Principle

Overview As of July 1, 2017, Royal College of Physicians and Surgeons of Canada (RCPSC) residency programs all across Canada will begin implementing Competency Based Medical Education (CBME). Competence by Design (CBD) is the Royal College's multi-year transformational change initiative aimed at implementing a CBME approach to residency training and specialty practice in Canada, which focuses on outcomes that are based on a framework of competence. With more targeted learning outcomes and frequent assessments of residents, successful progression through residency will now be based on the attainment of competencies and upon the successful progression from one stage of training to the next. Within this paradigm, residents will play an active role in their education.

This policy was developed to reflect the modifications made to resident assessment, promotion, probation and appeals under the new CBD framework.

Purpose

To describe the principles of assessment, promotion, dismissal and appeals for CBD residency programs at Memorial University of Newfoundland (Memorial).

Scope

Any resident currently enrolled in a CBD residency program at Memorial.

Definitions

Assessment — The wide variety of methods that are used by faculty to measure and document the academic readiness, learning progress, and skill acquisition of residents throughout the residency program.

Clinical Faculty — A physician in clinical practice with a full-time (tenure track; contractual) or part-time academic appointment with Memorial University.

Competence by Design — The Royal College’s multi-year transformational change initiative aimed at implementing a CBME approach to residency training and specialty practice in Canada, which focuses on outcomes that are based on a framework of competence.

Competence Committee — The committee responsible for synthesizing and reviewing the assessment data of residents to determine resident progress in achieving the specialty-specific requirements of a Competency by Design (CBD) residency program.

Competence Continuum — The Competence Continuum reflects the developmental stages of professional practice. In each stage, there are specific milestones that a resident will be expected to demonstrate. The duration (e.g. weeks, blocks, months) for each stage is determined by each residency program. Residency training is organized into four (4) developmental stages, each with its own set of markers for learning and assessment. The stages are: 1. Transition to discipline 2. Foundations of discipline 3. Core of Discipline 4. Transition to practice

Entrustable Professional Activity (EPA) — A task in the clinical setting that can be delegated to a postgraduate learner who has demonstrated sufficient competence.

Milestone — An observable marker of someone’s ability along a developmental continuum.

Modified Learning Plan — An individualized learning opportunity intended to guide a resident towards successful attainment of competencies.

Narrative Feedback — Written descriptions of a resident's performance organized in logical order, to illustrate the "story" or account of a resident's progress and performance, including strengths and areas for improvement to guide future efforts.

Probation — A formal academic standing that identifies a postgraduate learner as being in academic difficulty to the extent that their ability to continue training is, or is likely to be, significantly compromised. When a postgraduate learner is placed on probation, formal modifications to their training program are implemented to address specific identified weaknesses.

Remediation — A formal program of individualized educational support, assessment, and monitoring designed to assist a postgraduate learner in correcting identified performance deficiencies.

Residency Program Committee (RPC) — A committee established to assist the Program Director in the planning, organization, and supervision of the residency program.

Supervisor — A faculty member or resident who is responsible for a Phase 4 student during a period of clinical learning.

Policy

Policy

1.0 Resident Assessment

1.1 A resident’s execution of milestones and EPAs must be documented regularly by a supervisor.

1.1.1 Residents are responsible for ensuring a supervisor is observing and documenting their performance when completing a particular procedure/milestone/Entrustable Professional Activity (EPA) in real time.

1.1.2 Program Directors are responsible for ensuring regular assessments of a resident’s progress are being facilitated by the resident.

1.2 Each residency program shall determine the methods of assessment to be used for their program.

1.2.1 The methods of assessment must provide residents with narrative, actionable, and timely feedback.

1.2.2 Feedback must be discussed with the resident, preferably in person, and refine good practices and identify deficiencies.

1.3 The milestones and EPAs to be completed within each stage of training, the methods of assessment to be used, and the number of observations required for each EPA must be clearly outlined and made known to residents and faculty.

1.4 Residents shall be informed of the milestones and EPAs they are expected to accomplish within each clinical block by their residency program.

1.5 Where appropriate, observations of resident performance from other members of the healthcare team will be documented.

1.6 A resident is responsible for notifying their Program Director of circumstances that could affect their individual performance or the documentation of their performance.

2.0 Professional Conduct

2.1 Residents must adhere to the standards of ethical and professional behaviour for the medical profession, with their activities characterized by honesty, integrity, conscientiousness, and reliability.

2.2 A resident, whose behaviour violates the ethical and professional standards of the medical profession, may be deemed unfit for the practice of medicine in general.

