Radiology

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Diagnostic Radiology Residency Program Policy Manual: 2009-2010 6/26/2022 1 | Page

Transcript of Radiology

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Diagnostic Radiology Residency Program Policy Manual: 2009-2010

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i. INTRODUCTION

DEPARTMENT OF RADIOLOGY PROGRAM MANUAL

All physicians-in-training at the University are classified as either residents or fellows. The information contained in this Program Manual pertains to all residents in the Department’s programs except as otherwise identified in the Program Manual or addendum. This Manual outlines benefits, policies, guidelines and other regulations that apply to all resident training in the Department of Radiology.

The Institutional Policy Manual contains policies, procedures and information that apply to all residents throughout the University of Minnesota Medical School. The Program Manual is specific to each program. All materials are intended to be written in accordance with the Accreditation Council for Graduate Medical Education (ACGME). Please note that the Institutional Policy Manual and the Department Program Manual are designed to work together. Information contained in Institutional Policy Manual may not be replicated in Program Manual.

All information outlined in this Program Manual is subject to periodic review and change. All residents are subject to, and required to be familiar with and to comply with all policies and procedures of the University including the Institutional Policy and Department Program Manuals.

Throughout this Manual, individual institutions will be identified as follows:- University of Minnesota Medical Center: UMMC - Hennepin County Medical Center: HCMC- Veterans Affairs Medical Center: VAMC

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ii. DEPARTMENT MISSION STATEMENT

The mission of the Department of Radiology is to be a leader in enhancing the health of people through education, biomedical research, and clinical programs.

iii. PROGRAM MISSION STATEMENT

The Department of Radiology at the University of Minnesota School of Medicine, in conjunction with its affiliated institutions (including but not limited to the Veterans Affairs Medical Center and Hennepin County Medical Center) provides graduate medical education in Diagnostic Radiology and its subspecialties programs:

Breast Imaging Fellowship Diagnostic Radiology Residency Neuroradiology Fellowship Nuclear Medicine Fellowship Pediatric Fellowship Thoraco-Abdominal Radiology Fellowship Vascular and Interventional Radiology Fellowship

Our educational mission is to provide an atmosphere of learning and academic curiosity, and to provide strong basic training in diagnostic radiology and its subspecialties including but not limited to breast, cardiac, abdominal, musculoskeletal, neuro-, pediatric, noninvasive vascular, and thoracic imaging, as well as nuclear radiology and ultrasound.

Administrative oversight of these programs is provided by the ALRT Administrative Center - Departments of:AnesthesiologyLaboratory Medicine and Pathology, Diagnostic Radiology Therapeutic Radiology

The mission of the A.L.R.T. Administrative Center, as part of the University of Minnesota School of Medicine, is to provide uniform service delivery to our departments and institutes. These services consist of human resources, payroll, communication, education, grants management, financial reporting and budget. Our goal is to provide exceptional service while balancing the expectations of the multiple constituents. To achieve this goal we will foster a community based on communication, cooperation and expertise by drawing on our individual backgrounds, strengths and unique histories.

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TABLE OF CONTENTS

SECTION i. INTRODUCTION Page 2SECTION ii DEPARTMENT AND PROGRAM MISSION STATEMENTS Page 3

SECTION I. Student ServicesUniversal University Pagers Page 6E-mail and Internet Access Page 6Weekly E-Newsletter Page 6Campus Mail Page 6Tuition and Fees Page 7HIPAA Training & Data Security Page 7USB Drives Page 7Department USB Drive Page 7

SECTION II. BENEFITSStipends Page 8Paychecks and Pay Periods Page 8Resident Leave Page 8 Vacation Page 9 Illness Page 9 Other Leaves Page 9

Personal Leaves of Absence Page 9 Family Medical Leave Page 9 Family Medical Leave Act (FMLA) Page 10 Parental Leave for Childbirth Page 10 Parental/Domestic Partnership Leave – Adoption Page 10 Professional Leave Page 10 Military Leave Page 10 Jury Witness Duty Page 11 Bereavement Leave Page 11 Interview Time Off Page 11

Policy on Effect of Leave - ABR Graduation Requirement Page 11Holiday Schedule Block Out Dates

Page 13Page 14

Department Policy Regarding Pregnancy for Resident & Radiation Page 14Notary Service Page 14Resident Exercise Room Page 15Health and Dental Insurance Page 15Long-Term Disability Insurance Page 15Short-Term Disability Insurance Page 15Professional Liability Insurance Page 15Life Insurance Page 15Voluntary Life Insurance Page 15Insurance Coverage Change Page 15Worker’s Compensation Page 16Meal Program Page 16Laundry Services Page 16Parking Page 16 UMMC Page 16 HCMC Page 17 VAMC Page 17Book and Travel Fund Page 17SECTION III. INSTITUTIONAL RESPONSIBILITIES Page 18 SECTION IV. DISCIPLINARY AND GRIEVANCE PROCEDURES Page 19 Discipline/Dismissal for Academic Reasons Page 19Discipline/Dismissal for Non-academic Reasons Page 19Grievance Procedure and Due Process Page 19

SECTION V. GENERAL POLICIES AND PROCEDURES PAGE 20Program Goals Page 20

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Program Curriculum Page 20Program Schedules Page 20Program Requirements Page 20USMLE Step 3 Page 21Training/Graduation Requirements Page 21ACGME Competencies Page 23Duty Hours Page 23RMS – Residency Management Suite

Duty Hour Approval Policy/ProcedurePage 24

Duty Hours – Entering Hours Into RMS Page 24On-call Activities Page 26On-call Rooms Page 27Support Services Page 27Laboratory Medicine/Radiology Services Page 27Medical Records Page 27Security/Safety Page 27Radiation Badges Page 28Moonlighting Page 28Supervision/Graded Responsibility Page 28Steps in Evaluation Process Page 29Evaluation System - Electronic Page 29Completing Evaluations in RMS Page 30Monitoring of Resident Well-being Page 30ACLS/BLS Certification Requirements Page 30Travel Page 31Libraries

Institutional Departmental

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Rotations Involving Regions Hospital and Park Nicollet Page 32Goals and Objective for Teaching Medical Students Page 32SECTION VII. ADMINISTRATION CONTACT INFORMATION Page 33Graduate Medical Education Directors and Coordinators Page 36Site Addresses, Phone and Fax Numbers Page 37

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SECTION I. STUDENT SERVICES (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for Medical School Policies on the following: Academic Health Center (AHC) Portal Access; Child Care; Computer Discount/University Bookstore; Credit Unions; Disability Accommodations; Legal Services; Library Services; Medical School Campus Maps; Resident Assistance Program; Tuition Reciprocity; University Card (UCard); University Events Box Office; University Recreation Sports Center(s)) UNIVERSAL UNIVERSITY PAGERS

Residents are assigned UMMC-Fairview pagers at the beginning of their PGY2 Year for the duration of their residency. Contact the Shari Johnston, Program Coordinator, 612-626-5589 or [email protected] to report any missing or malfunctioning cards.

E-MAIL AND INTERNET ACCESSAs students at the University, all residents are provided with a University E-mail/Internet access account. With this account trainees can access the Internet and E-mail from any of their assigned training sites.

If you are using an independent ISP, you must forward your University E-mail account to your preferred E-mail account as required by the Medical School. Log on to http://www.umn.edu/validate to do so. (To learn the E-mail address assigned to you, go to the University’s web page, www.umn.edu, click on “People Search” then type your name into the “Search” box.)

Information regarding the University of Minnesota School of Medicine, Graduate Medical Education and/or the Department of Radiology can be located at the following web sites:

Medical School Web Site: http://www.med.umn.eduGraduate Medical Education Administration Web Site:

http://www.med.umn.edu/gmeDepartment of Radiology Web Site:http://www.radiology.umn.edu

Trainees are required to maintain an E-mail account and to check their E-mail daily for Program, Medical School and University notices.

WEEKLY E-NEWSLETTEREach Monday morning a departmental electronic newsletter is sent containing all non-time sensitive communication for the prior week.

CAMPUS MAILDEPARTMENT MAILROOM: ROOM B-221, MAYO MEMORIAL BUILDING

OUTGOING MAIL Can be left in the “Outgoing Hospital/Campus Mail” basket.

INCOMING MAIL Residents may receive professional related mail in their mailbox.

DEPARTMENT MAILING ADDRESS420 Delaware Street. S.E., MMC 292Minneapolis, MN. 55455

Residents are not to send or receive personal mail through the University system. Outgoing U.S. mail may also be placed in the United States Postal Service mailbox located just outside the main entrance of the University of Minnesota Medical Center (on Harvard Street).

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The mailbox at UMMC is the trainee’s MAIN mailbox, but HCMC and VAMC also have mailboxes for residents. The department is not responsible for moving mail between hospitals depending on your rotation.

Residents are required to check their mailboxes a WEEKLY basis for Program, Medical School and University notices. Residents are also required to empty their mailboxes on a regular basis.

TUITION AND FEESTuition and fees are being waived at this time. Residents who are enrolled in Graduate School pay tuition and fees.

