Göğüs Cerrahisi Eğitim Programı Gereklilikleri (Thoracic Surgery ACGME Program Requirements)

ACGME Program Requirements for Graduate Medical Education
in Thoracic Surgery
Effective: January 1, 2008
Introduction
Int.A. Residency is an essential dimension of the transformation of the medical
student to the independent practitioner along the continuum of medical
education. It is physically, emotionally, and intellectually demanding, and
requires longitudinally-concentrated effort on the part of the resident.
The specialty education of physicians to practice independently is
experiential, and necessarily occurs within the context of the health care
delivery system. Developing the skills, knowledge, and attitudes leading to
proficiency in all the domains of clinical competency requires the resident
physician to assume personal responsibility for the care of individual
patients. For the resident, the essential learning activity is interaction with
patients under the guidance and supervision of faculty members who give
value, context, and meaning to those interactions. As residents gain
experience and demonstrate growth in their ability to care for patients, they
assume roles that permit them to exercise those skills with greater
independence. This concept—graded and progressive responsibility—is
one of the core tenets of American graduate medical education.
Supervision in the setting of graduate medical education has the goals of
assuring the provision of safe and effective care to the individual patient;
assuring each resident’s development of the skills, knowledge, and
attitudes required to enter the unsupervised practice of medicine; and
establishing a foundation for continued professional growth.
Int.B. Definition and Scope of the Specialty
Thoracic Surgery encompasses the operative, perioperative, and critical care of
patients with pathologic conditions within the chest. This includes the surgical
care of coronary artery disease; diseases of the trachea, lungs, esophagus, and
chest wall; abnormalities of the great vessels and heart valves; congenital
anomalies of the chest and heart; tumors of the mediastinum; diseases of the
diaphragm; and management of chest injuries.
Int.C. Duration and Scope of Education
Int.C.1. Education in thoracic surgery must be provided in one of these three
formats:
Int.C.1.a) Independent Program (traditional format): Two years of thoracic
surgery education, preceded by a successfully completed surgery
residency program accredited by the Accreditation Council for
Graduate Medical Education (ACGME) or by the Royal College of
Physicians and Surgeons of Canada. Thoracic Surgery 2
Programs wishing to provide a three-year curriculum must
document an educational rationale for the program which must be
approved in advance by the Review Committee.
Int.C.1.b) Joint Surgery/Thoracic Surgery Program (the 4+3 program): All
seven years of the program must be completed in the same
institution, and all of the years must be accredited by the ACGME.
Assuming successful completion of the programs, this format
provides the graduate with the ability to apply for certification in
both surgery and thoracic surgery.
Int.C.1.c) Integrated Program: Six years of thoracic surgery education
(completed in one institution) following completion of an M.D. or
D.O. degree from an institution accredited by the Liaison
Committee of Medical Education (LCME). Graduates of medical
schools from countries other than the United States or Canada
must present evidence of final certification by the Education
Commission for Foreign Medical Graduates (ECFMG).
Int.C.1.c).(1) The integrated curriculum must document six years of
clinical thoracic surgery education under the authority and
direction of the thoracic surgery program director. The
sequencing of the thoracic surgery educational
components must be integrated throughout the program in
order to provide a cohesive, progressive, and longitudinal
educational experience.
Int.C.1.c).(2) A minimum of 24 months and a maximum of 36 months of
the program must include education in core surgical
education, including pre- and post-operative evaluation
and care. The remainder of the curriculum must include
education in oncology; transplantation; basic and
advanced laparoscopic surgery; surgical critical care and
trauma management; thoracic surgery; and adult and
congenital cardiac surgery.
Int.C.1.c).(3) The last year of the integrated program must comprise
chief resident responsibility on the thoracic surgery service
at the primary clinical site or at an integrated site.
I. Institutions
I.A. Sponsoring Institution
One sponsoring institution must assume ultimate responsibility for the
program, as described in the Institutional Requirements, and this
responsibility extends to resident assignments at all participating sites.
The sponsoring institution and the program must ensure that the program
director has sufficient protected time and financial support for his or her Thoracic Surgery 3
educational and administrative responsibilities to the program.
I.A.1. The sponsoring institution must ensure an administrative and academic
structure that provides for educational and financial resources dedicated
to the needs of the program; i.e., the appointment of teaching faculty and
residents, support for program planning and evaluation, the assurance of
sufficient ancillary personnel, and the provision for patient safety and the
alleviation of resident fatigue. The sponsoring institution must:
I.A.1.a) demonstrate commitment to education in thoracic surgery in their
support of the residency program;
I.A.1.b) provide at least 25% salary support for the program director; and,
I.A.1.c) provide and document faculty development for the program
director and the faculty in education and teaching.
I.B. Participating Sites
I.B.1. There must be a program letter of agreement (PLA) between the
program and each participating site providing a required
assignment. The PLA must be renewed at least every five years.
The PLA should:
I.B.1.a) identify the faculty who will assume both educational and
supervisory responsibilities for residents;
I.B.1.b) specify their responsibilities for teaching, supervision, and
formal evaluation of residents, as specified later in this
document;
I.B.1.c) specify the duration and content of the educational
experience; and,
I.B.1.d) state the policies and procedures that will govern resident
education during the assignment.
