Approved by Council: September 2003
Reviewed and Updated: May 2011
Downloadable Version: Professional Responsibilities in Postgraduate Medical Education
The delivery of postgraduate medical education in Ontario has significantly evolved over time. Today training occurs in a variety of environments – teaching sites are not limited to traditional teaching hospitals, but also extend to community settings, such as physicians’ private practices. Also,
training relies on a team-based approach to care, involving the provision of comprehensive health services to patients by multiple health-care professionals. There are no longer exclusive domains of practice; rather, care is delivered through multidisciplinary teams. This collaborative, teambased approach promotes optimal health care for patients.
In order to ensure both an appropriate educational experience for trainees and a safe and effective delivery of health care to patients, it is essential that supervisors and trainees in the postgraduate environment are aware of the responsibilities and expectations that their roles entail.
Trainees need to be given opportunities to observe and actively participate in clinical interactions in order to acquire the knowledge, skills, and judgment required for future practice. This occurs through a process of graduated responsibility, whereby trainees are expected to take on increased responsibility as they acquire greater competence. For this to occur safely, supervisors must be capable of assessing the competencies of the trainees they are supervising on an ongoing basis.
Trainees cultivate attitudes about professionalism through observing the attitudes and behaviours displayed by their supervisors. Positive role-modeling is therefore of the utmost importance and supervisors are expected not only to demonstrate a model of compassionate and ethical care, but also to interact with colleagues, patients, trainees, and other support staff in a professional manner.
An understanding of the responsibilities and expectations placed on supervisors and trainees is essential for ensuring patient safety in this complex environment. Thus, while this policy focuses on professional responsibilities in the postgraduate environment, supervisors and trainees are expected to be familiar with other applicable CPSO policies as well; these include, but are not limited to Delegation of Controlled Acts, Mandatory Reporting, Consent to Medical Treatment, Disclosure of Harm, Medical Records, and Physician Behaviour in the Professional Environment.
The purpose of this policy is to clarify the roles and responsibilities of the most responsible physicians (MRPs), supervisors and postgraduate trainees engaged in postgraduate medical education programs. This policy focuses on professional responsibilities related to the following aspects of postgraduate medical education:
- Supervision and Training
- Professional Relationships
- Patient Care within the Postgraduate Educational Environment
This policy applies to all physicians who are involved in the guidance, observation and assessment of postgraduate trainees enrolled in postgraduate medical programs in Ontario and to the postgraduate trainees, themselves.
Postgraduate Trainees (“trainees”)1 are 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 is the physician who has final accountability for the medical care of a patient when the trainee is providing care.
Supervisors are 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.
- Safe and effective care of the patient takes priority over the training endeavour.
- Proper training optimizes patient care as well as the educational experience.
- The autonomy and personal dignity of trainees and patients must be respected.
- Joint decision-making and exchange of information between most responsible physician, supervisor, and trainee provides an optimal educational experience.
- Professionalism, which includes demonstration of compassion, service, altruism, and trustworthiness, is essential in all interactions in the training environment in order to provide the best quality care to patients.2
1. Supervision and Training
The supervisor and/or most responsible physician must provide appropriate supervision to the trainee. This includes:
- being familiar with program objectives;
- making the patient or substitute decision-maker3 aware of the identity of the most responsible physician, and the fact that the most responsible physician 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 his or her 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 most responsible physician, and the fact that the most responsible physician is ultimately accountable for the patient’s care;
- communicate with the supervisor and/or most responsible physician:
- 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 his or her clinical findings and treatment plans and discuss these with the most responsible physician and/or the supervisor.
2. Professional Relationships
The most responsible physician, supervisor and trainee must demonstrate professional behaviour in their interactions with each other, as well as with patients, other trainees, colleagues and support staff. Displaying appropriate behaviour and providing an ethical and compassionate
model of patient care is particularly important for the most responsible physician and supervisor, as trainees often gain knowledge and develop attitudes about professionalism through role modeling.
The most responsible physician and supervisor must be mindful of the power differential in their relationship with the trainee. Also, they should not allow any personal relationships to interfere with their supervision and evaluation of the trainee. Any personal relationship, which pre-dates or develops during the training phase between the most responsible physician or supervisor and the trainee, e.g., family, dating, business, friendship, etc., must be disclosed to the appropriate responsible member of faculty (such as department or division head or postgraduate program director). The appropriate faculty member would need to decide whether alternate arrangements for supervision and
evaluation of the trainee are merited and, if necessary, make these arrangements.
Any form of behaviour that interferes with, or is likely to interfere with, quality health-care delivery or quality medical education is considered “disruptive behaviour.” This includes the use of inappropriate words, actions or inactions that interfere with the ability to function well with others.4 Physicians, in any setting, are expected to display professional behaviour at all times.
3. Patient Care within the Postgraduate Educational Environment
In the postgraduate environment, it is important for patients to understand that care involves a collaborative, team-based approach and that trainees are integral members of the health-care team.5 The delivery of care relies on MRPs, supervisors, and trainees fulfilling each of their obligations as outlined in section one “Supervision and Training”.
Trainee involvement in patient care will vary according to the trainee’s stage in a postgraduate training program as well as their individual level of competency. Trainees are expected to take on a graduated level of clinical responsibility in step with their demonstrated growing competency,
although never completely independent of appropriate supervision.
In accordance with the Health Care Consent Act6 and the CPSO’s policy on Consent to Medical Treatment,7 patient consent is required in all situations where a treatment or a change in treatment is proposed. In addition, there are some factors unique to the postgraduate environment
which should be disclosed to the patient in order for them to make an informed decision as to whether to give or refuse consent:
a) Significant component of procedure performed independently by trainee
When a significant component, or all, of a medical procedure is to be performed by a trainee without direct supervision, the patient must be made aware of this fact and where possible, express consent must be obtained. Express consent is directly given, either orally or in writing.
b) Examinations performed solely for educational purposes
An examination is defined as solely “educational” when it is unrelated to or unnecessary for patient care or treatment. An explanation of the educational purpose behind the proposed examination or clinical demonstration must be provided to the patient and their express consent must be obtained. This must occur whether or not the patient will be conscious during the examination. If express consent cannot be obtained, e.g., the patient is unconscious then the examination cannot be performed. The most responsible physician and/or supervisor should 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.
2. For more information about professionalism and the key values of practice, please refer to The Practice Guide: Medical Professionalism and College Policies.
3. For details about substitute decision-maker and consent, please refer to the CPSO policy Consent to Medical Treatment.
4. For more information, please refer to the CPSO policy Physician Behaviour in the Professional Environment.
5. Typically, hospitals and other clinical settings would have signage notifying patients that they are teaching institutions. However, physicians in private offices and clinics need to explicitly communicate this information.