tlaccommittee.htm to find committee members’ contact information. When a conflict arises, the parties directly involved should try to resolve the matter informally. Methods to resolve the issue informally may include: direct discussion between parties, involvement of course/clerkship/residency directors, department chairs, or Office of Medical Student Academic Affairs (Van Nuys Medical Science Building 274-7175) for example. If this informal approach is unsuccessful, a more structured process is available within the IUSM for resolving the matter through the Teacher Learner Advocacy Committee (TLAC). This process is designed to be fair to both the complainant and the respondent. It is designed to be impartial, effective, and avoid retaliation toward the complainant. The following procedures address 1) channels of communication; 2) privacy and confidentiality concerns; 3) record keeping; and 4) a method of communication to all parties involved throughout the process and at resolution of the process.

TLAC Composition and Process The Executive Associate Dean for Academic Affairs (EADAA) appoints the chairperson of the TLAC. The TLAC membership will include elected students, residents and faculty along with students, residents and faculty appointed by the EADAA. Every attempt will be made to have a broad-based and diverse membership. At times it will be necessary to convene a subgroup of the TLAC to investigate specific complaints; once convened, a subgroup's membership should remain consistent through the resolution of the individual case. The TLAC will hold two regularly scheduled meetings per year. One will be at the beginning of the academic year (August) to review the charge to the TLAC with the EADAA, and the other at the end of the academic year to review the policy and recommend appropriate changes to the policy and procedures. Other meetings will be held on an "as needed" basis. An individual wishing to discuss a possible complaint can seek 'consultation' with any member of the TLAC. Following that consultation if the complainant seeks to initiate a formal process, a written description of the complaint, signed by the complainant, must be submitted to a member of the TLAC who will forward the document to the TLAC chair. The TLAC will conduct a preliminary review of the complaint, giving the reporting complainant, and any other persons, as the TLAC shall determine, an opportunity to recount information on the matter. If the TLAC moves forward with the complaint to a formal hearing, the TLAC chair or his/her designee is responsible for notifying the involved parties in writing of the complaint and the time and place of the TLAC hearing. At this time confidentiality of the complainant cannot be guaranteed by the TLAC. When the TLAC convenes a hearing, the EADAA will also be notified. A Recorder will be selected by the TLAC during each hearing. The Recorder will record adequate minutes of every meeting. The TLAC Recorder will not record deliberations of the TLAC on findings and recommendations or TLAC deliberations regarding excusing TLAC members from sitting on the case. This record shall serve as the official documentation of the hearing. The Recorder will maintain minutes until resolution of the complaint at which time they will be sent to and stored in the office of the EADAA. The complainant and the respondent have an opportunity to submit written documents to and to address the TLAC. The complainant shall present any information first, followed by a presentation by the individual against whom a complaint is made. The respondent has the right to access the hearing minutes that include statements made by the complainant or any witness, or be present during hearings as determined by the TLAC. Similarly, the complainant has the right to access the hearing minutes that include statements made by the respondent or any witness, or be present during hearings as determined by the TLAC members. As an internal dispute resolution

process, no party will be permitted to be represented by legal counsel during the TLAC hearings. Witnesses will be present only when they are called to give information. After speaking, they will be asked to leave and will not speak to each other prior to or during the proceedings. Both the respondent and the complainant can be harmed by breaches of confidentiality, and all who are involved in the process of responding to allegations must be cautioned to maintain confidentiality. The TLAC's record and summary of deliberations will be sent to the EADAA. The EADAA will then decide what action to take with recommendations from the TLAC members as well as other IUSM leadership. The EADAA or his/her designee will advise the respondent and complainant concerning the final disposition of the matter. Approved by TLAC members September 2001 Note: This procedure is not intended to supplant or replace other remedies a complainant or respondent may have, but simply to provide a voluntary forum for the resolution of disputes. Formal charges of discrimination should be filed with the Office of Affirmative Action. CLOSURE/REDUCTION POLICY FOR RESIDENCY/FELLOWSHIP PROGRAMS At the present time there is more likelihood for the closure of institutions or residency programs or the reduction of residency positions than there has been in the past. The closure/reduction may result for a number of reasons such as loss of accreditation of a program or of the sponsoring institution or loss of patient revenue. The IU School of Medicine has no reason to believe such a program closure or loss of accreditation will occur here. However, in view of the remote possibility, the following policy is promulgated. 1) In case of such a closure/reduction or in case of closure of an affiliated hospital, the School will make every effort to provide house staff with treatment equal to that provided to other staff affected by the closing. This will include notification of a projected closing at as early a date as possible. The School will make every effort to allow those residents in the program to complete their education at IUSM and the affiliated hospitals. If possible, payment of stipends and benefits will continue to the conclusion of the current contract. If any residents are displaced by the program or a reduction in the number of residents in a program, the School will make every effort to assist the residents in identifying a program in which they can continue their graduate medical education. Provision will also be made for the proper disposition of residency education records, including appropriate notification to licensure and specialty boards.

