Principle

Triple C is a competency-based curriculum for Family Medicine residency programs based on the CanMEDS-FM framework and the Evaluation Objectives in Family Medicine. The evaluation objectives are grounded in a process of continuous reflective assessment in the workplace. There are three components of Triple C:

 Comprehensive education and patient care

 Continuity of education and patient care

 Centered in family medicine

The Triple C curriculum provides residents with the relevant learning contexts and strategies to enable them to integrate competencies, while acquiring evidence to determine that a resident is ready to begin to practice in the specialty of Family Medicine. The overall length of the Family Medicine residency program (not including Enhanced Skills programs) shall not exceed four (4) years from the date the program commenced, leaves excluded.

This policy was developed to reflect the modifications made to resident assessment, promotion, probation, dismissal and appeals under the Triple C framework.

Purpose

To describe the principles of assessment, promotion, dismissal and appeals for the Family Medicine residency program and the Enhanced Skills programs at Memorial University of Newfoundland (Memorial).

Scope

A resident currently or previously enrolled in the Family Medicine residency program or an Enhanced Skills 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.

Associate Dean, Postgraduate Medical Education (PGME) — The senior faculty officer, appointed by the Dean of Medicine, who is responsible for the overall conduct and supervision of PGME with the Faculty of Medicine (FoM).

College of Family Physicians of Canada (CFPC) — The professional organization responsible for establishing standards for the training, certification and lifelong education of family physicians and for advocating on behalf of the specialty of family medicine, family physicians and their patients.

Competence Committee or Assessment, Evaluation and Promotions Committee — The committee responsible for synthesizing and reviewing the assessment data of postgraduate learners to determine postgraduate learner progress in achieving specialty-specific requirements of a program. Each discipline will have their own Competence Committee or Assessment, Evaluation and Promotions Committee.

Competency — An observable ability of a health professional, integrating multiple components, such as knowledge, skills and attitudes.

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.

Program Director — The faculty member assigned responsibility for the overall conduct of the residency program in a given clinical discipline.

Remedial Program — A formal program of individualized educational support, assessment, and monitoring designed to assist a resident in correcting identified performance deficiencies.

Required clinical learning experience/rotation — A required clinical learning experience with a pre-identified timeline and set of objectives, which must be successfully completed to meet the requirement of the course or program.

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

Policy

1.0 Resident Assessment

1.1 The competencies to be attained within each clinical experience must be clearly outlined and made known to residents and faculty.

1.2 The Family Medicine residency program shall determine the methods of assessment to be used (see the Family Medicine webpage for a description of the assessment methods used).

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

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

1.3 A resident’s progress in the attainment of competencies must be documented regularly.

1.3.1 Faculty Advisors are responsible for ensuring regular assessments of a resident’s progress are being facilitated by the resident.

1.4 Resident’s Performance During a Clinical Experience

1.4.1 Residents are expected to obtain one (1) field note per half-day of clinical work during clinical experiences.

1.4.2 An In-Training Assessment Report (ITAR) must be completed by a resident’s supervising faculty member:

1.4.2.1 at the mid-point of any clinical experience longer than four (4) weeks in duration, or at least every two (2) months, when applicable; and,

1.4.2.2 at the end of a clinical experience.

1.4.3 If a weakness in a resident’s performance is identified during the clinical experience, the supervising faculty must bring it to the attention of the resident promptly, preferably in writing.

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.

1.7 A resident will only receive credit for the successful completion of a clinical experience.

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, or dismissal.

3.0 Time Away from Service

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

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

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

3.3 If a resident is returning to their program after being on leave for an extended period of time, the Assessment, Evaluation and Promotions Committee is responsible for determining the plan for the resident to resume their training.

4.0 Progress Review and Promotion

4.1 Promotion

4.1.1 A resident shall be granted clear promotion to the next clinical experience if they progressed as expected through the clinical experience and attained all required competencies.

4.1.2 A resident will be promoted to the second year of training (if applicable) if they have achieved all required competencies, and any other training requirements of their first year of training.

4.1.2.1 A resident who has shown consistently weak performance may not be promoted if they are not adequately prepared to succeed at the next year of training.

