Doc. T00-024
Passed by the Board of Trustees on February 2, 2000

I. Administration

A. Purpose

The purpose of this booklet is to provide residents and clinical fellows in the University of Massachusetts Medical School (UMMS) graduate medical education programs with information about personnel policies and procedures, which affect their daily professional activities and personal concerns.

The Medical School, as the sponsoring organization for Graduate Medical Education (GME,) has developed these Personnel Policies to ensure compliance with the institutional requirements of the Accreditation Council for Graduate medical education (ACGME). The University reserves the right to amend, modify, or revoke any of the provisions herein by action of the Board of Trustees. All policies contained and referenced herein are applicable to all residents and fellows employed by the Medical School and supersede University of Massachusetts Medical School Personnel Policies unless otherwise noted.

B. Definitions

  1. Department Chairperson: the head of a University of Massachusetts Medical School basic or clinical science department who is responsible for the administration of the department and who is appointed by the Dean.
  2. Service Director: a physician who is responsible for a patient care entity to which the resident or fellow is assigned. Patient care entity may be a hospital inpatient or outpatient service, ambulatory center or clinic, nursing home, or private medical practice.
  3. Residency/Fellowship Program: an organized graduate medical education training effort within a clinical department(s) or service(s) which is designed to prepare physicians for the practice of a medical specialty(ies) or subspecialty(ies), and, where applicable, to meet the requirements of the Accreditation Council for Graduate Medical Education (ACGME). Integrated and affiliated programs involve more than one institution while the program remains under the supervision of the University department chairperson(s). Combined or joint programs are shared between two clinical departments or divisions and remain under the supervision of the delegated program director or program directors and the respective department chairpersons.
  4. Residency/Fellowship Program Director: the department or division chair or designated faculty member who has the responsibility and authority for a specific residency/fellowship program’s administration, curriculum, resources, and activities as required by ACGME. Combined or joint residency programs may be under the responsibility and authority of a single program director or multiple program directors representing each participating specialty. The term “program director” (singular) as used in this document may also refer to “directors” (plural) when two or more program directors share responsibility for a combined or joint residency program.
  5. Residents: physicians and dentists appointed to an organized clinical residency or fellowship program; includes physicians commonly designated as interns and as clinical fellows. The term is used for physicians in both ACGME-accredited and non- ACGME-accredited programs. Residents have status both as students and as employees. This policy serves to clarify their relationship to UMMS, which is their sponsoring institution.
  6. Accreditation Council for Graduate Medical Education (ACGME): The national organization responsible for physician residency and fellowship program accreditation. The ACGME is made up of representatives from the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies.
  7. Residency Review Committee (RRC): Committees of the ACGME designated for review and accreditation of specific medical specialties.
  8. Graduate Medical Education Committee (GMEC): A committee, made up of representatives from each of the residency programs, Medical School administration, UMass Memorial Health Care administration, affiliated institutions, residents and residency program coordinators. The GMEC is charged with the oversight of residency education at UMMS and other responsibilities as required by the ACGME. The ACGME is chaired by the Associate Dean for Graduate Medical Education. The Chief Medical Officer of UMass Memorial Medical Center serves as Vice Chair.

C. Applicability

These Graduate Medical Education Personnel Policies shall apply to all physicians and dentists who have been appointed to a UMMS graduate medical education program position. Residents who are not in UMMS residency programs, but who are on temporary rotation assignment to UMass Memorial Medical Center, are expected to follow the procedures herein which relate to residents’ conduct and performance while at UMMS.

D. Governance

The University of Massachusetts Board of Trustees has all the authority, responsibility, rights, privileges, powers, and duties of organization and government of the University of Massachusetts Medical School (UMMS). UMMS is comprised of three (3) schools: the School of Medicine (SOM), the Graduate School of Nursing (GSN), and the Graduate School of Bio-Medical Science (GSBS). There is a Dean of the School of Medicine who is its chief academic officer. The Dean may appoint a designee such as the Senior Associate Dean for Educational Affairs or the Associate Dean for Graduate Medical Education to manage matters related to residency training.

The UMMS department chair has ultimate responsibility for a residency program and may designate a residency program director. Joint or combined programs are the responsibility of participating department chairs. The service director is responsible for the direct, on-site supervision of the resident when on rotation.