2) The School will also inform house staff of adverse accreditation actions taken by the Accreditation Council for Graduate Medical Education (ACGME) in a reasonable period of time after the action is taken. 3) The Graduate Medical Education Committee (GMEC) will supervise the implementation of this policy. PROCEDURES FOR GRIEVANCE, DISCIPLINE AND TERMINATION • General Policy: The duties, privileges, authority and responsibilities of members of the House Staff (Interns, Residents and Fellows) are governed by their contracts of appointment, by specific written authorization or delegation by the Dean, and by the rules, regulations, policies and procedures of the Medical Staff and Hospitals. The guidelines of the University concerning employees and students will not be applicable to members of the House Staff, unless so stated in the particular policy, regulation or guideline. • Terms of Appointment: Members of the House Staff will be appointed for the term or terms set out in their contracts of appointment, and will be renewed in accordance with the provisions of their contracts of appointment. • Grievance Procedure: The term "grievance" shall mean any dispute concerning the House Staff member's conditions of work, notice of non-reappointment, or the interpretation or application of any rule, regulation, contract of appointment, practice or policy of the Indiana University School of Medicine or its affiliated hospitals. Formal charges of discrimination based on race, sex, age, religion, national or ethnic origin, disability, marital status, sexual orientation, or veteran status, should be filed with the campus Affirmative Action Office. Prior to filing a formal complaint with the Affirmative Action Office, House Staff members are encouraged to utilize preliminary steps such as the Teacher-Learner Advocacy Committee discussed above. The submission of a grievance shall not relieve a House Staff member from his or her responsibilities, including patient care, pending the outcome of any grievance. For any grievance, other than one stemming from discipline or termination, the following procedure shall apply. First, the House Staff member shall promptly discuss his or her concern with the member's Program Director. If the matter is not satisfactorily resolved, the House Staff member shall forward his or her written grievance to the Associate Dean for Graduate Medical Education within five (5) days. The Associate Dean for Graduate Medical Education shall then review the written grievance and may, as he or she deems necessary, refer the grievance to an appropriate body or person (e.g., the Teacher-Learner Advocacy Committee or Affirmative Action Office) for an advisory recommendation.

Following review of the written grievance, and recommendation, if applicable, the Associate Dean for Graduate Medical Education shall, with the consultation and approval of the Dean of the School of Medicine, promptly render a final decision, thus completing the grievance process. For any grievance stemming from discipline or termination of the House Staff Member, the procedures outlined below shall govern. • Termination of Appointment: The appointment of a member of the House Staff may be revoked or terminated prior to the end of a current term of appointment for failure to abide by the rules and regulations, or policies and procedures of the Medical Staff and Hospitals, or for activities or professional conduct considered to be disruptive to the operations of the Hospital, or to the quality of patient care, or the teaching programs, or activities which constitute a material breach of the contract of appointment. • Procedure for Discipline or Termination: The Hospital Director, or Chair of the Department, or Program Director, or Chief of a Service, Department or Section, may lodge a complaint with the Associate Dean for Graduate Medical Education that there are reasons for the discipline or termination of the contract of appointment of a member of the House Staff, or the Associate Dean for Graduate Medical Education may initiate the matter. The chair of the TLAC may also report egregious actions by a house staff member that have come to the attention of the TLAC to the Associate Dean for Graduate Medical Education. If the complaint is made by a Chief of a Service or Director of a Section, or if the information has come to the Associate Dean for Graduate Medical Education from other sources including the TLAC, the complaint will be referred by the Associate Dean for Graduate Medical Education to the Chair of the Department or to the Program Director to which the house staff member is currently assigned. The Chair of the Department or the Program Director will then investigate the matter, and in not less than twenty (20) days after such referral, make a written report and recommendation to the Associate Dean for Graduate Medical Education. If the complaint is made by the Chair of the Department or Program Director in which the house staff member is currently assigned, the Chair will state the charges with reasonable particularity and make a written report and recommendations to the Associate Dean for Graduate Medical Education. If the matter has not been satisfactorily resolved, the Associate Dean for Graduate Medical Education will furnish to the affected person, a written notice of 1) the charges in reasonable particularity, 2) the Associate Dean for Graduate Medical Education's proposed recommendation, and 3) the right to be heard by the Associate Dean for Graduate Medical Education. Such notice will be sent by certified or registered mail, return receipt requested. Notice will be deemed delivered by either deposit via certified mail to the last known address of the affected member or by personal delivery. The house staff member will have fifteen (15) days