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

4.2 Progress Meetings

4.2.1 During the academic year, Faculty Advisors must meet with their respective residents to review the assessment portfolio of each resident. The assessment portfolio will include ITARs, field notes, resident reflections, and other assessment documentation. The number of meetings a Faculty Advisor must have with a resident in an academic year is determined by the program.

4.2.2 At least twice a year, Program Directors of the Enhanced Skills programs with meet with each resident in the program to review the resident’s assessment portfolio.

4.2.3 A learning plan will be developed during each progress meeting to help focus resident learning.

4.2.4 A summary report of each progress meeting will be completed by the Faculty Advisor/Program Director and be kept in the resident’s portfolio.

4.2.5 The Program Director must inform the Associate Dean, PGME, in writing, of any resident who is in academic or non-academic difficulty.

4.3 Assessment, Evaluation and Promotions Committee

4.3.1 The Assessment, Evaluation and Promotions Committee will meet every two (2) months to review resident progress in achieving the required competencies.

4.3.2 The Assessment, Evaluation and Promotions Committee will make the final decision regarding a resident’s performance during a clinical experience and will make recommendations for promotion, additional training, remediation, or probation as required.

4.3.3 The progress and promotion recommendations of the Assessment, Evaluation and Promotions Committee will be based on all evidence available in the resident’s assessment portfolio at the time of the progress/promotion meeting.

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

4.4. RTC

4.4.1. The RTC is responsible for determining if the resident can be promoted to the next academic year or recommended for program completion, based on the recommendations of the Assessment, Evaluation and Promotions Committee.

4.4.2. If the final decision of the RTC differs from the recommendation of the Assessment, Evaluation and Promotions Committee, a detailed rationale must be provided to the Assessment, Evaluation and Promotions Committee and Associate Dean, PGME, in writing.

4.4.3. All decisions by the RTC regarding a denied promotion must be discussed with the Associate Dean, PGME.

5.0 Additional Training

5.1 A resident may be required to complete additional training when:

5.1.1 the resident has not had ample opportunities to achieve competence in the required competencies;

5.1.2 they receive two (2) or more ratings of “some concerns noted” on an ITAR regarding their progress; and/or,

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

5.2. Additional training opportunities are designed by the Assessment, Evaluation and Promotion Committee or RTC as appropriate, and can be completed within the scope of a clinical experience.

5.3. A resident must comply with, and meet the requirements of, an additional training plan.

5.4. The completion of additional training may result in an extension of training.

6.0 Remediation

6.1 A resident will be required to complete a remedial program when:

6.1.1 they receive an overall progress rating of “Significant concerns noted” on an ITAR;

6.1.2 they are failing to progress in their training despite the completion of additional training designed to facilitate a resident’s attainment of specific competencies and/or to improve their professional conduct;

6.1.3 significant concerns about the professional conduct of a resident have been raised and are in areas that are deemed remediable.

6.2. The completion of a remedial program may result in an extension of training.

6.3. The terms and conditions of a remedial program are developed by the Assessment, Evaluation and Promotions Committee, PGME office and the RTC. The terms and conditions must be outlined in a Remediation Learning Plan which will describe the following:

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.

6.4. The resident must sign the Remediation Learning Plan in order to complete the remedial program.

6.4.1. A resident must comply with, and meet the necessary requirements of, the Remediation Learning Plan.

6.5. The Program Director and RTC are responsible for:

6.5.1. making the final decision of whether a resident met the terms and conditions of a remedial program; and,

6.5.2. determining if the resident can continue on in their residency program, requires additional remediation, or is to be placed on probation.

6.6 A resident who meets the terms and conditions of the remedial training may continue in their regular residency program out of phase, as resources and training opportunities dictate.

6.7 No leave of absence during a remedial program is permitted unless under exceptional circumstances.

7.0 Probation

7.1 A resident will be placed on probation if they receive an overall progress rating of “Significant concerns noted” on two (2) or more ITARs within an academic year.

7.2 A resident may be placed on probation if they fail to meet the terms and conditions of a remedial program.

7.3 The completion of a probationary period will result in an extension of training.

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

7.5 The terms and conditions of the probationary period are developed by the Assessment, Evaluation and Promotions Committee, PGME office and the RTC. The terms and conditions must be outlined in a written contract which will describe the following:

7.5.1.1 the learning experiences to be provided;

7.5.1.2 the competencies to be achieved;

7.5.1.3 the assessment processes to be followed;

7.5.1.4 the needed extension of training will not likely be greater than one (1) year, leaves excluded.

