Section 9: Leave, Moonlighting, Work Hours

Leave

All leave must adhere to the Command and GMEC policy, specifically the “NMCSD GMEC Residents’ Vacation and Leave of Absence Policy”, as well as the PCCM Fellowship-specific policy. The PCCM program-specific policy provides detailed interpretation and policies for fellows within the program, in compliance with the overarching policies from higher authorities.

Definitions:

NSIPS LEAVE

All leave must be submitted and approved through NSIPS. However, “earned” and “used” leave is not considered equivalent to fellowship vacation days.

TRAINING DAYS

These are clinical and academic days dedicated to the fellowship. During outpatient rotations, these are typically Monday to Friday, excluding holidays. For inpatient and consult rotations, these are the standard days that fellows are typically scheduled to work (usually six days per week).

MISSED TRAINING DAY

A day when a fellow is absent from their daily duties due to vacation, illness, medical and caregiver leave.

VACATION DAY

A day when a fellow is absent from their daily duties, not due to sickness or injury.

PARENTAL LEAVE

As defined by the NMCSD Graduate Medical Education Policy, parental leave is a period of time off granted to residents and fellows who are military personnel, for caring for and bonding with their newborn or adopted child. Both birth parents and non-birth parents, including adoptive parents or those with a child placed for adoption or long-term foster care, are eligible.

Policy:

Fellows are entitled to 4 weeks (which translates to approximately 20-30 training days, depending on rotation, to align with the 48-week training year) of vacation per year, consistent with the DoD and GMEC goal of approximately four weeks of time away from training annually.
Vacation can be taken during elective and research months and should generally not exceed one week.
Extended periods of up to two weeks can be taken if approved by the program director. This decision will typically be based on ensuring that academic and educational experiences are not significantly impacted by the extended leave period.
Leave should generally not be taken during consult and ICU months but can be approved on a case-by-case basis if “coverage” is available.
While sick days, medical, and caregiver leave do not count against vacation days, the ACGME allows for a certain amount of missed training days per year (refer to specific specialty board and ACGME requirements). Exceeding this threshold, or specific board requirements for time in training, may result in an extension of training.

Medical and Parental Leave:

The parental leave policy is outlined in the “NMCSD GMEC Residents’ Vacation and Leave of Absence Policy” and DTM 23-001. Military personnel are authorized up to twelve (12) weeks of parental leave for qualifying reasons related to the birth or adoption of a child. This applies to birth parents, non-birth parents, and parents adopting or taking in a child for long-term foster care.

Birth parents are authorized 12 weeks of parental leave following a period of medical convalescence.
Non-birth parents, adoptive parents, or those with a child placed for adoption or long-term foster care are eligible for 12 weeks of parental leave to care for the child, to be taken within one year of the event.
The leave can be taken consecutively or intermittently subject to policy guidelines.
Use of parental leave may result in an extension of training if it exceeds the ACGME and/or specialty board requirements for minimum time in training. Trainees are advised to work with their Program Director on a case-by-case basis to determine the impact of parental leave on their training program and the potential need for an extension.

Moonlighting

The Naval Medical Center San Diego strictly prohibits postgraduate trainees (including fellows) from moonlighting.

Work Hours

Policy Statement:

The work hour regulations as detailed in the “NMCSD GMEC Resident Clinical and Educational Work Hours Policy” and ACGME Policies will be strictly adhered to. Duty hours encompass all in-house clinical and academic activities related to the fellowship program, excluding time spent outside the hospital for preparation, study, or research done from home. Fellows are forbidden from carrying out after-hours work activities on-site that could be done from home if it would exceed the 80-hour weekly limit. As most calls are taken from home, there is minimal risk of breaching the “24 and 4 rule”. The program will ensure that fellows receive appropriate supervision and backup for all patient care activities, as outlined in section 5 of this handbook. The program will not excessively rely on fellows to meet department service obligations, ensuring that educational goals and objectives are not compromised. The scheduling of duty hours and call rosters will prioritize patient needs, continuity of care, and fellows’ educational requirements.

  
   ACGME Duty Hour Requirements:
  
     80-Hour Work Week:
    
    Duty hours must not exceed 80 hours per week, averaged over a four-week period, including all in-house call activities, and clinical work done from home.
   
     One Day Off per Week:
    
    Fellows will be granted one free day per week (a continuous 24-hour period free from all administrative, clinical and educational activities), averaged over a four-week period, including call. This day should be used for rest and personal wellness.
   
     Time Between Shifts:
    
    Residents should have 8 hours off between scheduled work periods. Residents must have 14 hours free from work after 24 hours of in-house call.
   
     At-Home Call:
    
    Fellows taking at-home calls will have one free day per week (24 hours) from all educational and clinical responsibilities, averaged over a four-week period. Any hours spent in-house or on clinical work from home (such as EHR or calls) after being called in from home will count towards the 80-hour limit.
   
     Study Time:
    
    ACGME work hour restrictions do not apply to reading, studying, or research done from home and in preparation for future cases.

In-house Call:

PCCM fellows rarely take in-house calls, but there may be instances when acute patient care necessitates overnight hospital stay.
Continuous on-site duty, including scheduled clinical assignments, must not surpass 24 consecutive hours. Fellows may stay on duty for up to 4 additional hours for activities related to patient safety, such as transitions of care and/or resident education; additional patient care responsibilities must not be assigned during this time.
After 24 continuous hours on duty, no new patients may be accepted. A new patient is defined as any patient the fellow has not previously cared for.

Duty Hours Monitoring:

Duty hours will be monitored by the program director, staff, and fellows to ensure a balance between education and service.
Fellows are expected to track their duty hours individually and log them in New-Innovations monthly.
Fellows must promptly report any ACGME duty hour standard violations to their immediate supervisor and program director.
All staff should be familiar with the ACGME and institutional duty hour standards and support fellow duties that ensure compliance.
The program director will oversee work hour requirement compliance by reviewing all individual duty hour logs and fellow evaluation programs. A comprehensive report of fellow duty hours will be submitted to the Graduate Medical Education in line with the GMEC policy in the Appendices.

  
   Fellow Fatigue Monitoring and Support System:
  
    All staff and fellows will be trained to identify signs and potential adverse effects of fatigue.
   
    Any fellow showing signs of fatigue or expressing health issues that could affect patient care will be immediately relieved from clinical duty until deemed fit to return by the supervising staff and/or program director, utilizing established back-up systems.
   
    On-call supervising staff should be vigilant of potential fatigue and ensure rest periods are given throughout the call night to maintain patient safety and physician vigilance.

References and Appendices

Section 9 Appendix 1: NAVMEDREADTRNCMD SAN DIEGO INSTRUCTION 1050.1 Leave and Liberty for Military Personnel
Section 9 Appendix 2: NMCSD GMEC Residents’ Vacation and Leave of Absence Policy (07 April 2025)
Section 9 Appendix 3: NMCSD GMEC Resident Clinical and Educational Work Hours Policy (21 January 2025)
Section 9 Appendix 4: Directive-type Memorandum 23-001 – Expansion of Military Parental Leave Program (04 January 2023)