HIPAA AND DATA SECURITY TRAINING

The University of Minnesota is required to remain in compliance with the training component of the Federal Health Information Portability and Accountability Act (HIPAA) privacy regulations and Data Security. All faculty, trainees and staff must be trained regarding this regulation as well as University-specific policies and procedures. Multi-media online training has been developed to facilitate this training as well as the required documentation in the regulation. Four courses have been developed and are available through the “My AHC” and “My U” portals.

All University faculty, staff, student workers and health science students and volunteers are required to complete the following HIPAA Privacy and Data Security courses:

HIPAA Privacy Introduction to HIPAA Privacy Video Privacy and Confidentiality in Research (for research faculty and staff) Privacy and Confidentiality in Clinical settings (for clinical faculty and staff)

HIPAA Data Security Data Security in Your Job Securing Your Computer Workstation Using University Data Managing Health Data Securely

To access your HIPAA and Data Security Training and to complete the course(s), please follow this link: www.myU.umn.edu (log in with your x500).

Please remember to LOG OUT of the portal when you are finished. If you leave the computer while you remain logged in, others could use your log-in to access your private information.

Department USB DriveResidents are given a Departmental encrypted USB drive for use during residency training and will be required to sign a contract agreeing to abide by HIPAA and Departmental policies. By accepting a Departmental USB drive you are agreeing to the terms of the contract. This device is being temporarily loaned to you by the Department of Radiology. You are required to return the USB drive to Program Coordinator upon completion of (or departure from) the Program. This contract is subject to change without notice.

Should you damage or misplace this device, you will be required to reimburse the Department.

This Department strictly prohibits the downloading of any patient demographic data (or any information that could identify a patient). To download such

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information would be in violation of Federal Health Information Portability and Accountability Act (HIPAA) regulations.

SECURITY/PRIVACY COORDINATOR Sally Sawyer, Graduate Medical Education Manager, serves as the ALRT Center Privacy Coordinator. Questions and/or concerns can be directed to Sally at 612-625-3518 or [email protected].

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SECTION II. BENEFITS (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for Medical

School Policies on the following: Boynton Health Services; Employee Health Services; Exercise Room at UMMC-F; FICA; Dental Insurance; Health Insurance; Life Insurance; Voluntary Life Insurance; Long-Term Disability; Short-Term Disability; Insurance Coverage Changes; Bereavement Leave; Family Medical Leave Act (FMLA); Holidays; Medical Leave; Military Leave; Parental Leave; Personal Leave; Professional Leave; Vacation/Sick Leave; Witness/Jury Duty; Effect of Leave for Satisfying Completion of Program; Loan Deferment; Minnesota Medical Association Membership; Minnesota Medical Foundation Emergency Loan Program; Pre-Tax Flexible Spending Accounts; Professional Liability Insurance; Stipends; Workers’ Compensation Benefits; Veterans Certification for Education Benefits).

STIPENDSMedical Residents who meet Departmental, Medical School and University requirements are appointed to one-year training positions from July 1 through June 30 of the following year (unless otherwise agreed to in writing).

Base stipend rates are posted at http://www.med.umn.edu/gme/directors/finance.html

Chief Residents receive $5,000 in addition to their base stipend above. Note that although Chief Residents serve as PGY4s, augmentation is received during their PGY5 year.

Medical Residents are subject to withholding of Federal and State income taxes, as well as FICA taxes (Social Security). Medical Residents pay insurance fees by payroll deduction over 26 pay periods.

PAYCHECKS AND PAY PERIODSBiweekly paychecks are issued every-other Wednesday beginning July 1st, 2009.

You are encouraged to have your checks automatically deposited to your banking institution to avoid loss or delay. Your pay statement can be viewed online at http://hrss.umn.edu. If you do not have direct deposit you will receive a check on payday. This check must be picked-up from ALRT Payroll (7th floor Mayo Building). It cannot be placed in your mailbox or mailed to your home. Please keep your pay statements for future reference, as they contain deduction amounts that you’ll need when you prepare your tax returns. The Department of Radiology keeps no record of your deductions.

Payroll forms (i.e., automatic deposit, W4, duplicate W2, etc.), can be obtained online at http://hrss.umn.edu A new W4 form must be completed each time a name or address change occurs.

CONTACT PERSON:Contact Sandy Connor at 612-6253682 or [email protected] regarding questions pertaining to payroll, taxes, deductions, W2s, etc.

RESIDENT LEAVE (INCLUDING VACATION, ILLNESS AND OTHER TYPES OF LEAVE)Except for unexpected absence related to illness, all leave must be pre-approved. All resident leave must be documented in RMS duty hours.

The Chief Residents and the Program Coordinator should be concurrently notified of leave requests by e-mail as soon as possible. The type of leave, as noted below, should be specified. Depending on scheduling considerations and in a timely manner, the Chief Residents will approve the request, forward the “chief approved request” by e-mail to the Program Coordinator including attached revised schedule noting changes for final approval by the Program Director.

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Unpaid Leave While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

1. VACATION Holiday schedule (including variation by location) and “block out dates” are indicated on page 14. Up to twenty (20) working days per year may be taken as vacation which is paid leave. Unused vacation time may not be carried over to the next year. Depending on rotation up to five (5) vacation days may be taken during a given month. Requests to exceed this limit must be approved by the Program Director in advance. No more than ten (10) total vacation days can be taken from any section during the residency without the Program Director’s approval.

To request time off – resident must complete and submit a vacation request form to Program Coordinator. The form is located on RMS and the Resident Intranet. Requests are reviewed on a bi-monthly basis by a committee. Committee decisions are communicated via email to resident.

The number of residents allowed to be on scheduled leave at any given time is as follows: UMMC: 2 residents (up to 3 residents if one is a first-year resident) and only 1 week of

vacation during their two-month UMNE and UMVI rotations. HCMC: 1 resident VAMC: 2 residents (up to 3 if one is a first-year resident)

2. ILLNESS

Residents must call in sick as soon as they know they are unable to show up for work because of acute illness of themselves or child/children. They must inform the Program Coordinator, Shari Johnston (612-626-5589), and the rotation they’re on (contact numbers in Residency Intranet). They should speak in person with either the residency coordinator, or someone in their rotation.

Days of absence due to illness are considered paid leave up to ten (10) days per year. Absence due to illness exceeding ten (10) work days in an academic year will be charged as vacation. There is no carryover from preceding years. In the event that a resident has exhausted all of his/her vacation leave, this time will be charged as unpaid leave. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

3. OTHER LEAVES PERSONAL LEAVE OF ABSENCE If vacation time is used up for the year, and upon the approval of the Program Director, a

Resident may arrange for a unpaid leave of absence away from the training program. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

MEDICAL LEAVE An unpaid leave of absence for serious illness of the resident; serious health condition of a spouse, parent or child/children; shall be granted through formal request. The Chief Residents and the Program Coordinator should be concurrently notified of the leave request by e-mail as soon as possible. The length of leave will be determined by the Program Director based upon an individual’s particular circumstances and the needs of the department, not to exceed twelve (12) weeks in any 12-month period. Residents taking family medical leave must submit the following documents to the Program Coordinator:

FMLA: Certification of Health Care ProviderFMLA: Leave Response/Notification

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The above forms can be accessed online in the Forms Library under “Human Resources” at http://www.fpd.finop.umn.edu/groups/ppd/documents/main/formhome.cfm. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

FAMILY MEDICAL LEAVE ACT (FMLA) FMLA is intended to allow employees to balance their work and family life by taking reasonable unpaid leave for a serious health condition, for the birth or adoption of a child, and for the care of a child, spouse, and registered same-sex domestic partner provided for by the University, or parent who has a serious health condition. The Act is intended to balance the demands of the workplace with the needs of families, to promote the stability and economic security of families, and to promote national interests in preserving family integrity.

http://www1.umn.edu/ohr/policies/leaves/fmla.html

PARENTAL LEAVE FOR CHILDBIRTH A female resident may, upon written request of the Residency Program director copied to a Chief Residents and Program Coordinator, take up to six weeks paid maternity leave related to the birth of her child.

The paid leave must fall within the term of appointment and must be taken consecutively and without interruption. After using paid maternity leave and all unused vacation, any additional leave will be without pay. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly)

A male resident or a partner in a registered domestic partnership may upon formal request , take up to two weeks paid paternity/partnership leave related to the birth of a child. The Chief Residents and the Program Coordinator should be concurrently notified of leave requests by e-mail as soon as possible. All leave time must fall within the term of appointment and must be taken consecutively and without interruption. After using all unused vacation, any additional leave will be without pay. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly)

Disabilities associated with childbirth and pregnancy will be treated like any other disability.