I.B.2. The program director must submit any additions or deletions of
participating sites routinely providing an educational experience,
required for all residents, of one month full time equivalent (FTE) or
more through the Accreditation Council for Graduate Medical
Education (ACGME) Accreditation Data System (ADS).
I.B.2.a) Multiple abbreviated assignments among several sites or
simultaneous assignments to more than one institution are not
acceptable. Exceptions for physically-connected or geographically
close sites require advance approval of the Review Committee.
I.B.2.b) Assignments of four months or more to any participating site must
be approved in advance by the Review Committee. Thoracic Surgery 4
I.B.2.c) Major changes in participating or integrated sites must be
supported by submission of the institutional operative data.
I.B.3. Integrated Sites
A formal, written integration agreement is required that specifies, in
addition to the points above, that the program director:
I.B.3.a) appoints the members of the teaching faculty at the integrated
site;
I.B.3.b) appoints the chief or director of the teaching service in the
integrated site;
I.B.3.c) appoints all residents in the program; and
I.B.3.d) determines all rotations and assignments of both residents and
members of the teaching faculty.
II. Program Personnel and Resources
II.A. Program Director
II.A.1. There must be a single program director with authority and
accountability for the operation of the program. The sponsoring
institution’s GMEC must approve a change in program director.
After approval, the program director must submit this change to the
ACGME via the ADS.
II.A.1.a) The review committee will approve the qualifications of each
program director prior to the appointment. A change in program
director may result in a site visit and program review within 18
months of the approved change.
II.A.2. The program director should continue in his or her position for a
length of time adequate to maintain continuity of leadership and
program stability.
II.A.3. Qualifications of the program director must include:
II.A.3.a) requisite specialty expertise and documented educational
and administrative experience acceptable to the Review
Committee;
II.A.3.b) current certification in the specialty by the American Board of
Thoracic Surgery, or specialty qualifications that are
acceptable to the Review Committee; and,
II.A.3.c) current medical licensure and appropriate medical staff
appointment. Thoracic Surgery 5
II.A.3.d) documented experience educating thoracic surgery residents and
membership (in good standing) in the Thoracic Surgery Directors’
Association, and
II.A.3.e) documentation of formal faculty development activities in
education and teaching, such as participation at local and national
program director workshops and other educational activities.
II.A.4. The program director must administer and maintain an educational
environment conducive to educating the residents in each of the
ACGME competency areas. The program director must:
II.A.4.a) oversee and ensure the quality of didactic and clinical
education in all sites that participate in the program;
II.A.4.b) approve a local director at each participating site who is
accountable for resident education;
II.A.4.c) approve the selection of program faculty as appropriate;
II.A.4.d) evaluate program faculty and approve the continued
participation of program faculty based on evaluation;
II.A.4.e) monitor resident supervision at all participating sites;
II.A.4.f) prepare and submit all information required and requested by
the ACGME, including but not limited to the program
information forms and annual program resident updates to
the ADS, and ensure that the information submitted is
accurate and complete;
II.A.4.g) provide each resident with documented semiannual
evaluation of performance with feedback;
II.A.4.h) ensure compliance with grievance and due process
procedures as set forth in the Institutional Requirements and
implemented by the sponsoring institution;
II.A.4.i) provide verification of residency education for all residents,
including those who leave the program prior to completion;
II.A.4.j) implement policies and procedures consistent with the
institutional and program requirements for resident duty
hours and the working environment, including moonlighting,
and, to that end, must:
II.A.4.j).(1) distribute these policies and procedures to the
residents and faculty;
II.A.4.j).(2) monitor resident duty hours, according to sponsoring Thoracic Surgery 6
institutional policies, with a frequency sufficient to
ensure compliance with ACGME requirements;
II.A.4.j).(3) adjust schedules as necessary to mitigate excessive
service demands and/or fatigue; and,
II.A.4.j).(4) if applicable, monitor the demands of at-home call and
adjust schedules as necessary to mitigate excessive
service demands and/or fatigue.
II.A.4.k) monitor the need for and ensure the provision of back up
support systems when patient care responsibilities are
unusually difficult or prolonged;
II.A.4.l) comply with the sponsoring institution’s written policies and
procedures, including those specified in the Institutional
Requirements, for selection, evaluation and promotion of
residents, disciplinary action, and supervision of residents;
II.A.4.m) be familiar with and comply with ACGME and Review
Committee policies and procedures as outlined in the ACGME
Manual of Policies and Procedures;
II.A.4.n) obtain review and approval of the sponsoring institution’s
GMEC/DIO before submitting to the ACGME information or
requests for the following:
II.A.4.n).(1) all applications for ACGME accreditation of new
programs;
II.A.4.n).(2) changes in resident complement;
II.A.4.n).(3) major changes in program structure or length of
training;
II.A.4.n).(4) progress reports requested by the Review Committee;
II.A.4.n).(5) responses to all proposed adverse actions;
II.A.4.n).(6) requests for increases or any change to resident duty
hours;
II.A.4.n).(7) voluntary withdrawals of ACGME-accredited
programs;
II.A.4.n).(8) requests for appeal of an adverse action;
II.A.4.n).(9) appeal presentations to a Board of Appeal or the
ACGME; and,
II.A.4.n).(10) proposals to ACGME for approval of innovative Thoracic Surgery 7
educational approaches.
