Policies and Procedures

Be informed about policies that guide and protect McGaw Medical Center of Northwestern University, trainees, and program staff.

 Examination Requirements

A passing score on both the USMLE Step 1 and Step 2 (Clinical Knowledge) exams - or, Canadian or osteopathic equivalent - is a prerequisite for starting training in any McGaw residency program.  All new residents will be asked to submit official score reports to the GME Office prior to starting training.

The above requirement also applies to international medical school graduates. 

All residents are strongly encouraged to take the USMLE Step 3 exam as soon as they are eligible.

All fellows must pass Step 3 (or equivalent) before starting a fellowship unless they are on a J-1 training visa and located outside of the United States of America, thus physically unable to sit for the examination.  All new fellows will be asked to submit an official score report to the GME Office prior to starting training.   

 Internationally Funded Training

Graduate medical education funded by external entities including foreign governments may represent an opportunity to train future regional and/or international thought leaders.  There are also a number of possible negative downstream consequences from engaging in such relationships.  In order to ensure centralized oversight of such funding partnerships, the following will be required:

  1. Prospective internationally funded trainees must have their prerequisite/prior training fully vetted by the sponsoring McGaw Program
  1. Trainees considering programs that utilize a national matching program (e.g. NRMP) should participate in the standard matching process
  1. Any prospective international funding must be approved by the McGaw Board of Directors prior to offering of a position or ranking a candidate
  1. The funds flow for international support must pass through the base hospital rather than McGaw, FSM, or the Department. Funding of the trainees will be the responsibility of the base hospital should the funding be delayed
  1. Internationally funding must extend for the entire duration of training at onset rather than annually renewable and include any unforeseen extension of training due to disciplinary action
  1. Internationally funded trainees are subject to all McGaw and base hospital policies and procedures, and
  1. Should a fellow undergo disciplinary action and training be terminated, the funding will not be recoverable by the funding entity.  

 Leaves of Absence

Any of the permissible leaves of absence are outlined on the Time Away from Training page under Benefits and Resources.

 Licensure

Each housestaff member must have a valid Illinois medical license.  No housestaff member shall begin training until a valid license is issued nor will credit be given for time spent in activities performed prior to obtaining a license.  It is the responsibility of each housestaff member to obtain or renew his or her permanent or temporary license.  

Temporary licenses are issued for three years, but if the housestaff member has not changed programs (and upon the approval of the Medical Examining Board), can be renewed for the length of the training program. 

Permanent licenses can be issued only after two full years of training and successful completion of the USMLE examinations.  Some housestaff members anticipate a future position in a state other than Illinois following training and thus do not wish to pursue a permanent Illinois license. 

Housestaff members who choose to complete training on a temporary license should nonetheless plan to complete the USMLE examinations as soon as they are eligible to do so.  Failure to complete these examinations in a timely manner may result in a delay in obtaining a permanent license once training is complete.  

 Off-Cycle and Part Time Training

Training at McGaw is to be on-cycle (July-June) and full time with only extraordinary extenuating circumstances being considered for exception.  Off-cycle training will be considered when preliminary training is extended resulting in a delayed end date and may be approved administratively by the DIO.  All other requests for off-cycle training and/or part time training must be submitted by the Program Director to the GMEC in writing with supporting documentation for its review and approval.  This submission must include written support by any relevant ACGME RRC and/or specialty Board.  Any impact on trainee complement must be considered and approved by the RRC. Funding impact must be approved by the relevant funding partner.  

 Program Closure or Reduction in Complement

If a decision is considered to reduce the complement of trainees in a program, or to close a training program, the program director will inform the DIO of the Graduate Medical Education Committee in order for the Committee to review and approve the decision.  All trainees in that program will be notified as soon as possible.  Current trainees in the program, including trainees who have not yet initiated training but who have been notified that they are accepted into the program, will be permitted to continue their education until completion of the total number of years defined by the ACGME for that program.

In the event of program closure, trainees will be permitted to complete the current training year.  The Program Director shall assist the trainees’ efforts to matriculate in other ACGME accredited programs.

 Raise Concerns and Provide Confidential Feedback without Retaliation or Intimidation

McGaw is committed to providing a supportive educational environment.  An important part of that commitment is to maintain an educational and professional culture that fosters learning for all housestaff members.  McGaw residents and fellows and Northwestern University Feinberg School of Medicine faculty members are governed by the Safe and Healthy Learning Environment Policy found here: 

http://www.feinberg.northwestern.edu/education/current-students/policies/safe-healthy-environment/index.html


All faculty members, students, residents, and fellows must review this policy yearly and attest they understand and will abide by its contents. 