PARENTAL/DOMESTIC PARTNERSHIP LEAVE - ADOPTION A female resident may, upon request, may take up to two weeks paid leave and up to two

weeks leave without pay related to the adoption/birth of a child. All leave time must fall within the term of appointment. All leave must be taken consecutively and without interruption. After using all unused vacation, any additional leave will be without pay. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

A male resident or partner in a registered domestic partnership may, upon request, take up to two weeks paid leave related to the adoption of a child. All leave time must fall within the term of appointment. All leave must be taken consecutively and without interruption. After using all unused vacation, any additional leave will be without pay. While on unpaid leave, the resident is responsible for payment of any insurance (residents on unpaid leave will be billed monthly).

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ACADEMIC/PROFESSIONAL LEAVE Up to five (5) working days per year may be taken as paid leave for academic leave and conferences. This time is in addition to regular vacation time and is at the discretion of the Program Director or Department Head. The Department may cover up to three days of reasonable expenses for residents presenting at national meetings.

Oral Board Travel: One day off before and the day of the boards. Resident is expected to be back to work the day after boards unless approval has been given by the Program Director.

MILITARY LEAVE Military leave is granted in full accordance with State and Federal regulations. The Program Director must be promptly notified in writing when a Medical Resident requires military leave.

JURY/WITNESS DUTY Jury duty and court leave will be authorized consistent with State and Federal Court requirements. The Program Director must be promptly notified in writing when a Medical Resident requires jury duty or court leave.

BEREAVEMENT LEAVE A resident may request bereavement leave through formal request of the Program

Director. Either sick or vacation time must be used. The Chief Residents and the Program Coordinator should be concurrently notified of leave requests by e-mail as soon as possible.

INTERVIEW TIME OFF A senior resident may take up to five (5) calendar days of non-vacation time to interview for a job or fellowship position.

POLICY ON EFFECT OF LEAVE FOR SATISFYING COMPLETION OF PROGRAM As is required by the American Board of Radiology (ABR), all resident leave is reported to the ABR on an annual basis. Per the ABR, the following terms in regards to leave must be met in order to be eligible to sit for the Board examination:

“Leaves of absence and vacation may be granted to residents at the discretion of the Program Director in accordance with local rules. Within the required period(s) of graduate medical education, the total such leave and vacation time may not exceed: Six (6) calendar weeks (30 working days) for residents in a program for one year, Twelve (12) calendar weeks (60 working days) for residents in a program for two

years, Eighteen (18) calendar weeks (90 working days) for residents in a program for

three years, or Twenty-four (24) calendar weeks (120 working days) for residents in a program for

four years. If a longer leave of absence is granted, the required period of graduate medical education must be extended accordingly.”

ABR REQUIREMENTS

Five years approved training

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ONE YEAR IN CLINICAL TRAINING

The first postgraduate year must be accredited clinical training in internal medicine, pediatrics, surgery or

surgical specialties, obstetrics & gynecology, neurology, family practice, emergency medicine, transitional year,

or any combination of these. No more than a total of three months may be spent in radiology, radiation oncology,

and/or pathology. All clinical training must be in an ACGME-, AOA-, or RCPSC- approved program (or equivalent).

FOUR YEARS IN A DIAGNOSTIC RADIOLOGY PROGRAM,

approved for training in diagnostic radiology by the Residency Review Committee ( RRC) for diagnostic radiology

of the ACGME, or by the RCPSC ( Canada).

A minimum of four months of the four-year diagnostic training program must be spent in nuclear

medicine. (See Nuclear Medicine 2004 Training Update.)

Three months in mammography, as required by The Graduate Medical Educational Directory--Essentials

No more than 12 months in any one discipline. (Research is considered a discipline. Those considering

careers in research may want to participate in the Holman Research Pathway.)

WILL BE A GRADUATE OF AN ACCREDITED U.S. OR CANADIAN PROGRAM BY SEPTEMBER 30TH OF THE YEAR THE

EXAM WILL BE TAKEN.

The following table shows when you can apply and take parts of the exam.

Diagnostic Radiology Examinations

May APPLY for written cognitive

exams

Eligible to take

Physics exam

Eligible to take

Clinical exam

Eligible to take oral exam (after passing

both written cognitive exams)

   1st year (0 to 12 months training)

x - - -

   2nd year (12 t0 24 months training)

x x - -

   3rd year (24 to 36 months training

x x x -

   4th year (36 to 48 months training)

x x x -

   48 months + clinical year completed

x x x x

TRANSFER

It is expected that you will remain in the same program for all four years. If you wish to transfer for any

reason, that transfer must be verified by the initial program director with whom you have successfully

completed the training. A listing of the specific rotations is required. This training must be accepted by

the new program director. If a program director states that a resident has not successfully completed

training, that statement must have the signatures of two other faculty members from the same program,

supporting the claim of unsatisfactory completion.

LEAVE OF ABSENCE

Leaves of absence and vacation may be granted to residents at the discretion of the program director in

accordance with local rules. Within the required period(s) of graduate medical education, the total such

leave and vacation time may not exceed SIX CALENDAR WEEKS (30 working days) for residents in a

program for one year, TWELVE CALENDAR WEEKS (60 working days) for residents in a program for two

years, EIGHTEEN CALENDAR WEEKS (90 working days) for residents in a program for three years, or

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TWENTY FOUR CALENDAR WEEKS (120 working days) for residents in a program for four years. If a longer

leave of absence is granted, the required period of graduate medical education must be extended

accordingly.

CARDIAC LIFE SUPPORT CERTIFICATION:

You must have basic cardiac life support certification. Advanced cardiac life support certification is encouraged.

HIGH MORAL AND ETHICAL STANDARDS:

You must be a specialist in diagnostic radiology and recognized by your peers to have high moral and ethical

standards in the profession.

PROOF OF VALID STATE LICENSURE:

HOLIDAY SCHEDULE AND BLOCK-OUT DATESHoliday schedules vary, depending on the institution. When rotating to a particular site, the holiday schedule for that institution must be followed.

NOTE: Residents on UMMC rotations follow the UMMC Fairview holiday schedule, not the “U of MN Staff” holiday schedule. Residents on outpatient rotations will make themselves available for hospital coverage in the event that the outpatient location is closed and the hospital is not.

The residency program also follows a schedule of Block-out Dates. These are dates during which staffing shortages are anticipated. Leave requests will not be granted during these periods without specific approval from the Program Director.

Date HolidayUMM

C HCM

CVAMC

Friday, July 3rd, 2009Independence Day

(Observed)No Yes Yes

Monday, September 7th, 2009

Labor Day Yes Yes Yes

Monday, October 12, 2009Columbus Day No No Yes

Wednesday, November 11, 2009 Veterans Day No No Yes

Thursday, November 26, 2009

Thanksgiving Yes Yes Yes

Friday, November 27, 2009Floating No No No

Friday, December 25th, 2009Christmas Yes Yes Yes

Friday, January 1, 2010New Year’s Day

(Observed)Yes Yes Yes

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Monday, January 18, 2010ML King Day (Observed)

No No Yes

Monday, February 15, 2010Presidents’ Day

No No Yes

Monday, May 31, 2010 Memorial Day Yes Yes Yes

BLOCK-OUT DATESEvent From: Through:

New Residents and Fellows July 1st, 2009 July 3rd, 2009

ABR Written Examinations September 10th, 2009 September 11th, 2009

Radiological Society of North America Meeting

November 29th, 2009 December 4th, 2009

ACR In-training Examination * February 4th, 2010 February 4th, 2010

Senior Hot Seat Review CoursesMarch 10th, 2010March 24th, 2010April 14th, 2010April 21st, 2010

March 14th, 2010March 28th, 2010April 18th, 2010April 25th, 2010

Duke Review Course April 11th, 2010 April 16th, 2010

Association of University Radiologists Meeting

March 23rd, 2010 March 26th, 2010

ABR Oral Examination May 23rd, 2010 May 26th, 2010

Terminal Leave/Vacation (Only Seniors)

June 21st, 2010June 25th, 28th – 30th,

2010

* MANDATORY examination for PGY2-4 -- Leave will not be granted.

DEPARTMENTAL POLICY REGARDING PREGNANCY FOR RESIDENTS

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The Department of Radiology will not differentiate in the treatment of potentially pregnant or confirmed pregnant residents. Specifically, on-call and fluoroscopy assignments will not be modified solely on the basis of a female resident being potentially pregnant or pregnant, in accordance with the official position of the American Association of Women in Radiology which states: “On the basis of available data, the elimination of fluoroscopy at any time during pregnancy cannot be justified on scientific grounds. Rationally, women of child-bearing age who enter the specialty of radiology should be willing to accept the theoretical risks involved in fluoroscopy.”

NOTARY SERVICE Shari Johnston

Phone: 612.626.5589Office: Mayo B-211

Pam HansenPhone: 612.626.6638Office: Mayo B-272

RESIDENT EXERCISE ROOM

The University of Minnesota Medical Center, Fairview Medical Executive Committee has graciously provided an exercise facility for use by University of Minnesota residents and fellows.

Location:Room C-496 Mayo Memorial Building(Locker rooms/showers are located directly across the hall)

Hours:The facility is open 24 hours a day, 7 days a week

Access Code to Exercise Room and Locker Rooms:9111 (Please do not share with anyone other than residents and fellows)

The space also includes a small kitchenette area with refrigerator, microwave, coffeemaker and hot/cold water dispenser.