II.A.4.o) obtain DIO review and co-signature on all program
information forms, as well as any correspondence or
document submitted to the ACGME that addresses:
II.A.4.o).(1) program citations, and/or
II.A.4.o).(2) request for changes in the program that would have
significant impact, including financial, on the program
or institution.
II.A.4.p) provide evidence that faculty are actively engaged in the
education and scholarly productivity of Thoracic Surgery
residents, as well as participation in medical student education;
II.A.4.q) provide separate and regularly-scheduled teaching conferences,
mortality and morbidity conferences, rounds, and other
educational activities in which both the thoracic surgery faculty
and the residents attend and participate;
II.A.4.r) provide an organized written plan and a block diagram for the
clinical assignments to the various services and sites in the
program;
II.A.4.s) ensure that at the time of application to the program, each
resident is notified in writing of the length of the program.
Documentation must be maintained in each resident’s file,
including any required unaccredited years;
II.A.4.t) submit a log, grouped by procedure, that details the operative
experience of each trainee/fellow with the thoracic surgery
resident logs at the time of the site visit;
II.A.4.u) keep records of conference attendance which must be available
for review by the site visitor; and,
II.A.4.v) create opportunities for peer interaction with residents in related
specialties at all participating sites.
II.B. Faculty
II.B.1. At each participating site, there must be a sufficient number of
faculty with documented qualifications to instruct and supervise all
residents at that location.
The faculty must:
II.B.1.a) devote sufficient time to the educational program to fulfill
their supervisory and teaching responsibilities; and to
demonstrate a strong interest in the education of residents, Thoracic Surgery 8
and
II.B.1.b) administer and maintain an educational environment
conducive to educating residents in each of the ACGME
competency areas.
II.B.1.c) include one designated cardiothoracic faculty member who should
be responsible for coordinating multidisciplinary clinical
conferences and for organizing instruction and research in general
thoracic surgery.
II.B.1.d) include qualified thoracic surgeons and other faculty in related
disciplines who should direct conferences.
II.B.2. The physician faculty must have current certification in the specialty
by the American Board of Thoracic Surgery, or possess qualifications
acceptable to the Review Committee.
II.B.3. The physician faculty must possess current medical licensure and
appropriate medical staff appointment.
II.B.4. The nonphysician faculty must have appropriate qualifications in
their field and hold appropriate institutional appointments.
II.B.5. The faculty must establish and maintain an environment of inquiry
and scholarship with an active research component.
II.B.5.a) The faculty must regularly participate in organized clinical
discussions, rounds, journal clubs, and conferences.
II.B.5.b) Some members of the faculty should also demonstrate
scholarship by one or more of the following:
II.B.5.b).(1) peer-reviewed funding;
II.B.5.b).(2) publication of original research or review articles in
peer-reviewed journals, or chapters in textbooks;
II.B.5.b).(3) publication or presentation of case reports or clinical
series at local, regional, or national professional and
scientific society meetings; or,
II.B.5.b).(4) participation in national committees or educational
organizations.
II.B.5.c) Faculty should encourage and support residents in scholarly
activities.
II.C. Other Program Personnel
The institution and the program must jointly ensure the availability of all Thoracic Surgery 9
necessary professional, technical, and clerical personnel for the effective
administration of the program.
II.C.1. The sponsoring institution must provide support for a coordinator who is
designated to the thoracic surgery program.
II.D. Resources
The institution and the program must jointly ensure the availability of
adequate resources for resident education, as defined in the specialty
program requirements.
II.D.1. provide access to information services that include:
II.D.1.a) the electronic retrieval of patient information;
II.D.1.b) a comprehensive data base for thoracic, adult cardiac, and
congenital cardiac disease; and
II.D.1.c) an on-site library or electronic access to appropriate texts and
journals;
II.D.2. provide access to a learning resources laboratory for resident education
and remediation;
II.E. Medical Information Access
Residents must have ready access to specialty-specific and other
appropriate reference material in print or electronic format. Electronic
medical literature databases with search capabilities should be available.
III. Resident Appointments
III.A. Eligibility Criteria
The program director must comply with the criteria for resident eligibility
as specified in the Institutional Requirements.
III.B. Number of Residents
The program director may not appoint more residents than approved by the
Review Committee, unless otherwise stated in the specialty-specific
requirements. The program’s educational resources must be adequate to
support the number of residents appointed to the program.
III.B.1. A minimum of one thoracic surgery resident should be appointed in each
year to provide for sufficient peer interaction.
III.C. Resident Transfers
III.C.1. Before accepting a resident who is transferring from another Thoracic Surgery 10
program, the program director must obtain written or electronic
verification of previous educational experiences and a summative
competency-based performance evaluation of the transferring
resident.
III.C.2. A program director must provide timely verification of residency
education and summative performance evaluations for residents
who leave the program prior to completion.
III.C.2.a) Documentation of the residents’ operative experience must be
included.
III.D. Appointment of Fellows and Other Learners
The presence of other learners (including, but not limited to, residents from
other specialties, subspecialty fellows, PhD students, and nurse
practitioners) in the program must not interfere with the appointed
residents’ education. The program director must report the presence of
other learners to the DIO and GMEC in accordance with sponsoring
institution guidelines.
III.D.1. All trainees in both ACGME-accredited and non-accredited programs at
the sponsoring and integrated sites which might affect the educational
experience of the thoracic surgery residents, must be identified and their
relationship to the thoracic surgery residents must be detailed.