Housestaff members who have any concerns regarding their educational and/or professional environment may raise their concerns either in writing or verbally in a variety of ways without fear of intimidation or retaliation.  There is no time limit to reporting concerns.  Methods to report include:

a)    Bringing concerns to their Program Director or other Departmental Advisor.

b)    If a housestaff member does not feel comfortable raising an issue with his/her Program Director, s/he may contact the ACGME Designated Institutional Official (DIO), Joshua Goldstein, MD.  Alternatively, a housestaff member may bring his/her concern to the attention of Nancy Parlapiano, McGaw Director of Graduate Medical Education.  Either of these individuals can be reached in person at the GME office on the first floor of the McGaw Pavilion, by email, or by phone at 312-503-7975.  

c)     McGaw also provides an online portal for submitting anonymous feedback.

d)    Housestaff may directly contact the confidential/discreet FSM Ombudsperson, Lisa Rone, MD who will review any situation and provide guidance.

e)    Housestaff may contact their peer representatives through the McGaw Housestaff Association.  Association leadership contact information is available on their dedicated page of the McGaw website.  Association leadership participate in the Graduate Medical Education Committee (GMEC) and report each month on issues affecting the learning environment.

f)     As detailed in the Feinberg Safe and Healthy Learning Policy, housestaff may also contact the Vice Dean for Education/President of McGaw, Diane Wayne, MD (312-503-9443) to raise issues or concerns.


McGaw forbids retaliation against anyone for reporting a concern, registering a complaint, or reporting harassment pursuant to Northwestern University’s Non-Harassment and Non-Discrimination policy, assisting in making a harassment complaint, participating in an investigation, filing a charge of discrimination, or otherwise pursuing his/her rights under applicable municipal, county, state, and federal laws.  Anyone experiencing or witnessing any conduct s/he believes to be retaliatory should immediately report it to any of the individuals named above, the confidential/discreet FSM Ombudsperson, or FSM leadership including the DIO/Associate Dean for GME or the Vice Dean of Education.  Please note that both Northwestern University and all member hospitals have code of conduct and non-retaliation policies that relate to the conduct of hospital employees in a teaching institution and the responsibility of a safe and healthy learning environment for trainees.  

More information can be found under Addressing Housestaff Concerns and Grievances.

Safe and Healthy Learning Environment

The McGaw Medical Center of Northwestern University, in association with Northwestern University Feinberg School of Medicine (FSM), is committed to the principle that educational relationships should be one of mutual respect between teacher and learner.  Because McGaw oversees the training of individuals who are entrusted with the lives and well-being of others, we have unique responsibilities to assure that residents and fellows learn as members of a community of scholars in an environment that is conducive to learning.  McGaw residents and fellows are subject to and covered under the Safe and Healthy Learning Environment policies.  Staff at member hospitals are likewise bound by the safe and healthy learning policy expectations through our affiliates’ code of conduct policies 

Both McGaw and Feinberg want to encourage residents and fellows to bring attention to any breach or perceived breach of the Safe and Healthy Learning Environment and wish to be open about the process the University has in place should such a claim be made. This process flow document offers a snapshot of our reporting, escalation, and resolution procedures related to a perceived mistreatment claim and is an option as outlined above for McGaw trainees.  The School also offers an ombudsperson for student, resident and fellow support.  The ombudsperson will strive to maintain the complaint or feedback as confidentially as possible.  There may be situations including those with safety concerns where some loss of confidentiality will be incurred.  These situations will be communicated with the complainant by the ombudsperson.  Details regarding the FSM safe and healthy learning environment policy/process are below.  Note that these represent one of many option for McGaw trainees.

I. INTRODUCTION
Maintaining a safe and healthy learning environment requires that the faculty, administration, residents, fellows, healthcare professionals, staff, and students treat each other with the respect due to colleagues.  All teachers should realize that students, residents, and fellows depend on them for evaluations and references, which can advance or impede their career development.  Teachers must take care to judiciously exercise this power and to maintain fairness of treatment, avoiding exploitation or the perception of mistreatment and exploitation. The quality and worth of a Feinberg School of Medicine education rest not only in the excellence of the content and the skills that are taught, but also in the example provided to students, residents and fellows of humane physicians and scientists who respect their professional colleagues at all career levels, their patients, and one another.