HEALTH AND DENTAL NSURANCE COVERAGEPlease refer to Institutional Policy Manual for further information. You may also contact the Program Coordinator.

FLEXIBLE SPENDING ACCOUNTPlease refer to Institutional Policy Manual for further information. You may also contact the Program Coordinator.

LONG-TERM DISABILITY NSURANCE COVERAGEPlease refer to Institutional Policy Manual for further information. You may also contact the Program Coordinator.

SHORT-TERM DISABILITY NSURANCE COVERAGEPlease refer to Institutional Policy Manual for further information. You may also contact the Program Coordinator.

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PROFESSIONAL LIABILITY NSURANCE COVERAGEPlease refer to Institutional Policy Manual for further information. You may also contact the Risk Management Office:

Office of Risk Management and Insurance1300 South 2nd StreetSuite #208 WBOBMinneapolis, MN 55454Phone: 612-624-5884

LIFE NSURANCE COVERAGEPlease refer to Institutional Policy Manual for further information. You may also contact the Program Coordinator.

VOLUNTARY LIFE NSURANCE COVERAGEYou may also contact the Program Coordinator.

INSURANCE COVERAGE CHANGESYou may also contact the Program Coordinator.

WORKER’S COMPENSATIONUniversity employees must promptly report on-the-job injuries/illnesses to the employee's supervisor. Within 24 hours of the employee's report the supervisor shall complete the First Report of Injury and the Employee Incident Report forms and forward these to the University's vendor and a copy to the University Workers' Compensation Department.

http://www.policy.umn.edu/groups/ppd/documents/policy/workers_comp

MEAL PROGRAMResidents on duty have access to adequate and appropriate food services at all institutions.

UMMC PGY3-5 Residents on-call are entitled to a fixed monthly meal allocation for each meal while on-call and are given swipe cards once a year beginning July 1st for use while on call at UMMC. Swipe cards are honored ONLY at the Bridges Cafeteria (University campus) or the East Side Market Café (Riverside campus).

The balance on the card can be obtained by asking the cashier at the register. When the balance reaches $0.00, the cashier will collect the card from the resident so that the card can be reprogrammed. Resident should contact GME Coordinator at HCMC and VAMC regarding their meal card

program.

LAUNDRY SERVICESTwo lab coats will be provided at the beginning of your residency. If you should require a

replacement lab coat during your residency program, please contact, Shari Johnston, Program Coordinator.

No laundry services are provided for Radiology residents. Scrubs are provided at all three institutions when you are on an appropriate rotation for scrubs. These are the property of the institutions and are to be used for this purpose only.

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- UMMC:Scrubs are available on a sign-out basis by using your UMMC identification badge in Room J2-104. The required bar code for the backside of your ID badge is provided by Kathy Monitor in Linen Services: 612-273-5793.

- HCMC: Scrubs are available by placing a $10 deposit per pair (3 pair maximum) at the Cashier (First floor, North block), and then bringing your voucher to Outpatient Supply (Third floor, North block). In order to be reimbursed for your deposit, you must return your scrubs to Outpatient Supply.Blue scrubs are available in the Radiology Department, but only for use in Special Procedures or the Operating Room.

- VAMC: Lab coats and scrubs are available on a sign-out basis by providing your VAMC identification badge to the VAMC Laundry (Room 1N-104).

PARKINGUMMC The Department provides general parking at Oak Street Ramp C for residents. Residents receive a parking card during their department orientation at the beginning of their PGY2 Year. If you encounter a problem with your parking card, contact Shari Johnston, Program Coordinator at 612-626-5589.

DO NOT TAKE YOUR KEY CARD INTO ANY MRI FACILITY, AS THESE UNITS WILL ERASE THE CARD’S MEMORY. EXITING PARKING FACILITY WITHOUT SCANNING CARD WILL AUTOMATICALLY RESULT IN YOUR CARD BEING LOCKED

ON-CALL PARKING: The Department covers parking expenses for residents taking departmental call. Those with departmental parking cards will use the same card for on-call parking as for daily parking when rotating to UMMC.

AFTER-HOURS PARKING Parking validation is available to residents for the sole purpose of attending Program-related conferences and activities while on rotations based away from UMMC (i.e., Diagnostic Radiology and Medical School Core Curriculum lectures, First-year Lecture Series, Physics Review, Senior Review and resident meetings). Parking tickets can be validated by the Program Coordinator.

HCMC Every resident can pick up his/her own parking card, with a $50 deposit. You will be allowed to keep it for the duration of your Radiology Residency.

You will have 30 days to return the card to the Parking/Security Office at the end of your residency. Their hours are: 6:00 am to 3:30 pm. forfeit.  If you do not return it within the 30-day period, you will forfeit the full deposit.   

VAMC

Residents may park in either the general parking lot or in the gated physician lot using VA ID badge.

BOOK AND TRAVEL FUND PGY-2 & PGY-3 residents will receive selected textbooks in lieu of book funds

beginning with the 2010 class. PGY-4 through PGY-5 residents will be allotted $500 each fiscal year for the

purchase of medical books and professional journals. PGY-5 residents may also include travel to Board review courses in their allotment. Residents beyond their fifth clinical year are considered to be in fellowship

positions and are not eligible for the reimbursement program.

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The University fiscal years run from July 1st through June 30th of the following year. Funds can be carried from one year to the next.

Residents are required to purchase books from online or retail source and submit receipt(s) to Shari Johnston, Program Coordinator, for reimbursement. Residents are NOT reimbursed for tax.

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SECTION III. INSTITUTIONAL RESPONSBILITIES (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for Medical School Policies on the following: ACGME Resident Survey Requirements; ACGME Site Visit Preparation Services; Institution Affiliation Agreements; Program Letters of Agreement; Confirmation of Receipt of Program Policy Manuals; Duty Hour Monitoring at the Institution Level Policy and Procedure; Funding; GME Competency Teaching Resources and Core Curriculum; Graduate Medical Education Committee Responsibilities; Graduate Medical Education Committee Resident Council Responsibilities; Institution and Program Requirements; Internal Review Process; International Medical Graduates Visa Requirements; New Training Program Approval Process; Orientation; Registration Policy ).

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SECTION IV. DISCIPLINARY AND GRIEVANCE PROCEDURES (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for Medical School Policies on the following: Discipline/Dismissal/Nonrenewal; Conflict Resolution Process for Student Academic Complaints; Academic Incivility Policy and Procedure; University Senate on Sexual Harassment Policy; Sexual Harassment and Discrimination Reporting; Sexual Assault Victim’s Rights Policy; Dispute Resolution Policy) Discipline/Dismissal for Academic Reasons

Trainee academic performance is determined by a review of evaluations and examination scores (see Section IV: Steps in Evaluation Process). If resident performance is felt to be below an acceptable level, discipline and possible dismissal will follow guidelines set forth in the Institutional Policy Manual (see Disciplinary and Grievance Procedures).

Procedures: The resident/fellow will be given verbal notice of performance deficiencies by the Program Director, an opportunity to remedy deficiencies, and the notice of possible dismissal or contract non-renewal if the deficiencies are not corrected, and a record of this will be placed in the trainee’s file.

When the resident continues to demonstrate a pattern of marginal or unsatisfactory academic performance, they will be placed on academic probation as specified in the Institutional Manual. A Radiology Graduate Medical Education Committee will meet to discuss the outcome of the probation, and may recommend: Removal from probation with a return to good academic standing; continued probation with new or remaining deficiencies sited; Non-promotion to the next level of training; Contract non-renewal and/or dismissal.

Discipline/Dismissal for Non-Academic ReasonsDiscipline/dismissal for non-academic reasons will follow the guidelines set forth in the Institutional Policy Manual.

Grievance Procedure and Due Process Refer to the Institutional Policy Manual

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SECTION V. GENERAL POLICIES AND PROCEDURES (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for Medical School Policies on the following: Academic Health Center (AHC) Student Background Study Policy; Background Study Policy and Procedure; Applicant Privacy Policy; Appointment Letter Policy and Procedure; Blood Borne Pathogen Diseases Policy; Certificate of Completion Policy; Classification and Appointment Policy; Compact for Teaching and Learning; Disability Policy; Disaster Planning Policy and Procedure; Documentation Requirements Policy; Documentation Retention Requirements for FICA Purposes Policy; Dress Code Policy; Duty Hours/On-Call Schedules; Duty Hours Policy; Duty Hours/Prioritization of On-Call Room Assignments; Effective Date for Stipends and Benefits Policy; Eligibility and Selection Policy; Essential Capacities for Matriculation, Promotion and Graduation for U of M GME Programs; Evaluation Policy; Health Insurance Portability and Accountability Act; Immunizations and Vaccinations; Immunizations: Hepatitis B Declination Form; Impaired Resident/Fellow Policy and Procedure; Licensure Policy: Life Support Certification Policy; Moonlighting Policy; National Provider Identification (NPI) Policy and Procedure; Nepotism Policy; Observer Policy; Post Call Cab Voucher Policy (UMMC-F; HCMC); Registered Same Sex Domestic Partner Policy; Release of Contact Information Policy; Residency Management Suite (RMS): Updating and Approving Assignments and Hours in the Duty Hours Module of RMS; Restrictive Covenants; Standing and Promotion Policy; Stipend Level Policy; Stipend Funding from External Organizations Policy; Supervision Policy; Training Program and/or Institution Closure or Reduction Policy; Transitional Year Policy; USMLE Step 3 Policy; Vendor Policy; Verification of Training and Summary for Credentialing Policy; Voluntary Life Insurance Procedure; Without Salary Appointment Policy ).PROGRAM GOALS AND OBJECTIVES

The objective of the residency program is to provide a high quality graduate medical educational experience in diagnostic radiology.