III.D.1.a) Fellows in non-accredited positions must either be contracted with
an ACGME-accredited thoracic surgery program or its equivalent,
have completed their ACGME-accredited thoracic surgery
educational program, or have requested and received an
exception in advance from the Review Committee.
III.D.1.b) The program director must provide an impact statement
addressing the goals and objectives, clinical responsibilities,
duration of the educational program, and the interactions of these
trainees/fellows as related to the thoracic surgery residents.
III.D.2. A chief thoracic surgery resident and a fellow (whether the fellow is in an
ACGME-accredited position or not) must not have primary responsibility
for the same patients.
IV. Educational Program
IV.A. The curriculum must contain the following educational components:
IV.A.1. Overall educational goals for the program, which the program must
distribute to residents and faculty annually;
IV.A.2. Competency-based goals and objectives for each assignment at
each educational level, which the program must distribute to
residents and faculty annually, in either written or electronic form. Thoracic Surgery 11
These should be reviewed by the resident at the start of each
rotation;
IV.A.3. Regularly scheduled didactic sessions;
IV.A.4. Delineation of resident responsibilities for patient care, progressive
responsibility for patient management, and supervision of residents
over the continuum of the program;
IV.A.5. ACGME Competencies
The program must integrate the following ACGME competencies
into the curriculum:
IV.A.5.a) Patient Care
Residents must be able to provide patient care that is
compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health. Residents:
IV.A.5.a).(1) will develop and execute patient care plans, demonstrate
technical ability, use information technology, and evaluate
diagnostic studies;
IV.A.5.a).(2) will under supervision of the thoracic surgery faculty:
IV.A.5.a).(2).(a) provide preoperative management, including the
selection and timing of operative intervention and
the selection of appropriate operative procedures;
IV.A.5.a).(2).(b) provide post-operative management of thoracic and
cardiovascular patients;
IV.A.5.a).(2).(c) provide critical care of patients with thoracic and
cardiovascular surgical disorders, including trauma
patients, whether or not operative intervention is
required;
IV.A.5.a).(2).(d) correlate the pathologic and diagnostic aspects of
cardiothoracic disorders, demonstrating skill in
diagnostic procedures (e.g., bronchoscopy and
esophagoscopy), and to interpret appropriate
imaging studies (e.g., ultrasound, computed
tomography, roentgenographic, radionuclide,
cardiac catheterization, pulmonary function, and
esophageal function studies); and,
IV.A.5.a).(2).(e) demonstrate knowledge in the use of cardiac and
respiratory support devices.
IV.A.5.a).(3) will have a minimum operative experience that must Thoracic Surgery 12
include:
IV.A.5.a).(3).(a) annually, a minimum of 125 major cases consistent
with those listed in the program information forms;
IV.A.5.a).(3).(b) an adequate volume of operative experience,
distribution of categories, and complexity of
procedures to ensure each resident a balanced and
equivalent clinical education;
IV.A.5.a).(3).(c) categories of procedures which must include but
are not limited to the lungs, pleura, and chest wall;
esophagus, mediastinum, and diaphragm; thoracic
aorta and great vessels; congenital heart
anomalies; valvular heart diseases; and myocardial
revascularization;
IV.A.5.a).(3).(d) these additional educational experiences: cardiac
pacemaker implantation, mediastinoscopy,
pleuroscopy, and flexible and rigid esophagoscopy
and bronchoscopy; endoscopic ultrasound,
endoscopic approaches to thoracic and esophageal
diseases; and multidisciplinary approaches to the
treatment of thoracic malignancy; and,
IV.A.5.a).(3).(e) required experience in endovascular stents (for
residents admitted on or after July 1, 2007).
IV.A.5.a).(4) will have documented operative experience showing they:
IV.A.5.a).(4).(a) participated in the diagnosis, preoperative planning,
and selection of the operation for the patient;
IV.A.5.a).(4).(b) performed those technical manipulations that
constituted the essential parts of the patient's
operation;
IV.A.5.a).(4).(c) were substantially involved in post-operative care;
and,
IV.A.5.a).(4).(d) were supervised by responsible faculty/teaching
staff.
IV.A.5.a).(5) will have assignments to nonsurgical areas (i.e., cardiac
catheterization and esophageal or pulmonary function
labs) for a period of time not exceeding a total of three
months during the clinical program, and this experience
may not occur in the chief year.
IV.A.5.a).(6) will spend their chief year in the sponsoring institute or
integrated sites for the program. (Exceptions require Thoracic Surgery 13
approval in advance by the Review Committee.) During
this year, the resident must assume senior responsibility
for the pre-, intra-, and post-operative care of patients with
thoracic and cardiovascular disease.
IV.A.5.a).(7) will have outpatient responsibilities which include the
following:
IV.A.5.a).(7).(a) The resident should have an opportunity to
examine the patient pre-operatively, to consult with
the attending surgeon regarding operative care,
and to participate in the surgery and postoperative
care;
IV.A.5.a).(7).(b) Outpatient care activities include resident
responsibility for seeing the patient personally in an
outpatient setting and, as a minimum in some
cases only, consulting with the attending surgeon
regarding the follow-up care rendered to the patient
in the doctor's office;
IV.A.5.a).(7).(c) The policies and procedures governing pre-hospital
and post-hospital involvement of the residents must
be documented. Documentation of this process
must be available to the site-visitor at the time of
program review; and,
IV.A.5.a).(8) perform clinical assignments that should be carefully
structured to ensure that graded levels of responsibility,
continuity in patient care, a balance between education
and service, and progressive clinical experiences are
achieved for each resident.