II. RESPONSIBILITIES OF TEACHERS AND LEARNERS
The teacher-learner relationship confers rights and responsibilities up-on both parties. Behaving in a way that embodies the ideal teacher-learner relationship fosters mutual respect, minimizes the likelihood of learner mistreatment, and optimizes the educational experience.

Responsibilities of Teachers

  • Treat learners fairly, respectfully, and without bias related to their race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status.
  • Distinguish between the Socratic Method, where insightful questions are a stimulus to learning and discovery, and overly aggressive questioning, where detailed queries are repeatedly presented with the endpoint of belittlement or humiliation of the learner.
  • Give learners timely, constructive, and accurate feedback and opportunities for remediation.
  • Provide written evaluations on time.
  • Be prepared and on-time for all activities.
  • Provide learners with current material and information and appropriate educational activities.

Responsibilities of Learners

Be courteous and respectful of others, regardless of their race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status.

  • A student, resident, or fellow should act in accordance with the handbook associated with their educational program.
  • Be prepared and on time for all activities.
  • Be aware of the medical condition and current therapy of patients.
  • Put patients' welfare ahead of educational needs.
  • Know limitations and ask for help when needed.
  • Maintain patient confidentiality.
  • View feedback as an opportunity to improve knowledge and performance skills.

III. DESCRIPTION OF INAPPROPRIATE BEHAVIOR

Inappropriate behaviors are those that are not respectful or professional in a teacher-learner relationship. Examples of inappropriate behaviors which compromise the integrity of the educational process include, but are not limited to:

  • Unwanted physical contact (such as touching, hitting, slapping, kicking, pushing) or the threat of the same;
  • Sexual harassment (see the Northwestern University Policy on Sexual Harassment);
  • Discrimination based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status (see the Northwestern University Policy on Discrimination and Harassment);
  • Requiring learners to perform personal chores (e.g., running errands or babysitting);
  • Verbal harassment, including humiliation or belittlement in public or privately (see the Northwestern University Policy on Civility);
  • Use of grading and other forms of assessment in a punitive or self-serving manner;
  • Romantic or sexual relationships between a teacher and student, resident or fellow (see the Northwestern University Policy on Consensual Romantic or Sexual Relationships Between Faculty, Staff, and Students). 

The list above identifies a few specific situations. See Mistreatment Examples for further examples. Other behaviors may qualify as mistreatment and, if the student, resident or fellow is unsure, s/he should consult with the appropriate faculty or university officials as detailed in Section V.

IV. RETALIATION

The university and medical school prohibit the taking of any retaliatory action for reporting or inquiring about alleged improper or wrongful activity.  For further details, see the Northwestern University Policy on Non-Retaliation.  There are additional polices of the base hospital that similarly prohibit retaliation from staff or faculty. 

V. WHAT TO DO IF YOU BELIEVE INAPPROPRIATE BEHAVIOR OR MISTREATMENT HAS OCCURRED

While we believe that professional behavior is generally practiced and respected by the members of our diverse community of scholars throughout Feinberg, we recognize there may be occasions when real or perceived incidents of unprofessional behavior directed toward learners occur.  In these circumstances, Feinberg is committed to establishing the facts through a fair process, which respects, to the extent possible, the privacy of the involved parties.

A complaint should be reported in a timely fashion, typically within 30 days of the end of an academic quarter or the clinical rotation in which the alleged incident occurred (although claims of discrimination can be reported at any time).  Depending upon the nature of the complaint, different avenues of reporting are available.  Our approach and process for addressing complaints are outlined below, illustrated in Appendix A, and described in more detail in Section VII.

To provide students, residents and fellows with an impartial initial point of contact, a faculty ombudsperson is available for students, residents, and fellows to contact fsmombuds@northwestern.edu.  There may be situations including those with safety concerns where some loss of confidentiality will be incurred.  These situations will be communicated with the complainant by the ombudsperson.  Alternative contacts are outlined above in the McGaw process for the raising of concerns and include the Dean for GME, the Vice Dean for Medical Education, and the housestaff association leadership. These individuals can either help address the concern directly or help with referral to an appropriate office or individual who is best suited to address the problem. 

If after discussion of the incident, the student, resident, or fellow and faculty point of contact agree that particular events could constitute mistreatment, the incident can be addressed as described below.  If the incident involves sexual harassment, sexual violence, or assault, the student, resident, or fellow will be referred to the University Sexual Harassment Prevention Office for further discussion and investigation.  If the incident involves other types of discrimination or discriminatory harassment, the student, resident, or fellow will be referred to the University Office of Equal Employment Opportunity and Access for further discussion and investigation.

