Chair's Column: Taking Stock of What We've Achieved

The Royal College external re-review of our Internal Medicine (IM) training program is now a year away. As a reminder, our IM program was given the accreditation status of “Full accredited, with intent to withdraw” in the spring of 2021 by the Royal College. The two major concerns that need to be addressed are:

1. Providing a safe environment for feedback

2. Increasing clinical support of trainees

In my last update to you in July 2022 I summarized the actions being taken to address the identified Areas for Improvement (AFIs), which have been guided by the recommendations put forward by our Internal Medicine (IM) Program Accreditation Task Force. Since then, work has proceeded remarkedly unabated, despite the fatigue that many Department members are experiencing. The efforts made by our IM Program Director, Jeannette Goguen, and her IM Residency Program team, including residents, faculty and staff, have been truly spectacular. BRAVO! Please know that the work you are doing and the sacrifices you are making on behalf of our residency program are meaningful and will positively shape our collective future and be a source of pride to you down the road!

Last week, Postgraduate Medical Education (PGME) at UofT conducted an internal review of the program that was designed to mirror the external Royal College review process, set for November 2023. While the official feedback has not been received, I am thrilled to report that we appear to be on the right track.

As we move forward, we’ve created an Internal Medicine Accreditation one-page document and FAQ to help keep you up to date on our progress, and to build awareness and understanding of the changes we have made. These documents will be updated as we head towards our IM external review. You will see that an IM Residency Scheduling Working Group has been struck, led by IM site lead Zac Feilchenfeld, as has an IM Accreditation Implementation Oversight Advisory Group, co-chaired by Drs. Chaim Bell and Ari Zaretsky. Membership and Terms of Reference (TOR) for these committees can be found on the Accreditation Webpage.

Providing Feedback without Fear of Retaliation (Resident to Faculty/Program and Faculty to Resident)

In my October 2022 Chair’s Column, I told you about our new guidance document, Optimizing Teaching Effectiveness and the Learner Experience in the DoM, which we have developed to enhance awareness, fairness and transparency for both learners and faculty members regarding our policies and practices for responding to critical learner feedback. This document has been reviewed extensively (Temerty Medicine, PGME, the IM RPC, the Accreditation Implementation Oversight Advisory Group and DoM Executive) and is now final. Please take a look and let me know if you have any questions.  

Supervision of Learners in the Clinical Environment

Times have changed. Medical education now occurs across diverse settings involving patients presenting with a vast range of acuity and complexity, a high volume of patient transitions, which demands effective communication among team members, patients, and their families, greater electronic documentation, and less nursing and allied health support staff. While relatively uncommon, ‘typical’ resident work hours may be disrupted by unanticipated patient emergencies that impact the availability of the Supervising Physician or end of day routine activities. Finally, in part due to COVID and in part due to the aging population and prevalence of medical conditions, specialist wait times for urgent consultation and treatment have grown dramatically, causing immense anxiety and stress on faculty members.

To respond to the changes in need for supervision by faculty members, we have established a second guidance document - the DoM Standard for Physicians Supervising Learners – with the goal of optimizing the learning environment by demonstrating a consistent and mutual understanding of roles and responsibilities. The principles outlined should ideally be reviewed with Learners at the beginning of all clinical rotations so as to initiate a mutual dialog about “What can you expect from me?” and “What do I expect from you?” This conversation can facilitate formal and informal coaching and feedback, competency-based evaluations, and ultimately improve team communication to ensure quality of care and patient safety. 

The most substantial change is that it is now expected that the Supervising Physician must:

• ALWAYS be identified and available to assist Learners in providing optimal patient care
• Be available to speak with Learners at any time to discuss changes in patient status and provide urgent review of patients with uncertain clinical presentations. 

The degree and means of availability (by phone, pager, or in-person) is determined by the volume and acuity of patients being cared for, case mix, compliment of Learners (types, levels), and time of year, e.g., beginning versus end of the academic year. Depending on the trainee's seniority and comfort, this may require in-person patient assessment after hours by the supervising physician on in-patient rotations. 

To enable the above, Supervising Physicians should ideally adjust their schedules (other clinical, academic, administrative activities) to ensure residents are adequately supported throughout the day and are able to consistently complete their workday by 6 pm. But, this is not always possible. Our patients are waiting for months and often longer to obtain our clinical services – cancelling a clinic or procedures to be available to our learners is not without consequences. If for any reason the Supervising Physician is unavailable to learners for a period of time, they must designate an eligible Acting Clinical Supervisor and ensure Learners are notified and aware.

Please read these new guidance documents and let me know directly at g.hawker@utoronto.ca if you have any questions. We look forward to discussing them with you at future faculty and resident orientations, in teaching and at rounds, and as part of annual faculty review.

All these changes are coming at a very difficult and dynamic time in medicine. I think most would agree that our health care ‘system’ is frankly in crisis, with no clear fixes in sight. I am well aware that you are tired and frustrated by the growing inability to get even mundane things done for your patients and the inability to perform your academic duties in the face of growing clinical responsibilities. This is the focus of a different conversation, but I want you to know that the DoM is advocating hard to address these issues and fully committed to making the critical changes to academic medicine that are needed to align with this ‘new normal’ in which we find ourselves and the desire and need to better balance our daily lives at work with our goals and aspirations outside medicine.

We have made and continue to make great strides to improve the experience of our learners and faculty members and staff, but more is needed. We are up to the challenge – we have the brightest most passionate and skilled physicians, teachers, educators, researchers, and innovators. We will continue to lead innovations in health care, medical education and academic medicine.

Sincerely,

Dr. Gillian Hawker