UMMS residents are subject to the rules, regulations, bylaws, accountabilities, and standards of conduct as applicable to all professional employees of the Commonwealth of Massachusetts, to all members of the medical staffs, and to all members of the medical profession; except as otherwise specified in these Personnel Policies. In addition, UMMS residents shall also abide by the policies, standards, rules, regulations, requirements, and procedures of the patient care entity to which they are assigned, and professional conduct as applicable to all other professional staff members. Where the entity’s policies and these UMMS Personnel Policies might conflict, the matter shall be referred to the department chair and the program director.

E. Implementation

Each UMMS department and residency/fellowship program is responsible for the implementation of these personnel policies, and shall maintain a program personnel file for each resident. Access to resident personnel files is limited to specified individuals to guarantee confidentiality as regulated by the Massachusetts Fair Information Practices Act (MFIPA) and University regulations promulgated thereunder. Information concerning the Resident as an applicant, such as National Resident Matching Program rank order and letters of recommendation, are filed in a confidential section of the resident's program and are governed by MFIPA. The UMMS Office of Graduate Medical Education (OGME) was established:

  1. To protect the educational integrity of all residency and clinical fellowship programs.
  2. To assist residency program directors and residents in administrative and personnel matters.
  3. To facilitate the implementation and coordination of systems for residency education such as core curricula, faculty development, performance and program evaluation, information resources, academic support and counseling services, and to ensure program and institutional compliance with ACGME, the Joint Commission, and other regulatory requirements.
  4. To develop fiscally sound GME budgets in cooperation with the Medical School, UMass Memorial Medical Center, and other affiliated health care institutions.
  5. To provide administrative support to the Graduate Medical Education Committee and its subcommittees.

F. Appointment (Eligibility and Selection)

Graduates of LCME- and AOA- approved U.S. and foreign medical schools are appointed to UMMS residency programs either through the National Resident Matching Program or, when allowed by the NRMP, by direct application. All applicants must use the Electronic Resident Application System (ERAS) when applying to participating programs. Graduates of medical schools outside of the United States who have completed a Fifth Pathway Program provided by an LCME-Accredited Medical School are also eligible. Graduates of foreign medical schools must have passed Steps 1 and 2CK and CS of the USMLE or COMLEX or equivalent Canadian Medical Licensing Examination and hold a valid ECFMG certificate. Graduates of accredited US medical schools MUST have passed Step 1 of the USMLE or COMLEX for appointment to a PGY1 position and Step 2CK and CS of the USMLE or COMLEX for appointment to a PGY2 position. Appointment eligibility is also subject to the Massachusetts Board of Registration in Medicine’s requirements for licensure. All applicants for PGY3 or higher level position MUST have passed Step 3 of USMLE or COMLEX or equivalent Canadian Medical Licensing Examination prior to their date of hire. An exception may be made for a resident transferring into a UMMS training program from a program that does not require passing UMSLE Step 3 prior to program completion. In such cases, the resident must take Step 3 within 6 months of transferring and must pass by the end of the academic year. This exception does not apply to applicant for fellowship positions. (UMMS Resident Selection and Appointment Criteria Attached). All applicants MUST meet the UMass Medical School Graduate Medical Education Technical Standards (including bloodborne pathogen policy) and any additional Residency/Fellowship Program-Specific Technical Standards. All residents and Fellows must sign the UMMS Graduate Medical Education Appointment Agreement and agree to abide by the provisions stated therein. Programs do not discriminate on the basis of gender, sexual orientation, race, age, religion, color, national origin, disability, or veteran status.

The Graduate Medical Education Appointment Agreement does not become effective until the applicant has been issued a Limited or Full Massachusetts Medical License by the Board of Registration in Medicine, has been approved by the UMass Memorial Medical Center Resident/Fellow Credentialing Subcommittee, and meets all other employment requirements of the University of Massachusetts including, but not limited to, (1) completion of payroll and benefits forms; (2) any necessary work authorization forms; (3) certification of compliance with physical examination and other health and safety requirements; and (4) completion of a malpractice insurance application and completion of mandatory orientation curriculum. Each appointment is limited to a maximum of one year (twelve months), which in most cases begins July 1st and ends June 30th.

G. Policies Review

The University reserves its right to modify, amend or change these policies at any time. New and revised policies will be made available to residents for review and comment. Policy revisions and amendments shall require consultation with the Department Chairpersons whose departments have a residency program (or residency program directors), and the chiefs of those services in affiliated hospitals, which are members of UMMS integrated residency programs. Any modifications, amendments, or changes to these policies require the approval of the Graduate Medical Education Committee, and the Chancellor/Dean of the Medical School, before submission to the Board of Trustees. The Board may take such action, as it deems appropriate on any proposed modifications, amendments, or changes.