after the mailing of such written notice or hand delivery to request a hearing by the Associate Dean for Graduate Medical Education, and failure to request a hearing will be deemed a waiver of the hearing. If the affected person does not request a hearing, the Associate Dean for Graduate Medical Education may request a hearing to obtain more information, or forward his/her recommendations to the Dean who will take final action. • Summary Suspension: Whenever a House Staff member's conduct or activities, in the opinion of the Associate Dean for Graduate Medical Education or his designee, may cause a threat of injury or damage to the health or safety of patients, employees or other persons in the hospital or to the House Staff member unless prompt remedial action is taken, or if it appears reasonable to believe that the House Staff member has failed to observe all laws or principles of medical ethics of the profession in such a manner as to impose a threat to patient care or the high ethical standards expected of members of the House Staff, the Associate Dean for Graduate Medical Education or his designee may summarily suspend all or any part of the House Staff member's duties at such time and for such duration and under such terms and conditions as stated in the Order of Summary Suspension. This action will be reported in writing to the Chair of the department, the Program Director, the Dean, and the affected House Staff member. The House Staff member has the right to a hearing to appeal the summary suspension in accordance with this article, providing the request is made within fifteen (15) days of the date of the Order of Summary Suspension. • Hearing: If a request is made for hearing by the Associate Dean for Graduate Medical Education, the Associate Dean for Graduate Medical Education will promptly and in no event less than five (5) days prior to the date of the hearing, notify the House Staff member in writing of the date, time, and place of the hearing, and will state in concise language the acts or omissions with which the House Staff member is charged. The Associate Dean for Graduate Medical Education may appoint an Ad Hoc Hearing Committee or may hear the grievance him/herself. An accurate record of the hearing will be kept, which may be accomplished by the use of a court reporter or a tape recorder. The affected person against whom the complaint has been lodged will have the right to be present at the hearing, but if the person fails without just or due cause to appear at the hearing, the failure will be deemed a waiver of the opportunity for hearing, in the same manner as though one had not been requested. The person will be entitled to be accompanied by or represented at the hearing by a member of the Medical Staff or an attorney. The Associate Dean for Graduate Medical Education may also be represented by an attorney. The hearing need not be conducted strictly according to the rules of law relating to the examination of witnesses or presentation of evidence, and will be conducted by the Associate Dean for Graduate Medical Education on an intra professional basis. Any relevant matter upon which responsible persons customarily rely in the conduct of serious affairs will be considered. The affected person will have the right to call and

examine witnesses, to introduce written evidence, to cross-examine any witness on any matter relevant to the issue of the hearing, and to challenge any witness and to rebut evidence. If the affected person does not testify in his own behalf, the person may be called and examined as if under cross-examination. The hearing will be confidential and open only to the Associate Dean for Graduate Medical Education and those participating in the hearing process. Observers are allowed only by mutual agreement of the parties. Within fourteen (14) days after the matter has been heard, the Associate Dean for Graduate Medical Education will transmit his recommendations to the Dean and the affected person. The affected person may request an informal hearing with the Dean within five (5) days of the Associate Dean for Graduate Medical Education's recommendation. Within five (5) days of the Associate Dean for Graduate Medical Education's recommendation, the Dean will make the decision, which will be final and will be transmitted in writing to the affected House Staff member, with a copy to the Associate Dean for Graduate Medical Education, the Chair of the Department, and the Program Director. • Exclusive Remedy: As stated above, the procedures and remedies provided herein will be the exclusive remedies available to a House Staff member who is disciplined, or whose contract of appointment, is modified or terminated. EQUAL OPPORTUNITY/AFFIRMATIVE ACTION Indiana University pledges itself to continue its commitment to the achievement of equal opportunity within the University and throughout American society as a whole. In this regard, Indiana University will recruit, hire, promote, educate, and provide services to persons based upon their individual qualifications. Indiana University prohibits discrimination based on arbitrary considerations of such characteristics as age, color, disability, ethnicity, gender, marital status, national origin, race, religion, sexual orientation or veteran status. Indiana University will take affirmative action, positive and extraordinary, to overcome the discriminatory effects of traditional policies and procedures with regard to the disabled, minorities, women, and Vietnam-era veterans. (Board of Trustees, Nov. 21, 1969; Amended: Board of Trustees, Dec. 4, 1992)