2.2.1 Unfitness is determined by ethical and professional performance as described in Appendix A.

2.3 Unfit ethical and professional performance represents a failure to meet the accepted standards of the medical profession, and may result in remediation, probation, suspension, dismissal, or a sanction imposed by the College of Physicians and Surgeons of Newfoundland and Labrador as per the Medical Act, 2011.

3.0 Time Away from Service

3.1 A resident should not miss more than one-third of a clinical block due to any combination of leaves (illness, conference, vacation, etc.). A clinical block is considered incomplete if a resident completes less than two-thirds of the expected time commitment for that clinical block.

3.2 A resident will be required to complete an incomplete block, which may result in an extension of training.

3.2.1 The time requirement necessary to complete the clinical block will be determined by the PGME office, in consultation with the Competence Committee and RPC based on the nature of the experience, the need for continuity, and the resident’s performance within the clinical block. The resident may be required to repeat the clinical block in full.

3.3 If a resident is returning to their program after being on leave for an extended period of time, the Competence Committee is responsible for determining where the resident will resume their training along the Competence Continuum.

4.0 Progress Review and Promotion

4.1 The Program Director or delegate, (e.g. academic advisor), shall meet with a resident at least twice a year to review the resident’s progress in achieving the required milestones and EPAs. Please refer to the role description for academic advisor.

4.2 The Competence Committee shall meet in accordance with their Terms of Reference, to review a resident’s progress in achieving competence in the required milestones and EPAs.

4.3 A summary report of each progress meeting will be completed by the Program Director or Competence Committee as applicable, and be kept in the resident’s assessment portfolio.

.4.4 Progress and promotion recommendations of the Competence Committee will be based on all evidence available in the resident’s assessment portfolio at the time of the progress/promotion meeting.

4.4.1 If there is not enough documentation to support a progress or promotion decision, the Program Director and resident will be notified in writing.

4.5 Final decisions regarding progress and promotion are reached by the Residency Program Committee (RPC) based on the recommendations of the Competence Committee.

4.5.1 If the final decision of the RPC differs from the recommendation of the Competence committee, a detailed rationale must be provided to the Competence Committee and Associate Dean, PGME, in writing.

4.6 A resident will be promoted to the next stage of training if they have achieved all required milestones, EPAs, and any other training requirements for their current stage of training.

4.6.1 A resident who does not meet the criteria for promotion will require appropriate modifications to their training, supervision, and assessment.

5.0. Modified Learning Plans

5.1. A resident will be required to complete a modified learning plan when it is determined:

5.1.1 the resident has not had ample opportunities to achieve competence in the required milestones/EPAs;

5.1.2 a resident is not progressing as expected; and/or,

5.1.3 concerns exist about the professional conduct of a resident in areas that are deemed rectifiable.

5.2 A resident may also have the opportunity to complete a modified learning plan if they are in a position to leverage enrichment opportunities to enhance their skills and accelerate learning.

5.2. Modified learning plans are developed by the Program Director and the RPC, based on the recommendations of the Competence Committee.

5.3. Modified learning plans shall be summarized in writing and describe:

5.3.1. the learning experiences to be provided;

5.3.2. the competencies to be achieved;

5.3.3. the assessment processes to be followed; and,

5.3.4. the personnel responsible for determining success.

5.4. The resident must sign the modified learning plan, which indicates they read and understood the terms and conditions of the modified learning plan.

5.4.1. A resident mist comply with, and meet the necessary requirements of, the modified learning plan.

5.5. Modified learning plans may result in an extension of training.

5.5.1. Modified learning plans for resident enrichment will not result in a shortened training program.

6.0 Remediation

6.1. A resident will be placed on remediation when they are failing to progress in their training despite the completion of modified learning plans designed to facilitate a resident’s attainment of specific competencies or to improve their professional conduct.

6.2. The terms and conditions of a remedial program will be developed by the RPC in consultation with the Program Director, resident, and PGME office based on the recommendations of the Competence Committee and must be outlined in a written agreement.

6.3. The terms and conditions of the remedial program shall describe:

6.3.1. the learning experiences to be provided;

6.3.2. the competencies to be achieved;

6.3.3. time frame for elements of the remedial program, including completion;

6.3.4. the assessment processes to be followed; and,

6.3.5. consequences for failing to progress in the remedial program, having regard for the status of the resident at the time of the remediation.

6.4. The resident must sign the written agreement, which indicates they read and understood the terms and conditions of the remedial program.

6.4.1. A resident mist comply with, and meet the necessary requirements of, the remedial program.

6.5. Remedial programs may result in an extension of training. Scheduled elective time cannot be used to complete a remedial program.