IV.A.5.b) Medical Knowledge
Residents must demonstrate knowledge of established and
evolving biomedical, clinical, epidemiological and socialbehavioral sciences, as well as the application of this
knowledge to patient care. Residents:
IV.A.5.b).(1) will know current medical information, and critically
evaluate scientific information;
IV.A.5.c) Practice-based Learning and Improvement
Residents must demonstrate the ability to investigate and
evaluate their care of patients, to appraise and assimilate
scientific evidence, and to continuously improve patient care
based on constant self-evaluation and life-long learning.
Residents are expected to develop skills and habits to be able
to meet the following goals: Thoracic Surgery 14
IV.A.5.c).(1) identify strengths, deficiencies, and limits in one’s
knowledge and expertise;
IV.A.5.c).(2) set learning and improvement goals;
IV.A.5.c).(3) identify and perform appropriate learning activities;
IV.A.5.c).(4) systematically analyze practice using quality
improvement methods, and implement changes with
the goal of practice improvement;
IV.A.5.c).(5) incorporate formative evaluation feedback into daily
practice;
IV.A.5.c).(6) locate, appraise, and assimilate evidence from
scientific studies related to their patients’ health
problems;
IV.A.5.c).(7) use information technology to optimize learning; and,
IV.A.5.c).(8) participate in the education of patients, families,
students, residents and other health professionals.
IV.A.5.c).(9) demonstrate the ability to practice lifelong learning,
analyze personal practice outcomes, and use information
technology to optimize patient care.
IV.A.5.d) Interpersonal and Communication Skills
Residents must demonstrate interpersonal and
communication skills that result in the effective exchange of
information and collaboration with patients, their families,
and health professionals. Residents are expected to:
IV.A.5.d).(1) communicate effectively with patients, families, and
the public, as appropriate, across a broad range of
socioeconomic and cultural backgrounds;
IV.A.5.d).(2) communicate effectively with physicians, other health
professionals, and health related agencies;
IV.A.5.d).(3) work effectively as a member or leader of a health care
team or other professional group;
IV.A.5.d).(4) act in a consultative role to other physicians and
health professionals; and,
IV.A.5.d).(5) maintain comprehensive, timely, and legible medical
records, if applicable. Thoracic Surgery 15
IV.A.5.e) Professionalism
Residents must demonstrate a commitment to carrying out
professional responsibilities and an adherence to ethical
principles. Residents are expected to demonstrate:
IV.A.5.e).(1) compassion, integrity, and respect for others;
IV.A.5.e).(2) responsiveness to patient needs that supersedes selfinterest;
IV.A.5.e).(3) respect for patient privacy and autonomy;
IV.A.5.e).(4) accountability to patients, society and the profession;
and,
IV.A.5.e).(5) sensitivity and responsiveness to a diverse patient
population, including but not limited to diversity in
gender, age, culture, race, religion, disabilities, and
sexual orientation.
IV.A.5.e).(6) high standards of ethical behavior; demonstrate continuity
of care (pre-operative, operative, and post-operative);
demonstrate sensitivity to age, gender, culture, and other
differences; and demonstrate honesty, dependability, and
commitment.
IV.A.5.f) Systems-based Practice
Residents must demonstrate an awareness of and
responsiveness to the larger context and system of health
care, as well as the ability to call effectively on other
resources in the system to provide optimal health care.
Residents are expected to:
IV.A.5.f).(1) work effectively in various health care delivery
settings and systems relevant to their clinical
specialty;
IV.A.5.f).(2) coordinate patient care within the health care system
relevant to their clinical specialty;
IV.A.5.f).(3) incorporate considerations of cost awareness and
risk-benefit analysis in patient and/or populationbased care as appropriate;
IV.A.5.f).(4) advocate for quality patient care and optimal patient
care systems;
IV.A.5.f).(5) work in interprofessional teams to enhance patient
safety and improve patient care quality; and, Thoracic Surgery 16
IV.A.5.f).(6) participate in identifying system errors and
implementing potential systems solutions.
IV.A.5.f).(7) practice cost-effective care without compromising quality,
promote disease prevention, demonstrate risk-benefit
analysis, and know how different practice systems operate
to deliver care.
IV.B. Residents’ Scholarly Activities
IV.B.1. The curriculum must advance residents’ knowledge of the basic
principles of research, including how research is conducted,
evaluated, explained to patients, and applied to patient care.
IV.B.2. Residents should participate in scholarly activity.
IV.B.2.a) A protected research assignment is not permitted during the
program. Resident participation in scholarly activities, however,
should be encouraged.
IV.B.3. The sponsoring institution and program should allocate adequate
educational resources to facilitate resident involvement in scholarly
activities.
IV.B.3.a) The sponsoring institution and program should provide support for
residents’ attendance at national professional meetings.
V. Evaluation
V.A. Resident Evaluation
V.A.1. Formative Evaluation
V.A.1.a) The faculty must evaluate resident performance in a timely
manner during each rotation or similar educational
assignment, and document this evaluation at completion of
the assignment.