AdvaMed Code of Ethics On Interactions with Health Care Professionals Adopted by the Advanced Medical Technology Association I. Preamble: Goal and Scope of AdvaMed Code The Advanced medical Technology Association (“AdvaMed”) is dedicated to the advancement of medical science, the improvement of patient care, and in particular to the contribution that high quality, cost-effective health care technology can make toward achieving t hose goals. In pursuing this mission, AdvaMed members 9”Members”) recognize that adherence to ethical standards and compliance with applicable laws are critical to the medical device industry’s ability to continue its collaboration with health care professionals. Members encourage ethical business practices and socially responsible industry conduct related to their interactions with health care professionals. Members also respect the obligation of health care professionals to make independent decisions regarding Member products. Consequently, AdvaMed adopts this voluntary Code of Ethics, effective January 1, 2004, to facilitate Members’ ethical interactions with those individuals or entities that purchase, lease, recommend, use, arrange for the purchase or lease of, or prescribe Members’ medical technology products in the United States (“Health Care Professionals”). There are many forms of interactions between Members and Health Care Professionals that advance medical science or improve patient care, including: ● Advancement of Medical Technology. Developing cutting edge medical technology and improving existing products are collaborative processes between Members and Health Care Professionals. Innovation and creativity are essential to the development and evolution of medical devices, often occurring outside the laboratories of medical device companies. Heart valves, MRI equipment, cardiac rhythm devices, surgical tools, and infusion pumps are just a few examples of the array of complex medical technologies developed through research collaborations and consulting relationships between Health Care Professionals and Members. ● Safe and Effective Use of Medical Technology. The safe and effective use of sophisticated electronic, in vitro diagnostic, surgical, or other medical technology often requires Members to offer Health Care Professionals appropriate instruction, education, training, service and technical support. Regulators may also require this type of training as a condition of product approval. ● Research and Education. Members’ support of bona fide medical research, education, and enhancement of professional skills serves patient safety and increases access to new technology. AdvaMed recognizes that members may interact with Health Care Professionals for many legitimate objectives other than selling, leasing, recommending, arranging for the sale or lease

of, or prescribing products, and that some of these relationships are not addressed in this Code. Any interpretation of the provisions of this Code, as well as Members’ interactions with Health Care Professionals not specifically addressed in this Code, should be made in light of the following principle: Members shall encourage ethical business practices and socially responsible industry conduct and shall not use any unlawful inducement in order to sell, lease, recommend, or arrange for the sale, lease, or prescription of, their products. II. Member-Sponsored Product Training and Education Members have a responsibility to make product education and training available to Health Care Professionals. In fact, the U.S. Food and Drug Administration mandates training and education to facilitate the safe and effective use of certain medical technology. Such programs often occur at centralized locations (necessitating out-of-town travel for some participants), and may extend more than one day. With regard to Member programs focused on the education and training in the safe and effective use of Member products: ● Programs and events should be conducted in clinical, educational, conference, or other settings, including hotel or other commercially available meeting facilities conducive to the effective transmission of knowledge. ● Programs requiring “hands on” training in medical procedures should be held at training facilities, medical institutions, laboratories, or other appropriate facilities. The training staff should have the proper qualifications and expertise to conduct such training. ● Members may provide Health Care Professional attendees with hospitality only in the form of modest meals and receptions in connection with these programs. Any such meals and receptions should be modest in value and subordinate in time and focus to the educational or training purpose of the meeting. ● Members may pay for reasonable travel and modest lodging costs incurred by attending Health Care Professionals. ● It is not appropriate for Members to pay for the meals, hospitality, travel, or other expenses for guests of Health Care Professionals or for any other person who does not have a bona fide professional interest in the information being shared at the meeting. III. Supporting Third Party Educational Conferences Bona fide independent, educational, scientific, or policymaking conferences promote scientific knowledge, medical advancement and the delivery of effective health care. These typically include conferences sponsored by national, regional, or specialty medical associations; conferences sponsored by accredited continuing medical education providers; and grand rounds. Members may support these conferences in various ways: ● Educational Grants. Members may provide a grant either directly to the conference sponsor to reduce conference costs, or to a training institution or the conference sponsor to allow attendance by medical students, residents, fellows, and others who are Health Care Professionals in training. Members may provide educational grants when:

(1) the gathering is primarily dedicated to promoting objective scientific and educational activities and discourse; and (2) the training institution or the conference sponsor selects the attending Health Care Professionals who are in training. Such grants should be paid only to organizations with a genuine educational purpose or function, and may be used only to reimburse the legitimate expenses for bona fide educational activities. Such grants also should be consistent with relevant guidelines established by professional societies or organizations. The conference sponsor should be responsible for and control the selection of program content, faculty, educational methods, and materials. ● Modest Meals and Hospitality. Members may provide funding to the conference sponsor to support the conference’s meals and hospitality. Also, Members themselves may provide meals and receptions for all Health Care Professional attendees, but only if it is provided in a manner that is also consistent with the sponsor’s guidelines. Any meals, receptions, and hospitality should be modest in value and should be subordinate in time and focus to the purpose of the conference. ● Faculty Expenses. Members may make grants to conference sponsors for reasonable honoraria, travel, lodging, and meals for Health Care professionals who are bona fide conference faculty members. ● Advertisements and Demonstration. Members may purchase advertisements and lease booth space for company displays at conferences. IV. Sales and Promotional Meetings It is appropriate for Members to meet with Health Care Professionals to discuss product features, contract negotiations, and sales terms. Often, these meetings occur close to the Health Care Professional’s place of business. It is appropriate for Members to pay for occasional hospitality only in the form of modest meals and receptions for Health Care Professional attendees that are conducive to the exchange of information. It is also appropriate to pay for reasonable travel costs of attendees when necessary (e.g., for plant tours or demonstrations of non-portable equipment). However, it is not appropriate to pay for meals, hospitality, travel, or lodging of guests of Health Care Professionals or any other person who does not have a bona fide professional interest in the information being shared at the meeting. V. Arrangements with Consultants Many Health Care Professionals serve as consultants to Members, providing valuable bona fide consulting services, including research, participation on advisory boards, presentations at Member-sponsored training, and product collaboration. It is appropriate to pay Health Care Professionals reasonable compensation for performing these services. The following factors support the existence of a bona fide consulting arrangement between Members and Health Care Professionals: ● Member consulting arrangements should be written, signed by the parties and specify all services to be provided.