6.6. The RPC, based on the recommendations of the Competence Committee, is responsible for making the final decision of whether a resident met the terms and conditions of a remedial program and if the resident can continue on in their residency program or if they require additional/extended remediation, or promotion.

6.7. Vacation time may be deferred to accommodate periods of remediation at the discretion of the PGME office in consultation with the Program Director.

7.0 Probation

7.1 A resident may be placed on probation when:

7.1.2 they fail to progress through a remedial program, demonstrating persistent deficits in performance; and/or,

7.1.3 significant concerns regarding the resident’s professional conduct exist.

7.2 Typically, a resident can be placed on probation only once during their residency program.

7.3 The terms and conditions of the probationary period are developed by the RPC in consultation with the Program Director, resident, and PGME office based on the recommendations of the Competence Committee.

7.3.1 The terms and conditions must be outlined in a written contract and describe:

7.3.1.1 the learning experiences to be provided;

7.3.1.2 the competencies to be achieved;

7.3.1.3 time frame for elements of the probation, including completion;

7.3.1.4 the assessment processes to be followed; and,

7.3.1.5 consequences for failing to progress in the probationary period, having regard for the status of the resident at the time of the probation.

7.4 The resident must sign the probation contract, which indicates they read and understood the terms and conditions of the probation contract.

7.4.1 A resident must comply with, and meet the necessary requirements of, the probation contract.

7.5 Vacation time may be deferred to accommodate periods of probation at the discretion of the PGME office in consultation with the Program Director.

7.6 At the end of a probationary period, the RPC, based on the recommendations of the Competence Committee, is responsible for deciding if the resident requires further training modifications (i.e. modified learning plan), can continue on in the residency program, or will be dismissed.

7.7 All decisions of the RPC regarding probation must be approved by the Associate Dean, PGME.

7.8 The completion of a probationary period may result in an extension of training.

8.0 Suspension

8.1 A resident may be suspended as an interim measure while a decision is being made on the best definitive course of action in the following circumstances:

8.1.1 There is reasonable suspicion of serious deficiencies (clinical or professional) in a resident’s performance such that their continued presence in their residency program would pose a threat to:

8.1.1.1 patients, colleagues, students, staff, and/or the resident themselves;

8.1.1.2 Memorial University; and/or,

8.1.1.3 the relevant Health Board Authority.

8.1.2 A resident refuses to agree to a remedial program written agreement or a probationary contract.

8.2 Suspension decisions are made by the Program Director and RPC, in consultation with the Competence Committee and Associate Dean, PGME.

8.3 When a resident is suspended, the following principles apply:

8.3.1 Educational registration with the College of Physicians and Surgeons of Newfoundland and Labrador (CPSNL) is suspended;

8.3.2 Payment through Eastern Health may be suspended;

8.3.3 A resident cannot engage in any academic or clinical activities within the Faculty of Medicine and no credit can be acquired towards their residency training.

9.0 Dismissal

9.1 A resident may be dismissed from their residency program if they:

9.1.1 fail to progress through a probationary period and the judgement of the Competence Committee and RPC is that further remediation is not likely to be successful;

9.1.2 are recommended for probation twice during their residency program;

9.1.3 are deemed unfit for the practice of medicine in general, determined by their ethical and professional behaviour as described in Appendix A;

9.1.4 have exceeded, or are reasonably expected to exceed, the time specified as a maximum time of training for the residency program, pro-rated for part-time training and approved leaves of absence. The maximum time of training will be decided by each residency program.

9.2 Credit for completion of training to date within the current academic year may be granted at the discretion of the Competence Committee.

9.3 All dismissal decisions by the RPC will occur in consultation with the Competence Committee and must be approved by the Associate Dean, PGME, and the Dean of Medicine.

9.4 When a resident is dismissed, the following principles apply:

9.4.1 Educational registration with the College of Physicians and Surgeons of Newfoundland and Labrador (CPSNL) is terminated;

9.4.2 Payment through Eastern Health is terminated; and,

9.4.3 Registration in the PGME program at Memorial is terminated.

9.5 The RPC reserves the right to dismiss a resident from the residency program at any time, with just cause.

10.0 Appeals

10.1 The only grounds for appeal that will be considered are extenuating circumstances or procedural errors.

10.2 A resident may appeal the following:

10.2.1 a decision by the RPC to place a resident on probation;

10.2.2 a decision by the RPC to dismiss the resident from their residency program.

10.3 It is the responsibility of the resident to make an appeal before the appropriate committee, as per the appeal procedure (Section A.0).

10.4 As per the University Regulations:

10.4.1 the principles of natural justice shall be applied to the appeals processes and decisions;

10.4.2 the academic, financial or other consequences of an appeal process rests with the resident.