PROGRAM CURRICULUM

http://www.med.umn.edu/radiology/education/residency/curriculum.html

PROGRAM SCHEDULESThe annual master resident rotation schedule is prepared in April or May by the Chief Residents who take into consideration residents’ ranks and plans, rotation and site availability, and institutional funding constraints. No resident is assigned to a rotation for other than meeting their educational goals. The final schedule requires the approval of the Program Director. The Program Director may change the annual master schedule without notice, as necessary to meet Program needs and obligations.

Program schedules for HCMC, UMMC and VAMC (master, monthly, weekly and vacation) are posted on the New Innovation (RMS) website.

NOTE: Schedules are revised frequently and residents are required to stay abreast of changes.

PROGRAM REQUIREMENTSAll residents are governing by the requirements in both the Institutional and Program Manual.

The Graduate Medical Education Committee, chaired by the Program Director, evaluates the progress of the residents, and makes recommendations for advancement or disciplinary actions. The Program Director with advice from Graduate Medical Education Committee members, determines candidates for admission to the training program,

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residents’ progress in the program, and residents satisfactory completion of graduation requirements.

Residents are expected to successfully complete their monthly rotations.

Residents are required to comply in a timely manner with administrative directives including those from the Program Coordinator. This includes, but not limited to:

Proper notification of all time away Weekly submission of duty hours in RMS Record conference attendance in RMS Conference Module for UMMC Conferences Prompt completion of RMS evaluations Reading/Studying during regular work hours – must be patient care related Compliance to USMLE policy (see below) Regular attendance at resident conferences is a mandatory requirement of this

program and trainees are required to document their attendance at appropriate conferences at their institution on days they are at work. Only those on call, post-call, ill, on leave, or attending the Armed Forces Institute of Pathology will be considered to have excused absences.

Residents are required to attend Grand Rounds and Core Curriculum Conferences at the University on days they are at work, regardless of which institution they are working at.

Residents who have not yet passed written Physics Boards are required to attend Physics lectures on days they are at work, regardless of which institution they are working at. When there is a conflict between conferences, PGY5 residents who will take the upcoming ABR Oral Board exam may attend Senior Reviews.

All PGY2 through 4 residents are required to take the American College of Radiology In-Training exams, unless they are excused by the Program Director.

In order to ensure residents are eligible for certification by the American Board of Radiology (ABR), the Program requires residents to meet ABR requirements for certification, which can be reviewed at http://www.theabr.org. All PGY2 residents are required to register with the American Board of Radiology for certification in the required time frame unless they have been prospectively excused from this by the Program Director.

Graduation certificates are awarded to residents who have successfully completed their PGY1 through 4 years of training, who are making satisfactory progress in completing their PGY5 year as determined by the Program Director, and who are not expected to extend their PGY5 year more than 3 months.

USMLE Step 3 Policy:Policy: “All residents must pass the USMLE Step 3 or an equivalent licensing examination (i.e. COMLEX) by March 1st of their PGY2 year to be eligible for a resident contract at the PGY3 level or beyond. Residents are encouraged to take the appropriate licensing examination early in their training to permit adequate time to re-take the exam if more than one attempt is needed”.

Procedure: "Residents should register for the USMLE Step 3 or equivalent licensing examination no late then November 1st of their PGY2 year to allow for scheduling, grading and notification of exam results by the March 1st deadline. Residents who do not notify their program of a passing score by March 1st forfeit their continuing position within the training program and are subject to contract non-renewal."

TRAINING/GRADUATION REQUIREMENTS This program adheres to the training requirements set forth by the American Board of Radiology. These requirements can be reviewed at http://www.theabr.org.

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Program Directors, along with the Graduate Medical Education Committee, a faculty committee of the Department of Diagnostic Radiology with representatives from UMMC, HCMC and VAMC, has the responsibility to evaluate candidates for admission to the training program, to evaluate trainees in the program, to promote those who are progressing satisfactorily and, ultimately, to make recommendations that trainees have met the criteria established by the faculty for completion of our training programs. The Graduate Medical Education Committee meets specifically at least twice per year for the purpose of evaluating the progress of each trainee, to make recommendations for evaluating his/her progress, and to make recommendations for advancement. These meetings are typically held in the fall and spring.

Graduation certificates are awarded to residents who successfully complete all of the Program requirements, have shown satisfactory progress toward the competent, independent practice of Diagnostic Radiology, and demonstrate professional and personal attributes dedicated to the life-long learning process associated with the practice of medicine. Program requirements are:

Application for and successful completion of the requirements to sit for the American Board of Radiology (ABR) examination

Successful completion of all scheduled rotations Successful passage of mini-boards examinations during PGY2 year All PGY2-4 Radiology residents must take the American College of Radiology (ACR)

In-training examination.ACGME CORE COMPETENCIES

All University of Minnesota Medical School Residency/Fellowship training programs define the specific knowledge, skills, attitudes, and educational experiences required by the ACGME/RRC to ensure its residents/fellows demonstrate the following:

1) Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

2) Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

3) Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.

4) Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals.

5) Professionalism , as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

6) Systems-based practice , as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.

DUTY HOURSDuty hours are defined as all clinical and academic activities related to the training 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.

- Duty hours are limited to eighty (80) hours per week, averaged over a 4-week period, inclusive of all in-house call activities.

- Residents are provided with one (1) day in seven (7) free from all educational and

clinical responsibilities, averaged over a 4-week period, inclusive of call.

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- The training program provides adequate time for rest and personal activities, which consists of a 10-hour time period provided between all daily duty periods and after in-house call.

- Residents track their duty hours through the RMS System. The duty hours reports are then reviewed by the Program Coordinator for any violations.

- Violators will be notified and required to submit written documentation as to why violation occurred.

Federal regulations mandates that GME programs account for all resident hours worked in order to maintain Medical Education funding. In addition to these federal regulations, ACGME also mandates programs monitor duty hours to ensure compliance with duty hour requirements. This means that residents must complete an online timecard of their hours worked in order to be compliant with these mandates and continue funding, accreditation, and flexibility of the program.

Duty hour violations are prohibited. Residents are responsible for making the program aware of impending violations before they occur.

RMS – RESIDENCY MANAGEMENT SUITEThe Minnesota Medical Council of Graduate Medical Education mandates the University of Minnesota use RMS to track resident duty hours. The department also uses RMS as an evaluation tool.

 DUTY HOUR APPROVAL POLICY & PROCEDUREAll activities performed by residents during their rotations are documented in an online system called Residency Management Suite (RMS). The data held within RMS is used to document and reconcile payments with the institutions where the fellows/residents rotate. Residents are required to enter their duty hours into RMS weekly and review for accuracy.

Residents are responsible for making any changes such as; start time, duration, applying activities they participated in and indicating those activities they did not participate in with “Did Not Work”.

Maintaining your duty hours is not only a GME requirement it is also a requirement for the completion of your degree.

Note: Failure to ensure accuracy of your rotation activities will be considered an act of Medicare fraud.

Duty hours are to be entered by 7AM on the first working day of the month. We are granting you the weekend now to get things in order.

All fixes indentified by Program Coordinator must be corrected by the following morning.

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If the above do not occur:

Residents on a U of M rotation will have their parking privileges revoked beginning the next day and will be in effect until the residency office has cleared you.

Residents at HCMC or VAMC will have their book funds debited in the amount of $25.00 per day beginning the next day and will remain in effect until the residency office has cleared you. If resident does not have funds remaining in their book fund account vacation will be revoked or call will be applied at my discretion.

PGY5s will have a letter placed in their permanent file reflecting a lack of professionalism if pattern continues.

Use of the New Innovations Residency Management Suite (RMS)Logging into RMS:

Use your browser to go to www.new-innov.com/login. Internet Explorer is the preferred browser.

Enter MMCGME for the Institution ID.

Enter your User Name and Password in the appropriate boxes.

Make sure that you have arrived at your Welcome Page. You should see your Department name in the upper left section of the screen, and your User Name will be listed just below that.

Duty Hours – Entry and Approval or Modification of Already Entered HoursA) Entry of New Duty Hours

1. From the Main Menu, select Duty Hours.

2. Select the Add Duty Hours link and ensure that Graphical entry is selected. Select the date you wish to enter hours for and click Continue. 