● Compensation paid to consultants should be consistent with fair market value for the services provided. ● Consulting agreements should be entered into only where a legitimate need and purpose for the services is identified in advance. ● Selection of consultants should be on the basis of the consultant’s qualifications and expertise to address the identified purpose, and should not be on the basis of volume or value of business generated by the consultant. ● The venue and circumstances for Member meetings with consultants should be appropriate to the subject matter of the consultation. These meetings should be conducted in clinical, educational, conference, or other setting, including hotel or other commercially available meeting facilities, conducive to the effective exchange of information. ● Member-sponsored hospitality that occurs in conjunction with a consultant meeting should be modest in value and should be subordinate in time and focus to the primary purpose of the meeting. ● Members may pay for reasonable and actual expenses incurred by consultants in carrying out the subject of the consulting arrangement, including reasonable and actual travel, modest meals and lodging costs incurred by consultants attending meetings with, or on behalf of, Members. ● When a Member contracts with a consultant for research services, there should be a written research protocol. VI. Gifts Members occasionally may provide modest gifts to Health Care Professionals, but only if the gifts benefit patients or serve a genuine educational function. Other than the gift of medical textbooks or anatomical models used for educational purposes, any gift from a Member should have a fair market value of less than $100. In addition, Members may occasionally give Health Care Professionals branded promotional items of minimal value related to the Health Care Professional’s work or for the benefit of patients. Gifts may not be given in the form of cash or cash equivalents. This section is not intended to address the legitimate practice of providing appropriate sample products and opportunities for product evaluation. VII. Provision of Reimbursement and Other Economic Information Members may support accurate and responsible billing to Medicare and other payors by providing reimbursement information to Health Care Professionals regarding Members’

products, including identifying appropriate coverage, coding, or billing of Member products, or of procedures using those products. Members may also provide information designed to offer technical or other support intended to aid in the appropriate and efficient use or installation of the Member’s products. However, it is inappropriate for Members to provide this technical or other support for the purpose of unlawfully inducing Health Care Professionals to purchase, lease, recommend, use, or arrange for the purchase, lease or prescription of Members’ products. VIII. Grants and Other Charitable Donations Members may make donations for a charitable purpose, such as supporting genuine independent medical research for the advancement of medical science or education, indigent care, patient education, public education, or the sponsorship of events where proceeds are intended for charitable purposes. Donations should be made only to charitable organizations or, in rare instances, to individuals engaged in genuine charitable missions for the support of that mission. It is not appropriate for Members to make such donations for the purpose of unlawfully inducing Health Care Professionals to purchase, lease, recommend, use, or arrange for the purchase, lease or prescription of Members’ products. All donations should be appropriately documented. Examples of appropriate charitable grants and related considerations are: ● Advancement of Medical Education. Members may make grants to support the genuine medical education of medical students, residents, and fellows participating in fellowship programs, which are charitable or have an academic affiliation or, where consistent with the preamble to this section, other medical personnel. (For additional considerations regarding educational grants, see Section III, Supporting Third Party Educational Conferences.) ● Support of Research with Scientific Merit. Members may make research grants to support genuine medical research. The purpose of the grant must be clearly documented. (For guidance as to the limitations that apply when a Member contracts with a Health Care Professional to provide research on behalf of a Member, see Section V, Arrangements with Consultants.) ● Public Education. Members may make grants for the purpose of supporting education of patients or the public about important health care topics. _________________________ Note: This Code supersedes and replaces all previous AdvaMed Code of Ethics. Members will communicate the principles of this Code to their employees, agents, dealers and distributors with the expectation that they will adhere to t his Code. All Members have an independent obligation to ascertain that their interactions with Health Care Professionals comply with all applicable laws and regulations. The information provided by the Department of Health and Human Services Office of Inspector General, as well as applicable laws or regulations, may provide more specificity than this Code, and Members should address any additional questions to their own attorneys. This Code of Ethics is intended to facilitate ethical behavior, and is not intended to be, nor should it be, construed as legal advice. The Code is not intended to define or create legal rights, standards or obligations.

