Approved by Council: September 2003
Reviewed and Updated: May 2011
Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.
Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.
Postgraduate Trainees (“trainees”)1: Physicians who hold a degree in medicine and are continuing in postgraduate medical education. Regardless of the class of certificate of registration held, postgraduate trainees cannot practice independently within the confines of the training program.
Most Responsible Physician (“MRP”): The physician who has final accountability for the medical care of a patient when the trainee is providing care.
Supervisors: Physicians who have taken on the responsibility by their respective training programs to guide, observe and assess the educational activities of trainees. The supervisor of a trainee involved in the care of a patient may or may not be the most responsible physician for that patient. Residents or fellows often serve in the role of supervisors, but do not act as the most responsible physician for patient care.
- While this policy focuses on professional responsibilities in the postgraduate environment, supervisors and trainees must be familiar with other applicable CPSO policies including, but not limited to Delegation of Controlled Acts, Mandatory Reporting, Consent to Treatment, Disclosure of Harm, Medical Records, and Physician Behaviour in the Professional Environment.
Supervision and Training
- The MRP and/or supervisor physician must provide appropriate supervision to the trainee. This includes:
- being familiar with program objectives;
- making the patient or substitute decision-maker aware of the identity of the MRP, and the fact that the MRP is ultimately accountable for the patient’s care;
- making the patient or substitute decision-maker aware of the identity of trainee(s) who are members of the treatment team, their stage in the postgraduate program, as well as their degree of involvement in patient care;
- being willing and available to see patients when required or when requested;
- regularly evaluating a trainee’s clinical competence and learning needs, and assigning graduated responsibility accordingly;
- making reasonable efforts to determine that the trainee has the necessary competence (knowledge, skill and judgment) to participate in a patient’s care and does not compromise that care;
- ensuring that all relevant clinical information is made available to the trainee, and directly assessing the patient as appropriate; and
- communicating regularly with the trainee to discuss and review the trainee’s patient assessments, management, and documentation of patient care in the medical record.
- The trainee must:
- participate in the care of patients as appropriate to their competencies, and specific circumstances, as well as to meet identified educational needs;
- make the patient or substitute decision-maker aware of their name, role, stage in the postgraduate program, and degree of involvement in patient care;
- make the patient or substitute decision-maker aware of the name and role of the MRP, and the fact that the MRP is ultimately accountable for the patient’s care;
- communicate with the supervisor and/or MRP:
- in accordance with guidelines of the postgraduate program and/or clinical placement setting,
- about patient assessments performed by the trainee,
- when there is a significant change in a patient’s condition,
- when the trainee is considering a significant change in a patient’s treatment plan or has a question about the proper treatment plan,
- about a patient discharge,
- when a patient or substitute decision-maker and family expresses significant concerns, or
- in any emergency situation or when there is significant risk to the patient’s well-being;
- document their clinical findings and treatment plans and discuss these with the MRP and/or the supervisor.
- The MRP, supervisor and trainee must demonstrate professional behaviour in their interactions with each other, as well as with patients, other trainees, colleagues and support staff. This includes avoiding “disruptive behaviour” which is any form of behaviour that interferes with, or is likely to interfere with quality health-care delivery or quality medical education. For example, the use of inappropriate words, actions or inactions that interfere with the ability to function well with others.2
- Positive role-modeling3 is of the utmost importance and MRPs and/or supervisors must demonstrate a model of ethical and compassionate care.
- The MRP and/or supervisor must be mindful of the power differential in their relationship with the trainee and must not allow any personal relationships to interfere with their supervision and evaluation of the trainee.
- In order for the appropriate faculty member to decide whether alternate arrangements for supervision and evaluation of the trainee are warranted, the MRP and/or supervisor must disclose any personal relationship, which pre-dates or develops during the training phase between the MRP and/or supervisor, and the trainee, e.g., family, dating, business, friendship, etc., to the appropriate responsible member of faculty (such as department or division head or postgraduate program director).
Patient Care within the Postgraduate Educational Environment
- In the postgraduate environment, the MRP, the supervisor or the trainee must ensure that patients are informed that care involves a collaborative, team-based approach and that trainees are integral members of the health-care team.4
- Trainees must only take on clinical responsibility in a graduated manner in step with their demonstrated growing competency, although never completely independent of appropriate supervision.
- While physicians must obtain patient consent5 for treatment or a proposed change in treatment in any setting, there are circumstances unique to the postgraduate environment, which require additional consideration:
- When a significant component, or all, of a medical procedure is to be performed by a trainee without direct supervision, the MRP, supervisor or trainee must ensure that the patient is made aware of this fact and where possible, must obtain express consent6.
- When an examination is performed solely for educational purposes7, the MRP and/or supervisor, must:
- provide an explanation of the educational purpose behind the proposed examination or clinical demonstration to the patient and obtain their express consent. This must occur whether or not the patient will be conscious during the examination.
- not allow the examination to be performed by the trainee if express consent cannot be obtained, e.g., the patient is unconscious.
- be confident that the proposed examination or clinical demonstration will not be detrimental to the patient, either physically or psychologically.
1. The majority of trainees in Ontario hold a certificate of registration authorizing postgraduate education, and are commonly referred to as “residents” or “fellows” in most teaching sites. However, a trainee may have a different class of registration depending on his/her individual circumstances: 1) pre-entry assessment program certificate of registration – commonly issued to international medical graduates (IMGs) for an initial “assessment phase”; this would include completing a “pre-entry assessment program” or “assessment verification period”; 2) restricted certificate of registration – trainees who have qualified under the Residents Working Additional Hours for Pay policy; 3) certificates of registration authorizing independent practice – trainees who have completed their residency program and qualified for full registration, but who continue to do fellowship training.
4. Typically, hospitals and other clinical settings would have signage notifying patients that they are in teaching institutions. However, physicians in private offices and clinics must explicitly communicate this information.
5. Obtaining informed consent includes the provision of information and the ability to answer questions about the material risks and benefits of the procedure, treatment or intervention proposed. For more information, please refer to the College’s Consent to Treatment policy and also, the Health Care Consent Act, 1996, c.2. Sched. A.