3. Choose an Assignment from the drop down menu and “paint” in your hours by holding your left mouse button down and dragging across the grid. Click Save regularly to avoid loosing the hours entered.

B) Approval or Modification of Already Entered Hours

1. Select the Approve Existing Hours link.  

2. If necessary, enter a date range to restrict the unapproved or conflicting logged Duty Hours to display, and then click the Update Table button.

  3. Where appropriate, place a check in one or more of the checkboxes located to the left of

the entries. Then click the Approve Selected Entries or the Did Not Work button. 

Note: A red asterisk (*) indicates that the entry conflicts with an existing entry (time periods overlap).

 Note: Text in bold red indicates the entry has caused a Duty Hour rule exception.

 Note: Hours will not be automatically approved if they were logged for future dates or times, if they conflict with existing logged hours, or if they trigger a Duty Hour exception. Hours that trigger a Duty Hour exception CAN be approved, although you may want to enter an explanation in the Comment box. Conflicting Duty Hour entries must be resolved

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before the entry can be successfully approved. Duty hours logged for any time in the future cannot be approved. 

Tip: Click the Details link to the far right of a entry to see more information about the entry (see second screenshot below).

 Tip: Click the Comments link to view, edit, or delete any comments that are associated with the logged hour entry OR to add another (see third screenshot below).  

ON-CALL ACTIVITIESThe objective of on-call and night float activities is to provide residents with emergency radiology experience, and is scheduled by the Chief Residents after approval of the Residency Program Director and Chairman.

Radiology residents are assigned call at UMMC, HCMC and VAMC. Call averages no more than one-in-four, but can change on an as-needed basis. Scheduling of the residents for call is the direct responsibility of the Chief Residents with Program Director approval.

ON-CALL ROOMSAn on-call room within the Department of Radiology is available to residents taking departmental call or night float at both UMMC and HCMC, where residents receive their in-house on-call experience. Any questions or concerns regarding departmental on-call rooms should be directed to your Chief Residents

On-call residents are also eligible to use one of eighteen (18) Mayo Building call rooms provided by UMMC. All rooms have punch code security access changed daily, and a security monitor on duty daily from 2:00 PM – 7:00 AM. All rooms have a desk, television, radio clocks and air conditioning.Check-in can only occur during designated check-in hours: 2:00 PM – 7:00 AM. - Go to the check-in desk located in the Resident Lounge (Mayo C-496). The check-in

desk is staffed by a security monitor during set hours seven (7) days/week and will require you to present your ID badge.

- The security monitor will assign you a room, the room access code, and the locker room and lounge access codes.

- All individuals must be out of their room by 8:00 AM. Housekeeping will begin cleaning by 7:00 AM. If you wish to sleep past 7:00 or 8:00 AM, make sure your “Do Not Disturb” sign is indicated on your door.

SUPPORT SERVICESA full range of patient support services are provided in a manner appropriate to and consistent with educational objectives and patient care. These include but are not limited to Care Management Services, Cardiopulmonary Services, Employee Health Service, Health Information Management, Infection Control, Laboratory Medicine and Pathology, Nursing Administration, Nutrition Services, Patient Relations, Patient Transport, Pharmacy Services, Radiology Film File Services, Rehabilitation Services, Security Services, Social Services, Spiritual Health Services, and Shuttle Service between the Riverside and University campuses.

LABORATORY / PATHOLOGY / RADIOLOGY SERVICESFederal and state regulations and regulatory agencies mandate competency validation for testing personnel (including physicians), documentation, quality assurance, quality control, etc. The regulations cover hospitals, clinics, physicians’ offices, nursing homes, and any site where testing is performed. Testing performed by physicians, practitioners, nursing staff, and laboratorians must meet regulatory guidelines. Failure to comply with the mandates can lead to suspension, revocation, or limitation of certification and denial of reimbursement.

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MEDICAL RECORDS - HEALTH INFORMATION MANAGEMENTA medical record system that documents the course of each patient’s illness and care is available at all times to support quality patient care, the education of residents, quality assurance activities, and provide a resource for scholarly activity. Additionally a provision of information systems is made for timely retrieval of medical records and radiologic information. To access please contact: UMMC Health Information Management Office at 612-626-3535.

SECURITY / SAFETYSecurity and personal safety measures are provided to residents at all locations including but not limited to parking facilities, on-call quarters, hospital and institutional grounds, and related clinical facilities (e.g., medical office buildings).

UMMCFairviewCampus

UMMCRiverside Campus

HCMC VAMCUniversityofMinnesota

SECURITY

612-672-4544

612-672-4544

612-873-3232

612-467-2007

612-624-9255

RADIATION BADGESRadiation badges must be worn in controlled radiation areas under penalty of State law. You may be fined by the State Health Department if found not wearing a badge during an inspection.

New badges will be placed in your mailbox at the institution to which you are assigned on the first working day of the month. Always keep your old badges until you get a replacement. Badges from the previous month must be returned to your mailbox by the 8th of each month.

Under University policy, late badges will result in a fine of $50 per badge (unless replacement badges have not arrived in time to make the exchange). The amount of the fine will be deducted from your educational (“book”) fund; if adequate funds do not remain, the resident will be billed for the amount owed. Residents who plan to be away during the exchange period are required to make arrangements with someone to exchange their badges in their absence.

Lost or stolen badges must be reported to Pamela Hansen at 612-626-6638 or [email protected] .

MOONLIGHTINGThis policy does not acknowledge in any way, any departmental acknowledgement of the resident’s ability to satisfactorily perform any moonlighting activities. Malpractice insurance is the responsibility of the resident involved. Accreditation is up to the party hiring the resident. Residents are not required to engage in moonlighting.

Because residency education is a full-time endeavor, moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

Residents are required to notify the Program Director of their moonlighting activities. They shall email the Program Coordinator the dates, times and locations of all moonlighting activities and will become a part of the residents file.

Moonlighting activities will not be allowed to conflict with the scheduled and unscheduled

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time demands of the educational program and its facility.

The resident’s performance will be monitored for the effect of these activities upon performance and that adverse effects may lead to withdrawal of permission.

Internal moonlighting must be counted toward the 80-hour weekly limit on duty hours.

Residents on J1 visas are NOT permitted to be employed outside the residency program.

A resident on an H-1B visa wishing to moonlight must obtain a separate H1-B visa for each facility where the resident works outside the training program.

SUPERVISION / GRADED RESPONSIBILITYAll patient care is supervised by qualified faculty. The Program Director ensures, directs, and documents adequate supervision of residents at all times. Residents are provided with rapid, reliable systems for communication with supervising faculty. Residents are supervised by teaching staff in such a way that the residents assume progressively increasing responsibility according to their level of education, ability, and experience.

On-call schedules for teaching staff are structured to ensure that supervision is readily available to residents on duty. The teaching staff determines the level of responsibility given to each resident/fellow. Faculty and residents are educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects.

Resident participation at all of our institutions is one of active participation under direct supervision of full-time teaching staff. However, at all times, final responsibility for patient care resides with the full-time staff. In this manner, the residents receive excellent training in diagnostic radiology with an appropriate degree of responsibility.

STEPS IN EVALUATION PROCESSThe Graduate Medical Education Committee, a Department of Diagnostic Radiology, faculty committee, has the responsibility to evaluate candidates for admission to the training program, evaluate residents in the program, promote those who are progressing satisfactorily and, ultimately, to make recommendations that they have met the criteria established by the faculty for completion of our Diagnostic Radiology Residency Program. The committee shall meet four times per year.

Resident performance is determined in many ways. Evaluation methods available to the Committee are the following:

- Mini-board Examination: Mini-board Examination: This oral examination is taken by the residents at the end of their first year of training, at the start of their third year and during the lead-up to the oral boards. The format of the examination parallels that of the oral examination of the American Board of Radiology.

For the first-year residents, the subject material covered is the areas of radiology in which the residents have spent time. Each resident must receive a passing grade in each of the subjects. If a resident’s grade is below passing in any subject, he or she must take a make-up examination by the end of July so as to be able to go on-call as of July 1. The make-up examination is arranged with a different examiner. The purpose of all the mini-board examinations is to evaluate the progress of the resident as well as to acquaint them with the style of the Board examination that they will take at the completion of their training.

- In-training Examination: This written examination is required of all PGY2-PGY4 Radiology residents and is sponsored by the American College of Radiology (ACR). The

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national exam is given annually the first Thursday in February and requires four hours. It is of value to the residents because: 1) It is quite similar to the written examination given by the American Board of Radiology; 2) Evaluation of the scores in each of the areas of the examination allows the resident to determine if he or she has any weak spots; 3) The national character of the examination and the reporting of the scores in percentiles allows the resident to compare his or her progress with that of residents in other parts of the country; 4) Overall standings are provided to the department, allowing us to compare the performance of our training program with other programs.

- Monthly and 360 Evaluations: At the end of each clinical rotation, an evaluation of the resident’s progress is prepared by the faculty member(s) in that area. This is done via a RMS. Evaluations are accessible to residents on-line. Residents also evaluate their rotations at the end of each clinical rotation and faculty twice annually.