AMA Guidelines Regarding the Relationship Between Industry and Physicians Over time, many gifts to physicians from pharmaceutical, device and medical equipment industry sales-representatives have served an important and beneficial function. For example, industry has provided funds for educational seminars and conferences for many years. During the late 1980s, however, some of these gifts were becoming lavish, ranging from frequent flier miles to cash and trips to luxury resorts, and their appropriateness was increasingly being called into question. The AMA studied the issue, and in December of 1990, the AMA’s House of Delegates adopted CEJA's ethical guidelines to prevent inappropriate gift- giving practices. The AMA’s "Guidelines on Gifts to Physicians from Industry" later appeared in its Code of Medical Ethics (CEJA Ethical Opinion 8.061). The Pharmaceutical Manufacturer’s Association (PMA), which later became Pharma (Pharmaceutical Research and Manufacturers of America), also adopted the guidelines. Opinion 8.061, "Gifts to Physicians from Industry" Many gifts given to physicians by companies in the pharmaceutical, device, and medical equipment industries serve an important and socially beneficial function. For example, companies have long provided funds for educational seminars and conferences. However, there has been growing concern about certain gifts from industry to physicians. Some gifts that reflect customary practices of industry may not be consistent with the Principles of Medical Ethics. To avoid the acceptance of inappropriate gifts, physicians should observe the following guidelines: (1) Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value. Accordingly, textbooks, modest meals, and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. _The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members. (2) Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g., pens and notepads). (3) The Council on Ethical and Judicial Affairs defines a legitimate “conference” or “meeting” as any activity, held at an appropriate location, where (a) the gathering is primarily dedicated, in both time and effort, to promoting objective scientific and educational activities and discourse (one or more educational presentation(s) should be the highlight of the gathering), and (b) the main incentive for bringing attendees together is to further their knowledge on the topic(s) being presented. An appropriate disclosure of financial support or conflict of interest should be made.

(4) Subsidies to underwrite the costs of continuing medical education conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. Since the giving of a subsidy directly to a physician by a company’s representative may create a relationship that could influence the use of the company’s products, any subsidy should be accepted by the conference’s sponsor who in turn can use the money to reduce the conference’s registration fee. Payments to defray the costs of a conference should not be accepted directly from the company by the physicians attending the conference. (5) Subsidies from industry should not be accepted directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings, nor should subsidies be accepted to compensate for the physicians’ time. Subsidies for hospitality should not be accepted outside of modest meals or social events held as a part of a conference or meeting. It is appropriate for faculty at conferences or meetings to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging, and meal expenses. It is also appropriate for consultants who provide genuine services to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging, and meal expenses. Token consulting or advisory arrangements cannot be used to justify the compensation of physicians for their time or their travel, lodging, and other out-of-pocket expenses. (6) Scholarship or other special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible as long as the selection of students, residents, or fellows who will receive the funds is made by the academic or training institution. Carefully selected educational conferences are generally defined as the major educational, scientific or policy-making meetings of national, regional or specialty medical associations. (7) No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the physician’s prescribing practices. In addition, when companies underwrite medical conferences or lectures other than their own, responsibility for and control over the selection of content, faculty, educational methods, and materials should belong to the organizers of the conferences or lectures. (II) Issued June 1992 based on the report "Gifts to Physicians from Industry," adopted December 1990 (JAMA. 1991; 265: 501 and Food and Drug Law Journal. 2001; 56: 27-40); Updated June 1996 and June 1998. Opinion E-8.061: clarifying addendum In response to frequent questions, an addendum to Opinion E-8.061 is offered for clarification.

