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The Draft CanMEDS 2015 Milestones Guide*

Series I Series IIMay 2014

Editors

Jason R. Frank | Linda S. Snell | Jonathan Sherbino

*Extracted from the Draft CanMEDS 2015 Physician Competency Framework – Series II

Draft CanMEDS 2015 Milestones Guide – May 2014

Royal College of Physicians and Surgeons of Canada774 Echo DriveOttawa ON K1S 5N8Canada

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Copyright © 2014 by the Royal College of Physicians and Surgeons of Canada.

All rights reserved. This material may be reproduced in full for educational, personal, non-commercial purposes only, with attribution to the source as noted below. Written permission from the Royal College is required for all other uses, including commercial use of the CanMEDS illustrations or its framework.

Printed in Ottawa.

How to reference this document:Frank JR, Snell LS, Sherbino J, et al. Draft CanMEDS 2015 Milestones Guide – May 2014. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2014 May.


The Draft CanMEDS 2015 Physician Competency Framework Series II

What’s new in CanMEDS 2015: milestones

Unlike past updates, CanMEDS 2015 is part of the Competence by Design (CBD) project. This major initiative of the Royal College is intended to improve the fundamental building blocks of Canadian medical training. At its core, CBD is a move away from credentialing physicians solely on the basis of time spent on rotations and activities, in favour of assessing achievement on the basis of attained milestones of competence. The addition of these milestones is arguably the biggest change from the 2005 to the 2015 version of the CanMEDS Framework.

The 2005 Framework describes the competencies expected of trainees at the end of their training (i.e., at the point when they are “ready” to enter practice). All trainees and their program directors know from the start what competencies are expected of them by the end of their training, but no standard expectations are articulated for other phases of their career. With the introduction of milestones—descriptions of the abilities expected of a trainee or physician at a defined stage of professional development—all of that will change. Trainees, educators, and practitioners will have specific guidelines to help them determine at every phase whether they are “on track.” Thus, milestones will be used to

• mark the progression of competence from the start of medical training through advanced practice

• provide clearly defined targets to guide authentic learning and assessment

• enable learners to focus their learning activities more effectively

• enable assessors (and programs) to know when a learner has achieved a given milestone or set of milestones and is truly ready to move to the next stage of training or development

About the Series II milestones

CanMEDS 2015 Series II signals the release of the first draft of national competency milestones in Canadian medical education. It is the result of hundreds of hours of work defining the development of medical expertise across the continuum of training and into

practice. We refer to the collection of milestones as the “CanMEDS 2015 Milestones Guide,” and you can find the milestones woven throughout this document in each domain of CanMEDS. For each enabling competency, teams of experts have carefully crafted statements that indicate reasonable expectations for the level of expertise at each stage of development.Some important points:

• The Series II milestones are a draft. Although they were many months in the making by hundreds of physicians and others, the milestones are a first-draft attempt to engage the medical education community in a dialogue about the stages through which the attainment of medical expertise progresses. We welcome your thoughts and suggestions, and we fully expect further changes and edits to occur in subsequent CanMEDS 2015 releases.

• The milestones are generic. The milestones in this document have been written to apply to any medical discipline (Obstetrics, Internal Medicine, General Surgery, etc). We expect the milestones will be tailored to each and every discipline to be truly useful for teaching, learning, assessment, and policy.

• The milestones represent a continuum of learning. The expert working group authors were given the task of crafting milestones for Canadian medicine from the first day of medical school to the last day of practice. Why? We felt that the success of the initiative required coherency across all the stages of physician expertise. Competence by Design is an example of a competency-based medical education project: It takes a developmental perspective on training. To write useful milestones for residency education, we felt that statements of ability were needed for undergraduate training. Similarly, to write advanced milestones for learning in practice, the exit competencies of residency needed to be clear. We aspire to make explicit for the first time the critical path to becoming a master clinician in our health care system. Let us know how close we have come. We invite all those interested in medical education to comment on any of the statements proposed here.




• The final number of milestones will be determined over the next 12 months. The “raw” milestones that arrived from the expert working groups were 1010 in total—a large number that spanned the entire career of physicians from day one of medical school to the end of practice. After editing, Series II is being released with 847 milestones. We anticipate that more changes willbe made in the coming months as the medical education community weighs in.

• The milestones are a guide. We hope that these milestones will evolve to become a “palette” of competency statements for groups of educators such as deans and specialty committees to choose among as they design curricula and learning and assessment tools. We don’t anticipate that each and every one of these milestones will be used for every physician over the course of his or her career. Moreover, the milestones may be used in combination with EPAs (entrustable professional activities) for a robust design.

Milestones have the potential to be a powerful tool to organize training. We welcome your comments on this first draft of a national template.