- The Program Director will meet with each resident twice a year to conduct their Bi-Annual Continuation Review to go over their mini-boards results, In-training examination results, monthly & 360 evaluations as well as to ascertain if there are any problems or concerns.

EVALUATION SYSTEM - ELECTRONICThis Program has integrated a web-based electronic evaluation system. Evaluations both of and by residents are essential parts of maintaining our status as an accredited residency program and producing superior resident-physicians. While traditional paper-based systems allow for simple data tracking, they do not provide an easy means for improving the quality of the program. The information obtained from the analysis of evaluation data is instrumental in objectively assessing the quality of all aspects of the residency program and for identifying and continuously monitoring areas for improvement.

RMS is a completely web-based computer system that allows us all to enter evaluations, receive rapid feedback, view reports, and compare teaching performance with other programs. The system is highly secure and flexible. Faculty and trainees are expected to complete evaluations on a monthly basis.

The web address for RMS is https://www.new-innov.com. If you experience any problems with logging into, please contact the Program Coordinator at 612-626-5589.

COMPLETING EVALUATIONS IN RMS

• Log into RMS

• Enter your User ID & password – Click “login”

• Click “continue”

• Under the notifications box you will see the number of evaluations you have pending completion. Click the text that reads “complete them”.

• Click the “evaluate” link next to the evaluation you wish to complete; this will bring you to the evaluation.

• NOTE: If you have not worked with the faculty - place a check mark in the box and click “submit selected evaluation as NET”.

1. Login to RMS. From the Main Menu, select Evaluations or click the link in your Notifications box on your Welcome Page.

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2. Select the evaluations you wish to complete from the list. For evaluations where you did not spend enough time with the person to warrant an evaluation, place a check mark in the box and click NET.

3. To view your evaluations select Evaluations from the main menu and click View Completed Evaluations.

MONITORING OF RESIDENT WELL-BEINGBoth the Program Director and faculty are sensitive to the need for timely provision of confidential counseling and psychological support services to the residents.

Residents feeling fatigued or stressed are encouraged to discuss their concerns with the Program Director, or to contact the (RAP) Resident Assistance Program at 651-430-3383 or 1-800-632-7643, especially if unable to provide safe patient care.

ACLS/BLS/PALS CERTIFICATION REQUIREMENTS

BLS – All residents must remain current on their Basic Life Support Training. ACLS – It is recommended that residents maintain Advanced Life Support Training

Travel

The Department may cover up to three days of expenses for residents presenting at national meetings. Individuals traveling on University business are covered under the Worldwide Travel Accident Policy, providing they have obtained permission to travel before travel begins.

Requests to travel are made via the University’s Travel Authorization form. This form can be obtained from the Travel Services website.

AUR Meetings: Incoming Chief Residents (2nd year residents) and Current Chief Residents (3rd year) may attend using three academic days off.

RSNA: 4th year 3 academic days off. ACR Conference: 3 academic days off for first year residents

BEFORE THE TRIP :1. Submit complete conference registration form to Program Coordinator along with

department approval documentation for processing.

2. Submit proposed flight plan Program Coordinator for processing.

3. Resident is responsible for making travel arrangements.

AFTER THE TRIP: 1. Receipts are required for reimbursements of $25 and above (accept for Per Diem

meals).

2. Gather all receipts and submit to Program Coordinator for processing reimbursement. Program Coordinator will contact resident when the University Employee Reimbursement Form is ready for their signature.

LIBRARIES

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INSTITUTIONAL LIBRARIES University of Minnesota Biomedical Library (Diehl Hall)

Hours of operation:Monday through Friday: 7:00 AM – 12:00 AMSaturday: 8:00 AM – 8:00 PMSunday: 12:00 PM – 12:00 AM

Hennepin County Medical CenterHours of operation:

Monday through Thursday: 7:00 AM – 9:00 PMFriday: 7:00 AM – 5:30 PMSaturday: 9:00 AM – 5:00 PMSunday: 10:00 AM – 5:00 PM

Veterans Affairs Medical CenterHours of operation:

Monday through Friday: 8:00 AM – 4:30 PMAccessible with VAMC identification badge 24 hours per day, 7 days per week

DEPARTMENTAL LIBRARIES University of Minnesota Medical Center, Fairview Radiology Department

Eugene Gedgaudas Learning Center, Mayo – Room B-218Hours of operation:

Accessible via combination lock 24 hours per day, 7 days per weekIn addition to the departmental library, there are subspecialty reference books and online access in each reading room.

ROTATIONS INVOLVING REGIONS HOSPITAL AND PARK NICOLLET

REGIONS – BREAST ROTATION Residents spend time at Regions Hospital during a regularly scheduled UMMC Breast rotation on Thursdays of their second month rotation. They must register at the Regions Hospital Graduate Medical Education Department on their first day of service there. Upon completion of registration residents will be given a parking key card for use during the rotation.

Park in the WEST ramp (formerly the North ramp), pull a ticket and bring with them for validation.  Take the Gillette Hospital elevators (North Elevators) to the first floor, turn right, then a left, walk straight ahead to the GME Office, Room 123. 

REGIONS – ER ROTATION Residents in their first year will spend time at Regions Hospital during their

regularly scheduled UMMC Breast rotation. The typical length of rotation is five (5) nights from 10:00PM-3:00AM. Dr. Lee typically works nights, one week on followed by two (2) weeks off.

To schedule the rotation contact Dr. David Lee at [email protected]. Once scheduled your rotation contact Deb Collier in the GME office at 651-254-3456. She will have you fill out some paperwork. Her office is on the 1st floor of the North Building adjacent to the North elevators (Room 125).

PARK NICOLLET – BREAST ROTATION Residents spend time at Park Nicollet during their regularly scheduled UMMC

Breast rotation on Wednesdays of their second month rotation.

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Two weeks prior to the start of your Park Nicollet rotation at the Jane Brattain Breast Center you MUST fax the following documents to Barb Ricke at 952-993-0212.

YOU WILL NOT BE ABLE TO PARTICIPATE IF YOU FAIL TO SUBMIT YOUR DOCUMENTATION

Application Form Confidentiality Agreement Immune Status Form Immunization Documentation – must be current (obtain from Boynton Clinic) Positive mantoux - (obtain from Boynton Clinic) Background check – will be submitted by the program coordinator

Goal and Objectives for Teaching Medical Students

Teaching Medical Students

Residents are an essential part of the teaching of medical students. It is critical that any resident who supervises or teaches medical students must be familiar with the educational objectives of the course or clerkship and be prepared for their roles in teaching and evaluation. Therefore, we’ve included in this manual the URL to the objectives for the Clerkship(s) specific to our Department as well as the overall Educational Program Objectives.

Educational Program ObjectivesUniversity of Minnesota Medical School

Graduates of the University of Minnesota Medical School should be able to:

OBJECTIVE OUTCOME MEASURES ACGME ESSENTIAL COMPETENCY

1.        Demonstrate mastery of key concepts and principles in the basic sciences and clinical disciplines that are the basis of current and future medical practice.

   USMLE Steps 1 and 2   Year 1 and 2 course performance,

based on standardized examinations

   Clinical rotation performance   Feedback from residency directors

Medical Knowledge

2.        Demonstrate mastery of key concepts and principles of other sciences and humanities that apply to current and future medical practice, including epidemiology, biostatistics, healthcare delivery and finance, ethics, human behavior, nutrition, preventive medicine, and the cultural contexts of medical care.

   USMLE Steps 1 and 2   Course performance (esp. in Physician

and Society, Nutrition, and Human Behavior at TC campus; Medical Sociology, Medical Epidemiology and biometrics, Family Medicine I, Medical Ethics, Human Behavioral Development and Problems, and Psycho-Social-Spiritual Aspects of Life-Threatening Illness at DU campus)

   Clinical rotation performance   Feedback from residency directors

Medical Knowledge

3.        Competently gather and present in oral and written form relevant patient information through the performance of a complete history and physical examination.

   Yr 2 OSCE   Physician and Patient (PAP) course

performance at TC campus, assessed by tutors using global rating forms and observed practical exams

   Course performance at DU campus in

Patient Care;Interpersonal and Communication Skills

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Applied Anatomy, Clinical Rounds & Clerkship (CR & C), Clinical Pathology Conference, and Integrated Clinical Medicine

   Clinical rotation performance4.        Competently establish a doctor-patient

relationship that facilitates patients’ abilities to effectively contribute to the decision making and management of their own health maintenance and disease treatment.

   Yr 2 OSCE and Primary Care Clerkship (PCC) OSCE

   PAP course performance at TC campus, assessed by tutors using global rating forms and observed practical exams

   Preceptorship and CR & C course performance at DU campus

   Clinical rotation performance

Patient Care; Interpersonal and Communication Skills

5.        Competently diagnose and manage common medical problems in patients.

   PCC OSCE   Clinical rotation performance

Medical Knowledge;Patient Care

6.        Assist in the diagnosis and management of uncommon medical problems; and, through knowing the limits of her/his own knowledge, adequately determine the need for referral.

