Chair’s Column April 2024 - External Review of the DoM: 2018-2023
In early October 2023, the Department of Medicine underwent an external review led by Dr. Seth Landefeld, Chair of Medicine at the University of Alabama at Birmingham in the US, and Dr. Anita Palepu, Chair of Medicine at the University of British Columbia. Thank you to all the faculty, learners and staff who met with the reviewers and provided their candid perspectives regarding how we are doing and your wishes for the future. Much obliged.
The external reviewers' report, my response to the review as Chair, Dr. Patricia Houston's response as Interim Dean and the Department of Medicine's Self-Study Report (2018-2023) are now available on our website for your review:
External Review Report
Chair's response to the review
Interim Dean's response to the review
Department of Medicine: Self-Study Report (2018 - 2023)
These documents, which lay the foundation for the next Chair’s priority setting, provide a broad SWOT (strengths, weaknesses, opportunities, and threats) of our department. I strongly encourage you to take a look if you’re able and let me know what you think. If not, I’ve provided a brief synopsis, below.
What we are doing well…
The department was noted for its "internationally prominent faculty and programs in research, training, and patient care…” and praised for its progress and achievements. They were somewhat envious of our ability to “…attract and develop incredibly talented and committed trainees and junior faculty” and commended us for how we “…support them as much as possible to develop as leading faculty, noting that “few departments have this track record.”
They remarked that our success was particularly notable given the tremendous challenges over the past few years (COVID-19 pandemic, Royal College accreditation) and limited financial resources. They noted that “further investment would likely have tremendous return in terms of [developing] the next generation of physician-investigators and the expansion of clinical training.”
They reported that MD and PGME learners value the educational experiences received in the department and the department’s teachers, who are devoted to providing high-quality clinical teaching across all teaching sites. They noted that “… a great deal of attention (had been paid) to promoting learner well-being and resiliency in the educational environment in the past five years” and that this, and the “…strong focus on EDI in the UofT DoM and the Vice Chair, Culture and Inclusion portfolio, has provided additional support to learners.” As a result, “The medical students, residents, clinical fellows, and scientists in training all endorsed a highly supportive learning environment with the exception of during the acute surge of COVID-19 in 2020…” The external departmental review occurred just prior to the Royal College (RC) review of the Internal Medicine training program, which was a success. We expect the final accreditation report in the spring of 2024.
They commended us for the enormous efforts we’ve made to demonstrate our respect for and support of our Clinician Teachers (CTs), with evidence of some success based on the number of faculty now seeking senior promotion based on sustained excellence in teaching and the number of CTs seeking promotion on any basis.
The reviewers praised the department’s scholarly productivity and impact. “It is truly remarkable to review the scope, quality, and relevance of research activities of the UofT DoM, especially in light of the COVID-19 pandemic… DoM produced 38% of all UofT scholarly output in health sciences from 2017-22.” They were truly impressed that all faculty members, irrespective of their academic position description, contributed to scholarly productivity. They highlighted the value of our city-wide research networks, the Clinician Scientist Training Program (CSTP), and the very high caliber of our CSTP trainees.
They were duly impressed by the “Incredible thinking, policies and operational changes, and programs… Deep passion and commitment to wellness, EDI, and mentorship…and on mutual respect, compassion, integrity, and inclusion”, led by our Culture and Inclusion Portfolio." The DoM has a very highly developed structure to promote equity, diversity, inclusion, and wellness across the Department. In fact, the DoM structure is a model that might be useful to other departments outside UofT and perhaps at UofT.” We are incredibly fortunate to have such dedicated faculty and staff leadership, and the buy-in of (most of) our enormous department in enabling the success of this portfolio.
To sum it up simply, they determined that our department delivers terrific programs with outstanding, committed people, despite limited physical and financial resources.
What could we do better…
The reviewers remarked on the high proportion of faculty members that reported symptoms of burnout on our 2022 Faculty Survey. They noted that our “CTs are feeling at their max with additional asks and stresses from the university and their hospital in the current health system… There is a need to provide more support and recognition to the CT ….” While the major drivers of burnout are beyond the department’s control (provincial and federal budgets, demise of Canadian health care, administrative loads, high burden of acute and complex patient care required), we will continue our efforts to contribute to faculty member’s well-being through formal recognition, advocacy, provision of high-quality mentorship/sponsorship, and opportunities for city-wide collaboration and celebration.
The promotion timeline (for CTs based on sustained excellence in teaching) is still longer than other categories….” How “sustained excellence in teaching” is defined has been a source of much debate at the TFOM. The department has made some gains with the Decanal Committee, but there remains the status quo of a 10-year period as a requirement for ‘sustained excellence.’
The reviewers reported that “CBD has been a huge additional workload for faculty and the programs with unclear value in terms of improvement in the educational outcome for residents. Many programs have had challenges with administrative support in terms of turnover and insufficient funding to cover all the required tasks. The residents did not perceive they derived substantive value from the feedback received on EPAs for the most part.”