V.A.1.b) The program must:
V.A.1.b).(1) provide objective assessments of competence in
patient care, medical knowledge, practice-based
learning and improvement, interpersonal and
communication skills, professionalism, and systemsbased practice;
V.A.1.b).(2) use multiple evaluators (e.g., faculty, peers, patients,
self, and other professional staff);
V.A.1.b).(3) document progressive resident performance Thoracic Surgery 17
improvement appropriate to educational level; and,
V.A.1.b).(4) provide each resident with documented semiannual
evaluation of performance with feedback.
V.A.1.c) The evaluations of resident performance must be accessible
for review by the resident, in accordance with institutional
policy.
V.A.2. Summative Evaluation
The program director must provide a summative evaluation for each
resident upon completion of the program. This evaluation must
become part of the resident’s permanent record maintained by the
institution, and must be accessible for review by the resident in
accordance with institutional policy. This evaluation must:
V.A.2.a) document the resident’s performance during the final period
of education, and
V.A.2.b) verify that the resident has demonstrated sufficient
competence to enter practice without direct supervision.
V.B. Faculty Evaluation
V.B.1. At least annually, the program must evaluate faculty performance as
it relates to the educational program.
V.B.2. These evaluations should include a review of the faculty’s clinical
teaching abilities, commitment to the educational program, clinical
knowledge, professionalism, and scholarly activities.
V.B.3. This evaluation must include at least annual written confidential
evaluations by the residents.
V.B.4. Because of the small resident cohort in each program, assurance that the
content of resident evaluations of the faculty does not adversely affect
resident progression is required.
V.C. Program Evaluation and Improvement
V.C.1. The program must document formal, systematic evaluation of the
curriculum at least annually. The program must monitor and track
each of the following areas:
V.C.1.a) resident performance; (e.g., educational activities that document
improved resident cognitive performance, technical skills, and
professional behaviors);
V.C.1.b) faculty development; Thoracic Surgery 18
V.C.1.c) graduate performance, including performance of program
graduates on the certification examination; and,
V.C.1.d) program quality. Specifically:
V.C.1.d).(1) Residents and faculty must have the opportunity to
evaluate the program confidentially and in writing at
least annually, and
V.C.1.d).(2) The program must use the results of residents’
assessments of the program together with other
program evaluation results to improve the program.
V.C.1.d).(3) Program improvement (e.g., quality of the didactic and
clinical curriculum, and the use of educational tools such
as skills labs and other activities);
V.C.1.d).(4) Faculty improvement (e.g., development activities to
improve the faculty's teaching and evaluation skills,
continuing education activities related to education, the
development of new skills in their specialty to improve
patient care, and scholarly activities); and,
V.C.1.d).(5) The program must document its active participation in
clinical databases that are used to assess and improve
patient outcomes.
V.C.2. If deficiencies are found, the program should prepare a written plan
of action to document initiatives to improve performance in the
areas listed in section V.C.1. The action plan should be reviewed
and approved by the teaching faculty and documented in meeting
minutes.
VI. Resident Duty Hours in the Learning and Working Environment
VI.A. Professionalism, Personal Responsibility, and Patient Safety
VI.A.1. Programs and sponsoring institutions must educate residents and
faculty members concerning the professional responsibilities of
physicians to appear for duty appropriately rested and fit to provide
the services required by their patients.
VI.A.2. The program must be committed to and responsible for promoting
patient safety and resident well-being in a supportive educational
environment.
VI.A.3. The program director must ensure that residents are integrated and
actively participate in interdisciplinary clinical quality improvement
and patient safety programs.
VI.A.4. The learning objectives of the program must: Thoracic Surgery 19
VI.A.4.a) be accomplished through an appropriate blend of supervised
patient care responsibilities, clinical teaching, and didactic
educational events; and,
VI.A.4.b) not be compromised by excessive reliance on residents to
fulfill non-physician service obligations.
VI.A.5. The program director and institution must ensure a culture of
professionalism that supports patient safety and personal
responsibility. Residents and faculty members must demonstrate an
understanding and acceptance of their personal role in the
following:
VI.A.5.a) assurance of the safety and welfare of patients entrusted to
their care;
VI.A.5.b) provision of patient- and family-centered care;
VI.A.5.c) assurance of their fitness for duty;
VI.A.5.d) management of their time before, during, and after clinical
assignments;
VI.A.5.e) recognition of impairment, including illness and fatigue, in
themselves and in their peers;
VI.A.5.f) attention to lifelong learning;
VI.A.5.g) the monitoring of their patient care performance improvement
indicators; and,
VI.A.5.h) honest and accurate reporting of duty hours, patient
outcomes, and clinical experience data.
VI.A.6. All residents and faculty members must demonstrate
responsiveness to patient needs that supersedes self-interest.
Physicians must recognize that under certain circumstances, the
best interests of the patient may be served by transitioning that
patient’s care to another qualified and rested provider.
VI.B. Transitions of Care
VI.B.1. Programs must design clinical assignments to minimize the number
of transitions in patient care.
VI.B.2. Sponsoring institutions and programs must ensure and monitor
effective, structured hand-over processes to facilitate both
continuity of care and patient safety.
VI.B.3. Programs must ensure that residents are competent in Thoracic Surgery 20
communicating with team members in the hand-over process.