If the incident does not fall into either of these categories, a first choice, where appropriate, is to seek informal resolution.  This may be achieved through direct communication between the student, resident, or fellow and/or faculty point of contact and the respondent (individual being reported by the student) or, potentially, other avenues of communication.  If an informal approach is either not appropriate or unsuccessful, then the student, resident, or fellow should make a formal complaint with the Dean for GME or Vice Dean for Education.

If the incident does not involve sexual harassment or other types of discrimination or discriminatory harassment and the student, resident, or fellow and faculty point of contact disagree that the incident was mistreatment, the student, resident, or fellow may pursue the matter directly with McGaw.

Students, residents, and fellows may always directly contact an office empowered to address specific policies.  In cases of possible sexual harassment or sexual assault or violence, the University Sexual Harassment Prevention Office may be contacted directly at sexual-harassment@northwestern.edu or 847-491-3745.  Additional information related to a student, resident, or fellow’s rights and options if they have experienced sexual assault or violence is available on the Title IX resource page.  For concerns related to discrimination and harassment, the Office of Equal Opportunity and Access may be contacted at eeo@northwestern.edu or 847-491-7458.

VI. CONFLICTS AND DOCUMENTATION

  • If the Dean for GME of McGaw is part of the complaint or in any other way has a conflict of interest or the appearance of a conflict of interest, s/he is obligated to remove him or herself from the case during the investigation and the Dean of the School of Medicine shall appoint someone else to assume responsibility for the complaint. 
  • The School of Medicine may act under these procedures, irrespective of possible civil or criminal claims arising out of the same or other events.  The Dean for GME, with the concurrence of the Dean of the School of Medicine, after consulting with the Office of the General Counsel, shall determine whether the University shall, in fact, proceed against a respondent who also faces related charges in a civil or criminal complaint.  If the University defers proceedings, it may subsequently proceed, irrespective of the time provisions set forth in these procedures.
  • The Dean for GME shall have the authority to take any actions on behalf of the School of Medicine that s/he deems necessary to protect the complainant and/or the respondent, or to address other needs or deliberations related to the situation, pending the investigation and resolution of the complaint.

VII. PROCESS FOR COMPLAINTS HANDLED BY THE DEAN FOR GME EDUCATION

As described in section V above, students, residents, and fellows with concerns related to mistreatment can use the faculty ombudsperson that is designated specifically for this purpose, college mentors, or a trusted faculty member as an initial point of contact.  Together with this individual, the student, resident, or fellow can decide whether to seek an informal resolution to the problem and/or whether to move forward with a formal complaint. 

If the complaint alleges discrimination or sexual harassment, the complaint must be referred to the University Office of Equal Employment Opportunity and Access or the Sexual Harassment Prevention Office, respectively.  Complaints brought to the Sexual Harassment Prevention Office or the University Office of Equal Employment Opportunity and Access will be handled using the processes and procedures of these offices, per University protocol and policy. Otherwise, if the student, resident, or fellow decides to proceed with a formal complaint of mistreatment, it will be addressed according to the process described below.

The process for addressing formal complaints of mistreatment is as follows:

  • Inquiry into a violation of the standards of conduct committed by any individual, whether or not affiliated with the University, should be initiated by written complaint and filed with the Vice Dean for Education as soon as possible, typically within 30 days of the end of an academic quarter or the clinical rotation in which the alleged incident occurred.  A delay in filing may be grounds for rejection of a complaint.
  • The complaint must be detailed, specific, and accompanied by appropriate Documentation, if available.
  • After receipt of a properly documented complaint, which has been made in good faith, the Vice Dean shall inform the respondent of the nature of the charges.  The Vice Dean will also remind the respondent about the non-retaliation policy of the University described above in Section IV.
  • To initiate an investigation, the Vice Dean shall appoint an investigation committee of not less than three individuals, all of whom shall be faculty members of the School of Medicine but not members of the same department as, or collaborators with, the complainant or respondent.  The investigation shall be initiated within two weeks of forming the committee, and the complainant and respondent will be notified that the investigation has been initiated.  The Vice Dean shall also make every effort to protect the identities of both complainant and respondent with respect to the larger community.
  • The investigation committee shall undertake a thorough examination of the charges.  Whenever possible, interviews shall be conducted with the complainant and respondent.  Interviews may also be conducted with others having information regarding the allegations, if the committee deems it necessary.  Summaries of these interviews shall be prepared, provided to the interviewed party for comment or revision, and included as part of the file.  When appearing before the committee, the respondent and the complainant may each be accompanied by a non-attorney adviser.  The student, resident, or fellow's adviser shall be a School of Medicine faculty member and the respondent's adviser must be a Northwestern University employee.  The committee shall not conduct formal hearings.  Except in unusual cases, the respondent and the complainant shall not appear before the committee at the same time.
  • Following the completion of its investigation, the committee shall submit a report of its findings to the Vice Dean for Education (who will share it with the Dean), with copies to the complainant and respondent.  This report shall describe the policies and procedures under which the investigation was conducted, how and from whom information was obtained, the findings, the basis of the findings, and texts or summaries of the interviews conducted by the committee.  This report shall ordinarily be submitted to the Vice Dean for Education within 60 days of the appointment of the formal investigation committee.  The complainant and respondent shall be permitted to make a written reply to the Vice Dean within 15 calendar days of receipt of the report.  Such replies shall be incorporated as appendices to the report of the investigation committee.  The entire investigation process shall typically be completed within 90 calendar days of its initiation, unless circumstances warrant a delay.  In such cases, the reasons for a delay shall be documented.