   Clinical rotation performance   Documented achievement of

procedural skills in the Competencies Required for Graduation

Medical Knowledge; Patient Care;Practice-Based Learning and Improvement

7.        Begin to individualize care through integration of knowledge from the basic sciences, clinical disciplines, evidence-based medicine, and population-based medicine with specific information about the patient and patient’s life situation.

   Clinical rotation performance   Feedback from residency directors

Patient Care; Medical Knowledge; Interpersonal and Communication Skills; Professionalism

8.        Demonstrate competence practicing in ambulatory and hospital settings, effectively working with other health professionals in a team approach towardintegrative care.

   Yr 2 and PCC OSCE   PAP course performance at TC

campus, assessed by tutors using global rating forms and observed practical exams

   Physician and Society (PAS) course performance at TC campus

   Preceptorship, CR & C, and Introduction to Rural Primary Care Medicine course performance at DU campus

   Clinical rotation performance

Practice-Based Learning and Improvement; Systems-Based Practice

9.        Demonstrate basic understanding of health systems and how physicians can work effectively in health care organizations, including:      Use of electronic communication and

database management for patient care.      Quality assessment and improvement.      Cost-effectiveness of health interventions.      Assessment of patient satisfaction.      Identification and alleviation of medical

errors.

   PAS course performance at TC campus   Medical Sociology and CR & C course

performance at DU campus   Clinical rotation performance,

especially the PCC   Feedback from residency directors   Feedback from local health plans

Practice-Based Learning and Improvement; Systems-Based Practice

10.     Competently evaluate and manage medical information.

   Critical reading exercises in PAS and other courses at TC campus

   Clinical Pathology Conference performance and exercises in Problem Based Learning Cases at DU campus

   Year 2 Health disparities project   PCC EBM project

Patient Care; Medical Knowledge; Practice-Based Learning and Improvement; Systems-Based Practice

11.     Uphold and demonstrate in action/practice    PAS course performance at TC campus Professionalism

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basic precepts of the medical profession: altruism, respect, compassion, honesty, integrity and confidentiality.

   Preceptorship and Cr & C course performance at DU campus

   Clinical rotation performance   Participation in honor code and student

peer assessment program   Participation in anatomy memorial   Participation in volunteer service

activities12.     Exhibit the beginning of a pattern of

continuous learning and self-care through self-directed learning and systematic reflection on their experiences.

   PBL cases at DU campus   Yr 2 Health disparities project   Clinical rotation performance   Participation in research

Professionalism

13.     Demonstrate a basic understanding of the healthcare needs of society and a commitment to contribute to society both in the medical field and in the broader contexts of society needs.

   Course performance in all years   Introduction to Rural Primary Care

Medicine course project at DU campus

   Involvement of students in international study

   Enrollment in RPAP, RCAM, and UCAM

   Yr 2 Health disparities project   Feedback from residency directors   Participation in volunteer service

activities

Patient Care; Medical Knowledge; Practice-Based Learning and Improvement; Professionalism; Systems-Based Practice

These objectives are written to reflect the qualities and competencies expected of our graduates. Each objective specifies the expected competency level to be attained by our students, the outcome measures used to evaluate attainment of the objective, and the essential qualities and competencies of a physician (as defined by the six ACGME Essential Competencies) addressed by the objective. The Accreditation Council for Graduate Medical Education (ACGME) has formulated essential competencies felt to be necessary for physicians practicing in the current health care climate. They are:

     Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

     Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

         Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

         Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

         Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

         Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal patient care

The objectives for the undergraduate curriculum can be grouped as follows:

Objectives 1-3: Knowledge and skills addressed principally in the first two (preclinical) curricular years;

Objectives 4-9: Knowledge and skills addressed principally in the second two (clinical) curricular years;

Objectives 10-13: Knowledge, attitudes, and skills addressed throughout the curriculum.

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The objectives, which relate to the ACGME essential competencies, are designed to be modified for use also by the graduate (GME) programs at the University of Minnesota Medical School. Residency programs can modify the competency level stated in the objectives and the outcome measures to reflect their own programs, while maintaining the overall integration of basic learning objectives across undergraduate and graduate medical education.

One of the primary outcome measures for the objectives is clinical rotation performance. To expand on this; clinical rotation performance is assessed by attending physicians and residents using a Web-based global rating form, evaluating the following knowledge, competencies, skills, and attitudes:

     Medical knowledge and the ability to apply knowledge in clinical situations     Competency in patient care including communication and relationships with

patients/families     Skills in data gathering from the history, physical examination, clinical and

academic sources, and diagnostic tests      Assessment and prioritization of problems     Management of problems, including knowledge of patient data and progress     Appropriate decision making     Communication in written and oral reports     Professionalism, including: patient care and management in teams (work habits),

independent learning, personal characteristics, and commitment to medicine      Specific procedural skills (see report outlining Competencies Required for

Graduation)

Ratified by Education Council 2/18/03

SECTION VI. ADMINISTRATION (Please refer to Institution Policy Manual at http://www.med.umn.edu/gme/residents/parta.html for

Medical School Policies on the following: University of Minnesota Physicians, GME Administration Contact List, GME Administration by Job Duty; GME Organization Chart)

UMMC PROGRAM ADMINISTRATION

DIRECTOR & CHAIRMAN: CHARLES DIETZ, JR. M.D.Office:B234 Mayo Bldg

Phone:612.626.3345

Fax:612.626.3366

Pager:612.899.7591

Mail Code:MMC292

Email:[email protected]

PROGRAM DIRECTOR, TIM EMORY, M.D.Office:B234 Mayo Bldg

Phone:612.626.5529

Fax:612.626.3366

Pager:612.899.1424

Mail Code:MMC292

Email:[email protected]

PROGRAM COORDINATOR, SHARI JOHNSTONOffice:B211 Mayo Bldg

Phone:612.626.5589

Fax:612.624.3188

Pager:N/A

Mail Code:MMC292

Email:[email protected]

ALRT GRADUATE MEDICAL EDUCATION MANAGER: SALLY SAWYEROffice:763 Mayo Bldg

Phone:612.625.3518

Fax:612.626.2696

Pager:N/A

Mail Code:MMC609

Email:[email protected]

HCMC PROGRAM ADMINISTRATION

ASSOCIATE DIRECTOR: ANOTHONY SEVERT, M.D.Office:2E-20 HCMC

Phone:612.873.2036

Fax:612.904.4567

Pager:612.530.8654

Mail Code:MMC822

Email:[email protected]

PROGRAM COORDINATOR: PAMELA THOMPSON

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Office:P4-221 HCMC

Phone:612.873.2036

Fax:612.904.4567

Pager:N/A

Mail Code:P4

Email:[email protected]

PROGRAM COORDINATOR, SHARI JOHNSTONOffice:P4-221 HCMC

Phone:612.873.2718

Fax:612.904.4567

Pager:N/A

Mail Code:P4

Email:[email protected]

VAMC PROGRAM ADMINISTRATION

ASSOCIATE DIRECTOR: HOWARD ANSEL, M.D.Office:1Q-109

Phone:612.725.2038

Fax:612.727.5635

Pager:612.660.7016

Mail Code:114

Email:[email protected]

PROGRAM COORDINATOR: CAROL STEVENSOffice: Phone:

612.467.2929

Fax:612.467.5635

Pager:N/A

Mail Code:114

Email:[email protected]

PARK NICOLLET PROGRAM ADMINISTRATION

DIRECTOR: TBAOffice:

Phone:612.

Fax:612.

Pager:612.

Mail Code:

Email:

PROGRAM COORDINATOR: BARB RICKEOffice: Phone:

952.993.6106

Fax:952.993.0212

Pager:N/A

Mail Code: Email:[email protected]

REGIONS PROGRAM ADMINISTRATION

DIRECTOR: JOSEPH TASHJIAN, M.D.Email Preferred: [email protected] ROTATION COORDINATOR: DAVID LEE, M.D.Email Preferred: [email protected] COORDINATOR: DEB COLLIEROffice:125

Phone:651.254.3456

Email: [email protected]

SITE CENTRAL CONTACT INFORMATION

UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW

420 DELAWARE STREET SE

MINNEAPOLIS, MN 55455PHONE 612.273.6004FAX: 612.626.3366

HENNEPIN COUNTY MEDICAL CENTER

701 PARK AVE SOUTH

MINNEAPOLIS, MN 55415PHONE 612.873.2036FAX: 612.94.4258

VETERANS ADMINISTRATION MEDICAL CENTER

ONE VETERANS DRIVE

MINNEAPOLIS, MN 55417PHONE 612.725.2038FAX: 612.727.5635

REGIONS HOSPITAL

640 JACKSON STREET

ST. PAUL, MN 55101PHONE 651.221.3793FAX: 651.221.2849

PARK NICOLLET MEDICAL

3800 PARK NICOLLET BLVD.ST. LOUIS PARK, MN 55416PHONE 952.993.6106FAX: 952.993.0212

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