AAOS Standards of Professionalism Orthopaedist-Industry Conflicts of Interest These Standards of Professionalism (SOPs) on Orthopaedist-Industry Conflicts of Interest take effect on April 18, 2007. Enforcement of these SOPs begins with acts occurring on or after January 1, 2008. The primary focus of the orthopaedic profession is care of the patient. As part of their lifetime commitment to patients, orthopaedic surgeons must maintain specialized knowledge and skills through participation in continuing medical education programs, seminars, and professional meetings. Often, these professional functions are sponsored by the community of medical device manufacturers, pharmaceutical companies, and other businesses who play an important role supporting continuing medical education (CME) events and the development of new technologies that contribute to the on-going patient-physician relationship. This collaborative effort ensures that patients have the best surgical outcomes through the invention and testing of new technology, research and evaluation of existing technology, and continued education of orthopaedic surgeons. Cooperative relationships between orthopaedic surgeons and industry benefit patients. Orthopaedic surgeons are best qualified to provide innovative ideas and feedback, conduct research trials, serve on scientific advisory boards, and serve as faculty to teach the use of new technology. Orthopaedic surgeons, in an effort to improve patient care, rely on industry to bring their creative ideas to fruition. A collaborative relationship between orthopaedic surgeons and industry is necessary to improve patient care, but must be carefully scrutinized to avoid pitfalls of improper inducements, whether real or perceived. Orthopaedic surgeons must be mindful of potential conflicts of interest with patient care in pursuing academic and commercial ventures. A conflict of interest exists when professional judgment concerning the well being of the patient has a reasonable chance of being influenced by other interests of the physician. The self-interest of the physician may be financial in nature. The competing interests may involve fame and notoriety for the physician or time for the physician or the physician’s family. When such conflicts exist, there is concern that care decisions may not be in the best interests of the patient. Disclosure of a conflict of interest is required in communications to patients, the public and colleagues. The benefit to the patient must be the primary goal and must not be compromised. Orthopaedic surgeons, like all physicians, have an ethical obligation to present themselves and the services they provide to patients in a clear and accurate manner. When faced with a potential conflict of interest that cannot be resolved, an orthopaedic surgeon should consult with colleagues or an institutional ethics committee to determine whether there is an actual or potential conflict of interest and how to address it. For purposes of these Standards of Professionalism, “industry” includes pharmaceutical, biomaterial, and device manufacturers.

For purposes of these Standards of Professionalism, “CME events” refer to educational events that meet the requirements of and have been approved by the Accreditation Council for Continuing Medical Education (ACCME). Further, it is understood that attendance at a CME event shall mean that the orthopaedic surgeon is attending and is not an instructor at that CME event. For purposes of these Standards of Professionalism, a conflict of interest occurs when an orthopaedic surgeon or an immediate family member has, directly or indirectly, a financial interest or positional interest or other relationship with industry that could be perceived as influencing the orthopaedic surgeon’s obligation to act in the best interest of the patient. A “financial interest,” “financial arrangement,” “financial inducement” or “financial support” includes, but is not limited to: ● Compensation from employment; ● Paid consultancy, advisory board service, etc.; ● Stock ownership or options; ● Intellectual property rights (patents, copyrights, trademarks, licensing agreements, and royalty arrangements); ● Paid expert testimony; ● Honoraria, speakers’ fees; ● Gifts; ● Travel; and ● Meals and hospitality A “positional interest” occurs when an orthopaedic surgeon or family member is an officer, director, trustee, editorial board member, consultant, or employee of a company with which the orthopaedic surgeon has or is considering a transaction or arrangement. Some states have enacted legislation regarding relationships between physicians and industry. When the law supersedes these Standards of Professionalism, AAOS Fellows and Members are expected to follow the law. These Standards of Professionalism draw from the aspirations Code of Medical Ethics and Professionalism for Orthopaedic Surgeons that appears in bold italics. The statements that follow the aspirational Code establish the mandatory minimum standards of acceptable conduct for orthopaedic surgeons when engaged in relationships with industry. Violations of these minimum standards may serve as grounds for a formal complaint to and action by the AAOS as outlined in the AAOS Bylaws Article VIII. The Standards of Professionalism on Orthopaedist-Industry Conflicts of Interest apply to all AAOS Fellows and Members. Only an AAOS Fellow or Member may file complaints of an alleged violation of these Standards of Professionalism regarding another AAOS Fellow or Member.

Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, I.A.: The orthopaedic profession exists for the primary purpose of caring for the patient. The physician-patient relationship is the central focus of all ethical concerns. Mandatory Standards: 1. An Orthopaedic surgeon shall, while caring for and treating a patient, regard his or her responsibility to the patient as paramount. 2. An orthopaedic surgeon shall prescribe drugs, devices, and other treatments primarily on the basis of medical considerations and patient needs, regardless of any direct or indirect interests in or benefit from industry. Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, II. C.: The orthopaedic surgeon should obey all laws, uphold the dignity and honor of the profession, and accept the profession’s self-imposed discipline. Within legal and other constraints, if the orthopaedic surgeon has a reasonable basis for believing that a physician or other health care provider has been involved in any unethical or illegal activity, he or she should attempt to prevent the continuation of this activity by communicating with that person and/or identifying that person to a duly- constituted peer review authority or the appropriate regulatory agency. In addition, the orthopaedic surgeon should cooperate with peer review and other authorities in their professional and legal efforts to prevent the continuation of unethical or illegal conduct. Mandatory Standard 3. An orthopaedic surgeon convicted of violating federal or state conflict of interest laws or regulations shall be subject to discipline under the AAOS Professional Compliance Program. Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, III.A.: The practice of medicine inherently presents potential conflicts of interest. When a conflict of interest arises, it must be resolved in the best interest of the patient. The orthopaedic surgeon should exercise all reasonable alternatives to ensure that the most appropriate care is provided to the patient. If the conflict of interest cannot be resolved, the orthopaedic surgeon should notify the patient of his or her intention to withdraw from the relationship. Mandatory Standards 4. An orthopaedic surgeon shall, when treating a patient, resolve conflicts of interest in accordance with the best interest of the patient, respecting a patient’s autonomy to make health care decisions.