VIII. RESOLUTION FOR COMPLAINTS HANDLED BY THE VICE DEAN FOR EDUCATION

  • If the investigation committee finds the charges to be unfounded, the matter shall be dropped and the concerned parties shall be informed.
  • If the investigation committee finds the charges against a respondent to be substantiated, the Dean will notify the following offices:
    • For a non-faculty employee of the Feinberg School of Medicine or one of its affiliated clinical entities (including but not limited to nursing, housestaff, and fellows), the Dean shall inform the Office of Human Resources of the appropriate institution (e.g., Northwestern University, Northwestern Memorial Hospital, Northwestern Medical Faculty Foundation, etc.) or, for a resident or fellow of the McGaw Medical Center of Northwestern University, the Associate Dean for Graduate Medical Education.
    • If charges against a faculty member are substantiated, the Dean will proceed to take whatever actions are appropriate to the seriousness of the offense, in consultation with the Provost and in accordance with University procedures, and which consider the previous record of the respondent.  For major offenses by any faculty members, the Dean of the School of Medicine shall determine with the Provost whether there is substantial reason to believe that just cause exists for imposition of a major sanction, e.g., termination of appointment or suspension.  Such action will be executed in accordance with the policies and procedures in the Faculty Handbook.  For less serious offenses the Dean of the School of Medicine may impose minor sanctions, as described in the Faculty Handbook.  These may include, but are not limited to, removal from a particular project, a letter of reprimand, special monitoring of future work, or probation.

 Recruitment and Appointment of Housestaff

Housestaff are considered eligible for appointment to accredited programs if they are graduates of U.S. or Canadian LCME-accredited medical schools, of U.S. colleges of osteopathic medicine accredited by the American Osteopathic Association, or of non U.S. or Canadian medical schools if they have a currently valid Educational Commission for Foreign Medical Graduates (ECFMG) certificate, a currently valid visa (J-1, H-1B, or O-1; or alternatively, Immigrant [permanent resident] status), and a currently valid license from the Illinois Department of Financial and Professional Regulation (IDFPR).  

Eligibility will be determined by each individual training program and will be based on preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity.  Programs shall not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status.  Selection of residents should occur through the National Resident Matching Program (NMRP) if that program is included in the NRMP.  Program Directors shall comply with the regulations and the spirit of the NRMP. 

 Responding to Training Verification and Other Requests from Medical Licensing Bodies and Other Third Parties

Program Directors and other McGaw residency and fellowship training program representatives frequently receive requests from state medical licensing bodies and other third parties (e.g. credentialing services, prospective employers, other residency or fellowship training programs, etc.) seeking information about current or former McGaw housestaff, including but not limited to verification of residency or fellowship training.  In most instances, the medical licensing body or other third party provides an authorization form or other comparable form signed by the housestaff member that authorizes the housestaff member’s training programs (such as McGaw) and their representatives to provide the requested information.  Some of these forms also include language releasing the training programs and their representatives from liability for providing the requested information.  For those housestaff who successfully completed their McGaw training program without having been placed on probation or subjected to some other form of corrective or disciplinary action, responding to such requests is typically straightforward.  For those housestaff who have been placed on probation or subjected to some other form of corrective or disciplinary action, up to and including termination or dismissal from a training program, responding to requests can become more complicated.