VI.B.4. The sponsoring institution must ensure the availability of schedules
that inform all members of the health care team of attending
physicians and residents currently responsible for each patient’s
care.
VI.C. Alertness Management/Fatigue Mitigation
VI.C.1. The program must:
VI.C.1.a) educate all faculty members and residents to recognize the
signs of fatigue and sleep deprivation;
VI.C.1.b) educate all faculty members and residents in alertness
management and fatigue mitigation processes; and,
VI.C.1.c) adopt fatigue mitigation processes to manage the potential
negative effects of fatigue on patient care and learning, such
as naps or back-up call schedules.
VI.C.2. Each program must have a process to ensure continuity of patient
care in the event that a resident may be unable to perform his/her
patient care duties.
VI.C.3. The sponsoring institution must provide adequate sleep facilities
and/or safe transportation options for residents who may be too
fatigued to safely return home.
VI.D. Supervision of Residents
VI.D.1. In the clinical learning environment, each patient must have an
identifiable, appropriately-credentialed and privileged attending
physician (or licensed independent practitioner as approved by each
Review Committee) who is ultimately responsible for that patient’s
care.
VI.D.1.a) This information should be available to residents, faculty
members, and patients.
VI.D.1.b) Residents and faculty members should inform patients of
their respective roles in each patient’s care.
VI.D.2. The program must demonstrate that the appropriate level of
supervision is in place for all residents who care for patients.
Supervision may be exercised through a variety of methods. Some
activities require the physical presence of the supervising faculty
member. For many aspects of patient care, the supervising
physician may be a more advanced resident or fellow. Other
portions of care provided by the resident can be adequately Thoracic Surgery 21
supervised by the immediate availability of the supervising faculty
member or resident physician, either in the institution, or by means
of telephonic and/or electronic modalities. In some circumstances,
supervision may include post-hoc review of resident-delivered care
with feedback as to the appropriateness of that care.
VI.D.3. Levels of Supervision
To ensure oversight of resident supervision and graded authority
and responsibility, the program must use the following classification
of supervision:
VI.D.3.a) Direct Supervision – the supervising physician is physically
present with the resident and patient.
VI.D.3.b) Indirect Supervision:
VI.D.3.b).(1) with direct supervision immediately available – the
supervising physician is physically within the hospital
or other site of patient care, and is immediately
available to provide Direct Supervision.
VI.D.3.b).(2) with direct supervision available – the supervising
physician is not physically present within the hospital
or other site of patient care, but is immediately
available by means of telephonic and/or electronic
modalities, and is available to provide Direct
Supervision.
VI.D.3.c) Oversight – the supervising physician is available to provide
review of procedures/encounters with feedback provided
after care is delivered.
VI.D.4. The privilege of progressive authority and responsibility, conditional
independence, and a supervisory role in patient care delegated to
each resident must be assigned by the program director and faculty
members.
VI.D.4.a) The program director must evaluate each resident’s abilities
based on specific criteria. When available, evaluation should
be guided by specific national standards-based criteria.
VI.D.4.b) Faculty members functioning as supervising physicians
should delegate portions of care to residents, based on the
needs of the patient and the skills of the residents.
VI.D.4.c) Senior residents or fellows should serve in a supervisory role
of junior residents in recognition of their progress toward
independence, based on the needs of each patient and the
skills of the individual resident or fellow. Thoracic Surgery 22
VI.D.5. Programs must set guidelines for circumstances and events in
which residents must communicate with appropriate supervising
faculty members, such as the transfer of a patient to an intensive
care unit, or end-of-life decisions.
VI.D.5.a) Each resident must know the limits of his/her scope of
authority, and the circumstances under which he/she is
permitted to act with conditional independence.
VI.D.5.a).(1) In particular, PGY-1 residents should be supervised
either directly or indirectly with direct supervision
immediately available.
VI.D.6. Faculty supervision assignments should be of sufficient duration to
assess the knowledge and skills of each resident and delegate to
him/her the appropriate level of patient care authority and
responsibility.
VI.E. Clinical Responsibilities
The clinical responsibilities for each resident must be based on PGY-level,
patient safety, resident education, severity and complexity of patient
illness/condition and available support services.
VI.F. Teamwork
Residents must care for patients in an environment that maximizes
effective communication. This must include the opportunity to work as a
member of effective interprofessional teams that are appropriate to the
delivery of care in the specialty.
VI.G. Resident Duty Hours
VI.G.1. Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, averaged over a
four-week period, inclusive of all in-house call activities and all
moonlighting.
VI.G.1.a) Duty Hour Exceptions
A Review Committee may grant exceptions for up to 10% or a
maximum of 88 hours to individual programs based on a
sound educational rationale.
VI.G.1.a).(1) In preparing a request for an exception the program
director must follow the duty hour exception policy
from the ACGME Manual on Policies and Procedures.
VI.G.1.a).(2) Prior to submitting the request to the Review
Committee, the program director must obtain approval Thoracic Surgery 23
of the institution’s GMEC and DIO.
VI.G.2. Moonlighting
VI.G.2.a) Moonlighting must not interfere with the ability of the resident
to achieve the goals and objectives of the educational
program.
VI.G.2.b) Time spent by residents in Internal and External Moonlighting
(as defined in the ACGME Glossary of Terms) must be
counted towards the 80-hour Maximum Weekly Hour Limit.