Regarding the large number of DoM fellows with a predominance of international trainees, they commented: “The cost of living has resulted in many basic science research fellows opting not to come to Toronto. Many fellows come…from abroad, and …encounter challenges. First, annual registration fees and re-enrolment fees are high relative to salary. …Second, delays occur in visa and work permit applications… Third, because a work permit is required for a police verification certificate, which is required for CPSO registration, the delay in a work permit delays CPSO registration. …It would be helpful to develop a clear process map and timelines particularly for international clinical fellows especially given the myriad of administrative issues that need to be navigated.”
They also noted potential threats to the research mission: fewer CSTP trainees pursuing basic science careers; stagnant salary support for the CSTP and CS/CI faculty; perception that support provided by the DoM and the hospital research institutes to CS faculty has eroded over time; and lack of harmonization of REB and contracts across the TAHSN institutions. We agree wholeheartedly that physicians play a critical integrating role in science. Thus, we must foster the development of physician researchers across all disciplines, including translational research. The CS/CI pipeline is a major focus of our CSTP Director, Mamatha Bhat and Vice Chair, Research, Jane Batt.
The reviewers noted a decline in the rate of growth of extramural funding from 19% growth from 2017-18 to 2018-29 to 13%, 5%, and 1% in subsequent years. This may reflect the impact of the COVID-19 pandemic, but also reduced time for research given increasing clinical demands. This requires ongoing monitoring and review.
Finally, they were concerned about the resources that would be needed to expand training sites and programs, e.g., to the new Scarborough Academy. They felt greater attention should be placed on understanding the potential unintended consequences of disseminating faculty appointments without maintaining current standards and expectations.
Recommendations…
Based on their review, Drs. Palepu and Landefeld made 13 recommendations. Their recommendations largely amplified our message to the TFOM that there is a mismatch of resources provided and deliverables expected. They acknowledge our concerns regarding the sustainability of the academic excellence of this department.
RECOMMENDATION 1.
Expand recognition of DoM leaders and faculty, with special attention to CTs.
RECOMMENDATION 2.
Steady, sustained attention from DoM leaders to the issues raised in the Residency Review will be important, even in the midst of formidable challenges of the health care environment. (DoM leadership) has catalyzed a cultural transformation that must be sustained.
RECOMMENDATION 3.
Expand efforts to promote well-being of faculty, staff, and learners, with appropriate resources.
RECOMMENDATION 4.
Increased transparency regarding how DoM funding is determined. This will enhance determination of which DoM investments are considered worthwhile.
RECOMMENDATION 5.
TFOM and DoM design a funding strategy that will sustainably increase funding for DoM.
RECOMMENDATION 6.
Assess resource needs to increase training sites and programs and determine the unintended consequences of disseminating faculty appointments without maintaining current standards and expectations.
RECOMMENDATION 7.
Harmonized pre-award research procedures, such as IRB and contracting, across TAHSN.
RECOMMENDATION 8.
Consider a formal review of priorities and initiatives by the Chair to inform allocation of resources and to clarify realistic expectations.
RECOMMENDATION 9.
Review the role of CTs and the resources available to them, with the goal of sustaining them and their substantial contributions.
RECOMMENDATION 10.
Insofar as possible, increase TFOM/DoM investment in attracting and developing the next generation of CS.
RECOMMENDATION 11.
With TFOM, identify programs of little value, as some think CBD is, and work together to eliminate or modify such programs.
RECOMMENDATION 12.
With TFOM, determine TFOM resources that might be valued by DoM faculty and develop strategies to make them available.
RECOMMENDATION 13.
Assess needs for research space and explore whether those needs can be met with space other than that controlled by the Research Institutes.
What comes next…
The external review process lays the foundation for the next DoM Chair to move the department forward. However, the reviewers’ report has already spurred much-needed discussion between the TFOM and the DoM regarding the budget model. Dr. Houston, Interim Dean, TFOM, has committed to a budget allocation process review with a focus on increased transparency, establishment of criteria and priorities for funding, enhanced accountability, and the standardization of financial processes across departments by TFOM. The faculty of medicine has also committed to a review of space allocation and needs assessments for all departments by the Temerty Space Planning Committee. Discussion is also underway regarding the “value proposition” of full-time academic medicine – the focus of the upcoming Clinical Chairs committee meeting – and amplifying the focus on our teachers. TAHSN-Research is already pushing hard to break down hospital silos that make collaboration across sites near impossible. And at the upcoming spring meeting of CAPM (Canadian Association of Professors of Medicine), the Royal College will present its recommendations for revamping CBD. This and a lot more is ongoing, and I thank ALL of you for lending a hand.
Let me close with my thanks for all your efforts as members of this spectacular academic Department of Medicine! This review reflects these efforts.