This procedure is intended to provide guidance to Program Directors and other McGaw residency and fellowship training program representatives who are asked to provide information to medical licensing bodies and other third parties about McGaw housestaff.

  1. If a training program receives a training verification request or other request for information relating to a housestaff member who has not been subjected to any corrective or disciplinary action, the program should respond to the request so long as the housestaff member has signed a form authorizing the training program to release the requested information.  Such authorization forms can be provided by the licensing body or other third party requesting information and need not specifically name McGaw or the training program so long as the form authorizes programs or other entities where the housestaff member has trained, worked, or participated in an educational program to provide information. 
  2. If a training program receives a training verification request or other request for information relating to a housestaff member who has been subjected to any corrective or disciplinary action, the program should respond to the request so long as (a) the housestaff member has signed a form authorizing the training program to release the requested information; and (b) the form also includes a waiver/release from liability stating that the housestaff member releases the training program and its representatives from liability in connection with providing the requested information.  Such authorization and waiver/release of liability form can be a form provided by the licensing body or other third party requesting information and need not specifically name McGaw or the training program so long as the form authorizes other entities where the housestaff member has trained, worked, or participated in an educational program to provide information and releases such entities from liability in connection with their disclosure of information.  Alternatively, McGaw has its own authorization and waiver/release of liability form, which can be signed by the housestaff member.  In either event, the housestaff member should be asked to sign a form that both authorizes the disclosure of requested information and releases McGaw and its representatives from liability in connection with the disclosure of the information.  A copy of any form(s) signed by the housestaff member should be kept in the program file, and a copy should also be sent to the Associate Dean/DIO of McGaw. 
  3. In instances where a housestaff member who has been subjected to any corrective or disciplinary action refuses to sign a form that both authorizes the disclosure of requested information and releases McGaw and its representatives from liability in connection with the disclosure of the requested information, McGaw’s Associate Dean/DIO should be consulted.  The Associate Dean/DIO, in his or her sole discretion, may decide whether to insist that the form include both an authorization and a waiver/release from liability.  In no event shall McGaw or the housestaff member’s program be required to provide the requested information without the housestaff member’s express written consent.


In all above situations, all information provided to third parties should be an accurate appraisal of the housestaff member’s performance as requested in the form and as supported by the documentation in the training file or other available sources of information.

Program Directors and other training program representatives are encouraged to consult with McGaw regarding any questions they might have about this policy or about any request for information regarding a housestaff member.  McGaw also reserves the right to modify this policy in its sole discretion depending upon the particular facts and circumstances of any given request for information. 

 Stipends

All residents, subspecialty residents, and fellows will be paid the published stipend rate appropriate to postgraduate year level for the clinical training program to which they are appointed.

 Telemedicine

Telemedicine can represent an excellent learning opportunity for McGaw trainees.  The possibility for a service over educational imbalance does exist. It is McGaw policy that any experience for McGaw trainees must include the following:

  1. A clear program policy for faculty oversight including faculty documentation in the electronic medical record (EMR) after all housestaff telemedicine encounters.
  2. A specific plan for trainee education and faculty driven feedback after all telemedicine encounters. 
  3. Any telemedicine experience must have documented formal goals and objectives.
  4. A tracking system to assess the service / educational balance for any telemedicine experience.
  5. A process to review of all telemedicine experiences at the annual program review (APR).
  6. A process for tracking all time spent performing telemedicine.  All duty hours including evening and nighttime hours spent performing telemedicine tasks must be included in duty hour logs as per ACGME program requirements.
  7. Telemedicine may not be a moonlighting activity.

 Trainee File Retention

Along with the ACGME, we recommend holding the full file for at least seven years from the resident/fellow’s completion of training or separation.  Should you want to streamline the file after seven years, hold on to the following: 

•             All milestone, semi-annual, and final review documentation.

•             Original application and supporting documentation.

•             Copies of completed verification requests. 

•             Copy of certificate of completion.

•             Copy of final procedure log (if applicable).

•             Copies of rotation schedules.

•             Any disciplinary records (if applicable).

•             Any documents the PD deems viable for future reference. 

If space is an issue, we encourage programs to scan these documents and upload them to each respective graduated trainee’s profile in New Innovations under their Files & Notes tab. 

 Training Certification

12 months of satisfactory performance as determined by the Program Director are eligible to receive a certificate for that training.

Duplicate certificates will be issued on proof of loss or theft.  There is a fee for duplicate certificates.