10.5 All records of appeals, including notes of meetings, interviews, and the results of an appeal, are kept confidential and handled in accordance with the Access to Information and Protection of Privacy Act, the University’s Privacy Policy, any other privacy legislation applicable to the University, or any collective/affiliation agreement that may be applicable.

10.6 While an appeal is pending, the RPC will determine if the appellant will continue with scheduled training or whether alternative arrangements are required.

10.6.1 Whether credit will be granted for activities undertaken during this period is at the discretion of the RPC.

Procedure

A.0 Appeals

A.1 There are three (3) levels at which a resident can appeal a decision of the Program Director and/or RPC regarding probation or dismissal.

A.1.1 PGME Committee

A.1.1.1 An appeal against a decision of the Program Director and/or RPC will be made to the PGME Committee.

A.1.1.2 A letter requesting an appeal is submitted by the appellant to the Associate Dean, PGME, within ten (10) business days of receiving the decision of the Program Director and/or RPC.

A.1.1.3 The appellant notifies the PGME committee if they are bringing legal counsel to the appeal hearing.

A.1.1.4 The Associate Dean, PGME, convenes a meeting of the PGME Committee to consider the appeal when quorum can be achieved.

A.1.1.4.1 The appellant may submit relevant documentation to the PGME committee.

A.1.1.4.2 All relevant written documentation is circulated to committee members and provided to the appellant 

and Program Director (or delegate) prior to the appeal hearing.

A.1.1.5 The Program Director (or delegate) and appellant will be invited to attend the appeal hearing. Appeal hearings are heard in person. Each may bring one (1) advisor (in the form of legal counsel or a support person). In the event that legal counsel attends as the advisor, legal counsel is the only person who will speak on behalf of the person who invited legal counsel to attend. Each party may bring witness(es).

A.1.1.6 When the appellant appears before the PGME Committee, the format is as follows:

A.1.1.6.1 The Chair of the committee outlines the process and briefly reviews the nature of the problem to the committee members.

A.1.1.6.2 The Program Director (or delegate) speaks first and outlines the reasons for the decision that was taken.

A.1.1.6.3 The appellant then has the opportunity to speak and outlines the reasons supporting the appeal.

A.1.1.6.4 Legal counsel, if present, asks questions of either party and of the witness(es).

A.1.1.6.5 Committee members ask questions of either party and of the witness(es).

A.1.1.6.6 Official written transcriptions of the appeal hearing submissions and discussions are kept.

A.1.1.6.7 The PGME Committee deliberates in camera.

A.1.1.6.8 The PGME Committee has the authority to uphold the decision of the Program Director and/or RPC, reverse the decision of the Program Director and/or RPC, or modify the decision of the Program Director and/or RPC and recommend modifications to a residents training, supervision and/or assessments.

A.1.1.6.9 The decision of the committee is conveyed in writing to the appellant within ten (10) business days after the appeal hearing.

A.1.2 Faculty of Medicine Appeals Committee

A.1.2.1 An appeal against a decision of the PGME Committee will be made to the Appeals Committee.

A.1.2.2 An appeal through the Appeals Committee will follow the process below:

A.1.2.2.1 Within ten (10) business days of receiving the decision in writing by the PGME Committee, the appellant indicates, in writing, a wish to appeal this decision. The letter should:

A.1.2.2.1.1 be addressed to the Dean (or delegate) and copied to the PGME office;

A.1.2.2.1.2 describe the decision being appealed, the grounds of the appeal, and the resolution being sought;

A.1.2.2.1.3 provide supporting documentation, as appropriate.

A.1.2.2.2 Upon receipt of a letter of appeal, the Dean of Medicine (or delegate) confers with the Office of the Registrar as to whether the letter satisfies the requirements for an appeal as stipulated in the University Calendar – Appeal of Decisions. The Dean of Medicine and the representative(s) from the Office of the Registrar chosen to review the appeal request will not sit on the Appeals Committee.

A.1.2.2.2.1 If the letter does not satisfy the requirements for an appeal, the appellant is advised as such in writing by the Dean of Medicine (or delegate) within five (5) business days.

A.1.2.2.2.2 If the letter satisfies the requirements for an appeal, the matter is sent to the Appeals Committee for adjudication as per the practice of the committee, as indicated in the Appeals Committee Terms of Reference.

A.1.2.2.3 The Vice Dean of Medicine (or delegate) calls a meeting of the Appeals Committee at the earliest opportunity when quorum can be achieved.

A.1.2.2.3.1 The appellant may submit relevant documentation to the Appeals Committee.

A.1.2.2.3.2 All relevant documentation is circulated to committee members and provided to the appellant and Program Director (or delegate) prior to the appeal hearing.