7.6. The resident must sign the probation contract in order to complete the probationary period.

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

7.7 Successful completion of a probationary period requires satisfactory evaluations for all portions of the probationary period.

7.8 No leave of absence during a probationary period is permitted unless under exceptional circumstances.

7.9 At the end of the probationary period, the RTC and Program Director are responsible for deciding if the resident can continue on in the residency program, requires further training modifications, or will be dismissed.

7.10 All decisions of the Program Director and RTC regarding probation must be approved by the Associate Dean, PGME.

7.11 A resident will not receive credit for successfully completing a probationary period but will continue in their residency program, out of phase, as resources and training opportunities dictate.

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 contract, or a probationary contract.

8.2 Suspension decisions are made by the Program Director and RTC in consultation with the 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 meet the terms and conditions of their probationary contract;

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 require greater than four (4) years of training, leaves excluded, to complete the competencies for entry to the independent practice of Family Medicine (residents completing an Enhanced Skills program excluded).

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

9.3 All dismissal decisions by the RTC will occur in consultation with the Assessment, Evaluation and Promotions Committee and must be approved by the Associate Dean, PGME, and the Dean of Medicine.

10.0 Appeals

10.1 A resident may appeal the following:

10.1.1 An overall progress rating of “Significant concerns noted” on an ITAR;

10.1.2 a decision by the RTC denying the resident promotion to the next academic level;

10.1.3 a decision by the Program Director and RTC that the resident did not meet the terms and conditions of a remedial program or probation;

10.1.4 a decision by the RTC to dismiss the resident from their residency program or Enhanced Skills program.

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

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 RTC will determine if the appellant will continue with regularly scheduled clinical experiences/educational experiences 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 RTC.

Related Documents

Procedure

A.0 Appeals

A.1 Appeal of an overall progress rating of “Significant concerns noted” on an ITAR.

A.1.1 First Stage - Reconsideration

A.1.1.1 A resident, who disagrees with an overall progress rating of “Significant concerns noted” on an ITAR, discusses the ITAR with the supervising faculty member within ten (10) business days of the ITAR being posted to One45.

A.1.1.1.1 The resident should identify any external factors which may have influenced the assessment or suggest other individuals knowledgeable of their performance who could speak positively on their behalf.

A.1.1.2 The supervising faculty member will review all relevant documentation, consulting with others if necessary.

A.1.1.3 Should the supervising faculty member revise the ITAR, the revised ITAR will become the official ITAR; otherwise, the original ITAR will stand.

A.1.1.4 The decision is communicated by the supervising faculty member, in writing, to the resident and the RTC within thirty (30) business days of the initial post of the ITAR to One45.

A.1.2 Second Stage – Formal Appeal

A.1.2.1 A resident who wishes to further contest an overall progress rating of “Significant concerns noted” on an ITAR, proceeds to the second and formal stage of the appeal process and submits an appeal request, in writing, to the RTC within ten (10) business days of the supervising faculty member’s final decision under section A.1.1.4.

A.1.2.2 The Program Director convenes a meeting of the RTC to consider the appeal as soon as possible. The appellant’s Program Director will chair the appeal hearing, provided they were not responsible for, or involved in, the assessment that is being contested. In this case, the Discipline Chair may chair the hearing.

A.1.2.2.1 The appellant may request that the resident representative(s) of the RTC be absent from the appeal hearing.

A.1.2.2.2 The appellant may submit relevant documentation to the RTC.

A.1.2.2.3 All relevant documentation is circulated to committee members and provided to the appellant and the supervising faculty member prior to the appeal hearing.

A.1.2.3 Before the appeal hearing proceedings start, the Chair of the appeal hearing explains the process and briefly reviews the nature of the problem to the committee members.

A.1.2.4 When the appellant appears before the RTC, the format is as follows:

A.1.2.4.1 The appellant and supervising faculty member are called to appear before the committee and are provided the opportunity to make submissions. Each may bring one (1) advisor.

A.1.2.4.2 Committee members ask questions of either party.

A.1.2.4.3 The RTC deliberates and renders a decision.