5. An orthopaedic surgeon shall notify the patient of his or her intention to withdraw from the patient-physician relationship, in a manner consistent with state law, if a conflict of interest cannot be resolved in the best interest of the patient. Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, III.C.: When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict exists which should be disclosed to the patient. When an orthopaedic surgeon receives inventor royalties from industry, the orthopaedic surgeon should disclose this fact to the patient if such royalties relate to the patient’s treatment. It is unethical for an orthopaedic surgeon to receive compensation of any kind from industry for using a particular device or medication. Reimbursement for reasonable administrative costs in conducting or participating in a scientifically sound research clinical trial is acceptable. Mandatory Standards: 6. An orthopaedic surgeon shall decline subsidies or other financial support from industry, except that an orthopaedic surgeon may accept gifts having a fair market value of less than $100, medical textbooks, or patient educational materials. 7. An orthopaedic surgeon who has influence in selecting a particular product or service for an entity shall disclose any relationship with industry to colleagues, the institution and other affected entities. 8. An orthopaedic surgeon shall disclose to the patient any financial arrangements with industry that relate to the patient’s treatment, including the receipt of inventor royalties, stock options or paid consulting arrangements with industry. 9. An orthopaedic surgeon shall accept no direct financial inducements from industry for utilizing a particular implant or for switching from one manufacturer’s product to another. 10. An orthopaedic surgeon shall enter into consulting agreements with industry only when such arrangements are established in advance and in writing to include evidence of the following: ● Documentation of an actual need for the service; ● Proof that the service was provided; ● Evidence that physician reimbursement for consulting services is consistent with fair market value; and ● Not based on the volume or value of business he or she generates 11. An orthopaedic surgeon shall participate in or consult at only those meetings that are conducted in clinical, educational, or conference settings conducive to the effective exchange of information.

Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, IV.A.: The orthopaedic surgeon continually should strive to maintain and improve medical knowledge and skill and should make available to patients and colleagues the benefits of his or her professional attainments. Each orthopaedic surgeon should participate in continuing medical educational activities. Mandatory Standards: 12. An orthopaedic surgeon shall accept no financial support from industry to attend industry-related social functions where there is no educational element. 13. An orthopaedic surgeon who is attending a CME event shall accept no industry financial support for attendance at a CME event. Residents and orthopaedists-intraining may accept an industry grant to attend a CME event if they are selected by their training institution or CME sponsor and the payment is made by the training program or CME sponsor. Bona fide faculty members at a CME event may accept industry-supported reasonable honoraria, travel expenses, lodging and meals from the conference sponsors. 14. An orthopaedic surgeon, when attending an industry-sponsored non-CME educational event, shall accept only tuition, travel and modest hospitality, including meals and receptions; the time and focus of the event must be for education or training. 15. An orthopaedic surgeon, when attending an industry-sponsored non-CME educational event, shall accept no financial support for meals, hospitality, travel, or other expenses for his or her guests or for any other person who does not have a bona fide professional interest in the information being shared at the meeting. Aspirational: AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, III.D.: An orthopaedic surgeon reporting on clinical research or experience with a given procedure or device must disclose any financial interest in that procedure or device if the orthopaedic surgeon or any institution with which that orthopaedic surgeon is connected has received anything of value from its inventor or manufacturer. Mandatory Standards 16. An orthopaedic surgeon, when reporting on clinical research or experience with a given procedure or device, shall disclose any financial interest in that procedure or device if he or she or any institution with which he or she is connected has received anything of value from its inventor or manufacturer.

17. An orthopaedic surgeon who is the principal investigator shall make his or her best efforts to ensure at the completion of the study that relevant research results are reported and reported truthfully and honestly with no bias or influence from funding sources, regardless of positive or negative findings.

Program Director: Randall T. Loder, M.D. Department of Orthopaedic Surgery Indiana University School of Medicine 702 Barnhill Drive, ROC 4250 Indianapolis, IN 46202 317-278-0961 317-274-7197 rloder@iupui.edu Contact Information: Donna L. Roberts Residency Program Coordinator Department of Orthopaedic Surgery Indiana University School of Medicine 541 Clinical Drive, Suite 600 Indianapolis, IN 46202-5111 317-274-3291 317-274-3702 fax danders@iupui.edu

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