VI.G.2.c) PGY-1 residents are not permitted to moonlight.
VI.G.3. Mandatory Time Free of Duty
Residents must be scheduled for a minimum of one day free of duty
every week (when averaged over four weeks). At-home call cannot
be assigned on these free days.
VI.G.4. Maximum Duty Period Length
VI.G.4.a) Duty periods of PGY-1 residents must not exceed 16 hours in
duration.
VI.G.4.b) Duty periods of PGY-2 residents and above may be
scheduled to a maximum of 24 hours of continuous duty in
the hospital. Programs must encourage residents to use
alertness management strategies in the context of patient
care responsibilities. Strategic napping, especially after 16
hours of continuous duty and between the hours of 10:00
p.m. and 8:00 a.m., is strongly suggested.
VI.G.4.b).(1) It is essential for patient safety and resident education
that effective transitions in care occur. Residents may
be allowed to remain on-site in order to accomplish
these tasks; however, this period of time must be no
longer than an additional four hours.
VI.G.4.b).(2) Residents must not be assigned additional clinical
responsibilities after 24 hours of continuous in-house
duty.
VI.G.4.b).(3) In unusual circumstances, residents, on their own
initiative, may remain beyond their scheduled period
of duty to continue to provide care to a single patient.
Justifications for such extensions of duty are limited
to reasons of required continuity for a severely ill or
unstable patient, academic importance of the events
transpiring, or humanistic attention to the needs of a
patient or family. Thoracic Surgery 24
VI.G.4.b).(3).(a) Under those circumstances, the resident must:
VI.G.4.b).(3).(a).(i) appropriately hand over the care of all
other patients to the team responsible
for their continuing care; and,
VI.G.4.b).(3).(a).(ii) document the reasons for remaining to
care for the patient in question and
submit that documentation in every
circumstance to the program director.
VI.G.4.b).(3).(b) The program director must review each
submission of additional service, and track
both individual resident and program-wide
episodes of additional duty.
VI.G.5. Minimum Time Off between Scheduled Duty Periods
VI.G.5.a) PGY-1 residents should have 10 hours, and must have eight
hours, free of duty between scheduled duty periods.
VI.G.5.b) Intermediate-level residents should have 10 hours free of
duty, and must have eight hours between scheduled duty
periods. They must have at least 14 hours free of duty after 24
hours of in-house duty.
For independent programs, Y-1, -2, and -3 residents are
considered to be in the final years of education.
For integrated programs, Y-2 and -3 fellows are considered to be
at the intermediate level.
VI.G.5.c) Residents in the final years of education must be prepared to
enter the unsupervised practice of medicine and care for
patients over irregular or extended periods.
For independent programs, Y-1, -2, and -3 residents are
considered to be in the final years of education.
For integrated programs, Y-4, -5, and -6 level residents are
considered to be in the final years of education.
VI.G.5.c).(1) This preparation must occur within the context of the
80-hour, maximum duty period length, and one-dayoff-in-seven standards. While it is desirable that
residents in their final years of education have eight
hours free of duty between scheduled duty periods,
there may be circumstances when these residents
must stay on duty to care for their patients or return to
the hospital with fewer than eight hours free of duty. Thoracic Surgery 25
VI.G.5.c).(1).(a) Circumstances of return-to-hospital activities
with fewer than eight hours away from the
hospital by residents in their final years of
education must be monitored by the program
director.
VI.G.5.c).(1).(b) The Review Committee defines such
circumstances as: required continuity of care for a
severely ill or unstable patient, or a complex patient
with whom the resident has been involved; events
of exceptional educational value; or, humanistic
attention to the needs of a patient or family.
VI.G.6. Maximum Frequency of In-House Night Float
Residents must not be scheduled for more than six consecutive
nights of night float.
VI.G.6.a) Residents must not have more than four consecutive weeks of
night float assignment, and night float cannot exceed one month
per year.
VI.G.7. Maximum In-House On-Call Frequency
PGY-2 residents and above must be scheduled for in-house call no
more frequently than every-third-night (when averaged over a fourweek period).
VI.G.8. At-Home Call
VI.G.8.a) Time spent in the hospital by residents on at-home call must
count towards the 80-hour maximum weekly hour limit. The
frequency of at-home call is not subject to the every-thirdnight limitation, but must satisfy the requirement for one-dayin-seven free of duty, when averaged over four weeks.
VI.G.8.a).(1) At-home call must not be so frequent or taxing as to
preclude rest or reasonable personal time for each
resident.
VI.G.8.b) Residents are permitted to return to the hospital while on athome call to care for new or established patients. Each
episode of this type of care, while it must be included in the
80-hour weekly maximum, will not initiate a new “off-duty
period”.
VII. Innovative Projects
Requests for innovative projects that may deviate from the institutional, common
and/or specialty specific program requirements must be approved in advance by Thoracic Surgery 26
the Review Committee. In preparing requests, the program director must follow
Procedures for Approving Proposals for Innovative Projects located in the
ACGME Manual on Policies and Procedures. Once a Review Committee approves
a project, the sponsoring institution and program are jointly responsible for the
quality of education offered to residents for the duration of such a project.
***
ACGME Approved: June 12, 2007 Effective: January 1, 2008
Editorial Revision: July 1, 2009
Revised Common Program Requirements Effective: July 1, 2011


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