A.1.2.4.4 Minutes are kept.

A.1.2.4.5 The RTC has the authority to:

A.1.2.4.5.1 uphold the original ITAR;

A.1.2.4.5.2 make appropriate modifications to the ITAR and recommend modifications to the residents training, supervision, and/or assessments, if required.

A.1.2.4.6 The decision of the RTC is conveyed in writing to the appellant within ten (10) business days after the appeal hearing and is sent to the PGME office.

A.1.2.4.7 The decision of the RTC is final.

A.2 There are three (3) levels at which a resident can appeal a decision of the Program Director and/or RTC regarding remediation, probation, denied promotion, or dismissal.

A.2.1 PGME Committee

A.2.1.1 An appeal against a decision of the Program Director and/or RTC will be made to the PGME Committee.

A.2.1.2 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 RTC.

A.2.1.3 The appellant notifies the PGME committee if they are bringing legal counsel to the appeal hearing.

A.2.1.4 The Associate Dean, PGME, convenes a meeting of the PGME Committee to consider the appeal when quorum can be achieved.

A.2.1.4.1 The appellant may submit relevant documentation to the PGME committee.

A.2.1.4.2 All relevant documentation is circulated to committee members and provided to the appellant and Program Director (or delegate) prior to the appeal hearing.

A.2.1.5 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.2.1.6 When the appellant appears before the PGME Committee, the format is as follows:

A.2.1.6.1 The Chair of the committee outlines the process and briefly reviews the nature of the problem to the committee members.

A.2.1.6.2 The Program Director (or delegate) speaks first and outlines the reasons for the decision that was taken.

A.2.1.6.3 The appellant then has the opportunity to speak and outlines the reasons supporting the appeal.

A.2.1.6.4 Legal counsel, if present, asks questions of either party and of the witness(es).

A.2.1.6.5 Committee members ask questions of either party and of the witness(es).

A.2.1.6.6 Official written transcriptions of the appeal hearing submissions and discussions are kept.

A.2.1.6.7 The PGME Committee deliberates in camera.

A.2.1.6.8 The PGME Committee has the authority to uphold the decision of the Program Director and/or RTC, reverse the decision of the Program Director and/or RTC, or modify the decision of the Program Director and/or RTC and recommend modifications to a residents training, supervision and/or assessments.

A.2.1.6.9 The decision of the committee is conveyed in writing to the appellant within ten (10) business days after the appeal hearing.

A.2.2 Faculty of Medicine Appeals Committee

A.2.2.1 An appeal against a decision of the PGME Committee will be made to the Appeals Committee.

A.2.2.2 An appeal through the Appeals Committee will follow the process below:

A.2.2.2.1 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.2.2.2.1.1 be addressed to the Dean of Medicine (or delegate) and copied to the PGME office;

A.2.2.2.1.2 describe the decision being appealed, the grounds of the appeal, and the resolution being sought;

A.2.2.2.1.3 Provide supporting documentation, as appropriate.

A.2.2.2.2 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.2.2.2.2.1 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.2.2.2.2.2 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.2.2.2.3 The Vice Dean of Medicine (or delegate) calls a meeting of the Appeals Committee at the earliest opportunity when quorum can be achieved.

A.2.2.2.3.1 The appellant may submit relevant documentation to the Appeals Committee.

A.2.2.2.3.2 All relevant documentation is circulated to committee members and provided to the appellant and Program Director (or delegate) prior to the appeal hearing.

A.2.2.2.4 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.2.2.2.5 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.2.2.2.6 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.2.2.2.7 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.2.2.2.8 Official written transcriptions of the appeal hearing submissions and discussions are kept.

A.2.2.3 The Appeals Committee may reach one of the following decisions:

A.2.2.3.1 Uphold the decision of the PGME Committee;

A.2.2.3.2 Reverse the decision of the PGME Committee;

A.2.2.3.3 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.2.2.4 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.2.3 Senate Committee on Academic Appeals

A.2.3.1 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.2.3.2 For further information, refer to the UNIVERSITY REGULATIONS - General Academic Regulations (Undergraduate) - Appeal of Decisions - Appeals to the Senate Committee on Academic Appeals.

A.2.3.2.1 Information is subject to amendments in the University Calendar.

Procedures:

There are no procedures associated with this policy.