A.1.2.2.4 The Program Director (or delegate) and appellant are invited to attend the appeal hearing. Each may bring one (1) advisor (in the form of legal counsel or a support person). In the event that legal counsel attends as the advisor, legal counsel is the only person who will speak on behalf of the person who invited legal counsel to attend.

A.1.2.2.5 The Program Director (or delegate), or legal counsel in the event that the Program Director (or delegate) engages legal counsel, will address the Appeals Committee in person and present information and answer questions from the Appeals Committee pertaining to the appellant’s performance. The appellant and the appellant’s advisor may be present; neither may question the presenter.

A.1.2.2.6 The appellant, or legal counsel in the event that the appellant engages legal counsel, will address the Appeals committee in person and present information and answer questions from the Appeals Committee pertaining to the appellant’s performance. The Program Director (or delegate) and the Program Director’s (or delegate’s) advisor may be present; neither may question the presenter.

A.1.2.2.7 The appellant, Program Director (or delegate), and advisors are excused from the Committee deliberations but may be recalled to answer questions of clarification posed by the Appeals Committee.

A.1.2.2.8 Official written transcriptions of the appeal hearing submissions and discussions are kept.

A.1.2.3 The Appeals Committee may reach one of the following decisions:

A.1.2.3.1 Uphold the decision of the PGME Committee;

A.1.2.3.2 Reverse the decision of the PGME Committee;

A.1.2.3.3 Refer the appeal to the PGME Committee for reconsideration. The Vice Dean (or delegate) will send new information along with its appropriate documentation to the PGME committee and advise the committee to reconsider its original decision on the basis of this new information.

A.1.2.4 If the decision is reached immediately following deliberations, the decision may be informally communicated to the appellant immediately after committee deliberations. The Vice-Dean (or delegate) will formally convey the decision to the appellant in writing within two (2) business days. This written communication will outline the next avenue of appeal available to the appellant. A copy of the correspondence will be sent to the Program Director, Associate Dean, PGME, and the Registrar.

A.1.3 Senate Committee on Academic Appeals

A.1.3.1 Should the original decision of the PGME Committee be sustained by the Faculty of Medicine Appeals Committee, the final level of appeal would be the Senate Committee on Academic Appeals.

A.1.3.2 For further information, refer to the UNIVERSITY REGULATIONS - General Academic Regulations (Undergraduate) - Appeal of Decisions - Appeals to the Senate Committee on Academic Appeals.

A.1.3.2.1 Information is subject to amendments in the University Calendar.

APPENDIX A

UNFITNESS FOR THE PRACTICE OF MEDICINE

Other behaviours not listed here may also be unacceptable. The behaviours listed below are not an exhaustive list.

A resident may be deemed unfit to practice medicine if they fail to demonstrate:

 adequate skill in communicating and interacting appropriately with patients, families, colleagues, support staff and allied health care professionals;

 respect, empathy and compassion for patients and their families;

 concern for the needs of the patients and their families to understand the nature of the illness and the goals and possible complications of investigations and treatment;

 respect for, and ability to work harmoniously with other allied health care personnel and medical colleagues;

 recognition of the importance of self-assessment and of lifelong learning for the maintenance of competent performance;

 a willingness to teach others in their own specialty, as well as other allied health care professionals;

 an understanding of the appropriate requirements for involvement of patients and their families in research;

 awareness of the effects that differences in cultural and social background have on the maintenance of health and the development of, and reaction to, illness;

 respect for the patient as an informed participant in decisions regarding their care, wherever possible;

 respect for institutional policies, guidelines and bylaws.

 appropriate behavior when using social media as per the College of Physicians and Surgeons of Newfoundland and Labrador (CPSNL) Physician Use of Social Media Standard of Practice, the FoM Guidelines for the Appropriate Use of Social Media, and the Eastern Health Social Media Policy.

Behaviour unacceptable to the professional practice of medicine includes but is not limited to:

 breach of any of the above principles of behaviour;

 referring to oneself as, or holding oneself to be, more qualified than one is;

 behaviour or inappropriate judgement which adversely affects the medical education of others;

 commission of a criminal act;

 failure to be available while on call;

 failure to respect patients' rights;

 breach of confidentiality;

 failure to provide transfer of responsibility for patient care;

 failure to keep proper medical records;

 falsification of medical records;

 sexual impropriety with a patient;

 being under the influence of alcohol or drugs while participating in patient care or on call;

 sexual or other harassment of colleagues or other members of the health care team; and

 any conduct unbecoming of a practicing physician.

Procedures:

There are no procedures associated with this policy.