Chair's Column: Moving Mountains to Address the Areas for Improvement Identified in the 2020 Internal Medicine Accreditation – Bravo to All and Fingers Crossed!
In advance of the return of the Royal College to review our Core Internal Medicine (IM) residency training program in November, I want to thank you for everything you have done to make our program the best possible.
As you know, IM is a flagship program within the DoM and within the Temerty Faculty of Medicine. It is the largest residency program in Canada, with approximately 70 residents in each of the PGY1, PGY2 and PGY3 years, 15 PGY4s and 6 CMRs. Virtually all of the clinical faculty members within our vast department interact with the IM residents across the fully affiliated teaching hospitals and in the community. The program is led by an amazing Program Director, Jeannette Goguen, and her team, comprised of 6 Site Directors, 2 Associate Program Directors (Rotation Improvement and Innovation; CaRMS), 8 Faculty Leads (Wellness, Resident Support & Remediation, Simulation, OSCE, PGY4, IMG/IFT Mentorship, Scholarly Activity, Academic Half Day), and 4 program administrative staff. It’s a massive team.
The past five years have seen enormous challenges posed to the structure and function of the program – introduction of competency-based medical education curriculum, the COVID-19 pandemic, and the results of the accreditation review. These challenges have necessitated enhanced administrative and faculty support for all our training programs, which has been challenging in the context of a healthcare system in crisis and insufficient human health and departmental resources.
Despite the enormity of these challenges, YOU came together as a team to move mountains to address our residents’ concerns.
Soon after we learned of the accreditation outcome, we established an arms-length Accreditation Task Force to gather feedback from residents on their experiences in the IM program and advice on ways to address Areas for Improvement (AFIs). Led by resident Michael Elfassy and faculty member Kevin Imrie, the recommendations of this task force informed the work undertaken over the past two years, overseen by the Accreditation Implementation Oversight Advisory Group.
Although the work had been initiated well before the 2020 accreditation review, the Division of General Internal Medicine fully implemented its GIM Redesign over the period of July 2021 - July 2023. To tackle concerns regarding adequate resident supervision in the clinical environment and continuity of care for patients, the GIM Redesign has increased the presence of senior residents on the CTUs. Standards for the Supervision of Learners by DoM Physicians have been developed and implemented to enhance transparency regarding the expectations for faculty supervising medical learners and learners themselves. For the IM program, there is now the expectation that all on-call CTU attendings be present, in person, on the weekends during the day to review cases and assist ‘on-call’ PGY1s as required.
Attendings must be accessible 24 hours a day by phone and able to come in to support learners when appropriate. In concert with this work, the summer of 2022 saw the development of similar standards for supervision of IM residents across the medicine specialties. All divisions have now implemented guidelines for supervision of learners in their ambulatory and in-patient rotations. This is no small feat and I want to thank the Departmental Division Directors, Program Directors, faculty, and learners for their contributions to this work.
Clinical and administrative workload across the CTUs was recognized to be negatively impacting the educational experience. Teachers need time to teach, and learners need time to learn and practice. To enable reduction of the number of patients within the CTUs, there has been heroic work performed by our PICs and their hospital leadership teams. To reduce hospitals’ dependence on the CTUs and learners for patient care coverage, all base hospitals have now implemented hospitalist training programs and many hospitalists have been hired. There has also been major recruitment of general internists and GIM subspecialists in the Clinician Teacher academic role, and a new faculty academic position description – the Academic Clinician – has been established to recognize in a tangible way the importance of expert, evidence-based patient care and the individuals providing it within our fully affiliated teaching hospitals.
Through the COVID-19 pandemic, our Vice Chair, Education, Dr Arno Kumagai, successfully advocated across TAHSN for city-wide restricted license registration for eligible residents to enable them to provide hospitalist moonlighting coverage. Furthermore, the department contributed $2 million dollars ($400,000 per site) to enhance administrative support for learners on the CTUs. To put this enormous team effort into context, as an example, currently half of all patients admitted to medicine at the UHN-TGH site and >25% at UHN-TWH are being cared for in resident-independent units.
Providing a Safe Environment for Feedback was the other major area requiring focus. As for clinical workload and optimal supervision, you have also moved mountains to address this AFI. With learners, the DoM has created the Optimizing Teaching Effectiveness and the Learner Experience document to provide transparency regarding how the DoM supports and recognizes the excellence of its teachers and collaborates with TFOM to ensure the safety and well-being of its learners. This is accomplished through Annual IM Program Site Reviews to provide opportunities for resident feedback and Mini Reviews, held 6 months after the main review, to ensure issues identified are being addressed. A Resident Navigation Tool now assists learners in finding help if mistreatment or harassment occurs. Other resources include CMR Debriefing Rounds, a newly appointed Resident Advisor, Resident Surveys, the Monthly Residency Program Committee (RPC) meetings, a Program Suggestion Box, and through contact with the Office of Learner Affairs (OLA). In addition to ensuring the learner voice is heard, the above noted feedback document describes in some detail how teaching and rotation evaluations are surveyed, as well as action taken should low scores or concerning comments appear. Finally, an Associate Program Director role was created to examine rotations with low rotation effectiveness scores in detail to ensure residents’ concerns are met.
For our teachers, we needed to ensure a fair and transparent process was in place to respond to negative comments and low teaching evaluation scores. I have personally witnessed the devastating impact of negative feedback on our teachers when it is not supported by any actionable details. Under the leadership of Vice Chair, Education, Arno Kumagai, and faculty members Tina Trinkaus and Maria Wolfs, sessions on giving and receiving feedback have been embedded in both learner and faculty orientations and annual review. The result is that we are seeing a clear improvement in the quality of feedback provided on teacher and rotation evaluations, enabling the department to respond swiftly to concerns as appropriate. Personally, I think a major accomplishment of this work is the recognition that clinical teaching and learning is about forming strong, trusted relationships between teachers and learners. When performance is less than optimal, we owe it to each other to provide timely and specific feedback about what was observed, in an appropriate setting. We need to provide time for self-reflection on the feedback given and not presume intent as doing so may assist in identifying wellness issues among both faculty and learners, which helps to define the best approach for improvement.
The expectations regarding working hours and the need for direct support for patient care have evolved considerably over the past several years. This has put pressure on everyone and affected the well-being of some more than others. If you are struggling, please reach out.
The Royal College will be back to conduct its External Review of the IM Program in one month - from Nov 7 – 9, 2023. I am hopeful that the massive amount of work that has gone into addressing the noted AFIs will be deemed successful. Continuous quality improvement will always be required, but we have put the processes and policies in place to guide this work going forward.
At the end of 2023, Dr. Goguen will pass the baton to Interim PD Dr. Pete Wu, currently Deputy IM PD, while we re-launch our search for Dr. Goguen’s successor. Now having completed the external accreditation review, this leadership transition provides an important opportunity for reflection on the overarching structure and function of this massive and critically important training program. As always, your thoughts for improvement are welcome. Stay tuned.