Milestones and the competency-based approach

Traditional stages of medical education. Within the traditional model of physician education, the path to becoming a specialist is broken down into the stages

below. These stages encompass undergraduate studies, specialty-specific training, and learning throughout practice:

• Junior medical student

• Senior medical student

• Junior resident

• Senior resident

• Practising physician

The CBD approach. By introducing a next-generation competency-based medical education (CBME) model into resident training and specialty practice, the CBD initiative will break down specialist education into a series of integrated stages—starting in medical school and moving through practice. (See diagram on p. 11.)

Each stage incorporates milestones from the new CanMEDS 2015 Framework, which defines the specific abilities expected at certain points within a physician’s career. By focusing on learning rather than time, the CBD approach will help align medical education with the realities of today’s practice, thus ensuring that physicians have the competencies they need at every stage of their career.

Medical education phases and stages

Physicians develop competencies at different stages: in medical school, during discipline-specific residency, and throughout practice.

Medical school. This phase of undergraduate medical education reflects the steps needed to acquire fundamentals and obtain a medical degree.

Medical school fundamentals. This stage of undergraduate education corresponds with the junior medical or pre-clinical phase of most medical schools. Students exiting this phase should have an understanding of the fundamental sciences and skills of medicine.

Early clinical activity. In this stage of undergraduate education there is an increased focus on clinical competencies and preparation for achieving the MD or equivalent degree. This stage corresponds roughly with the senior medical student or clerkship phase in North American training.

Competency-based medical education: some definitions

Competency-based medical education (CBME): An approach to designing medical training that is focused on outcomes in the form of the abilities of graduates.

Competency: An observable ability of a health professional that develops through stages of expertise from novice to master clinician.

Entrustable professional activity (EPA): A key task of a discipline that can be entrusted to an individual who possesses the appropriate level of competencies.

Milestone: The expected ability of a health professional at a stage of expertise.

See: Frank JR et al. Competency-based medical education: theory to practice. Med Teacher 2010; 32(8):638–45.




Discipline-specific residency. This phase is the period in which a physician trainee builds upon the foundational abilities acquired in medical school to learn the competencies needed for practice (four advancing stages: transition to discipline, foundations of discipline, core of discipline, and transition to practice).

Transition to discipline. In many cases this will be a new addition to the residency phase of medical education. This stage emphasizes the orientation and assessment of new trainees arriving from different medical schools and programs (including outside Canada). Although this stage does exist in some form in many residency programs (for example, residency “boot camps”), the CBD approach will formalize the assessment and orientation process, ensuring a level playing field for residents as they begin their specialist training. This stage may require a day, a month, or two months, depending on program needs.

Foundations of discipline. The second stage in the residency phase of medical education covers broad-based competencies that every trainee must acquire before moving on to more advanced, discipline-specific competencies. This may involve rotating through a number of clinical settings so the trainee can acquire a breadth of foundational abilities to prepare for core training.

Core of discipline.* The third stage in the residency phase of medical education covers the core competencies that make up the majority of a discipline.

Transition to practice. In the final stage in the residency phase of medical education, the senior trainee should demonstrate readiness to make the transition to autonomous practice: for example, acting as a chief resident, running an ambulatory clinic, teaching and performing increasingly independent procedures, and teaching others. Within CBD, examination would take place at the end of the

* Royal College examination: The CBD approach proposes that the Royal College examination be taken at the end of the “core of discipline” stage, rather than the end of the training stage (where it currently sits). Moving the exam will ensure trainees are able to focus on further clinical training in their final year, allowing them to use their final supervised training time to hone competencies. Emphasis will be placed on increasingly independent work and skills—creating physicians who are truly ready for independent practice.

“core of discipline” stage, allowing residents to hone their competencies in their last months of training. Royal College certification will be granted upon the successful completion of the “transition to practice” stage.

Continuing professional development (CPD). A physician maintains and enhances competence throughout practice in the following ways:

Maintenance of competence. A physician engages in CPD to remain up to date and sustain expertise within his or her scope of practice.

Enhanced expertise. The physician acquires new or expanded skills and abilities so that his or her practice can evolve over time in response to practice needs and interests.

Transition out of professional practice. In this last stage, physicians adapt to the final practice period and their changing health care role.




The Competence Continuum

Medical school

Early clinical activity

(orientation and assessment)

Foundations of discipline

Core of discipline

Transition to practice

(maintenance of competence and enhanced expertise)

Transition to discipline

fundamentals

Continuing professional development

Transition out of professional practice

Medical school

Discipline-specificresidency

Learning inpractice

Junior medical student

Senior medical student

Junior resident

Senior resident

Practisingphysician

Traditional stages Proposed CBD stages 1, 2 Medical education phases

1 Competence by Design (CBD)2 Milestones at each stage describe terminal competencies


© 2014 Royal College of Physicians and Surgeons of Canada 1


MEDICAL EXPERT MILESTONES: MEDICAL SCHOOL

Medical school fundamentals Early clinical activity

1. Practise medicine within their defined clinical scope of practice and expertise

1.1 Demonstrate a commitment to high-quality care of their patients

1.2 Integrate the CanMEDS Intrinsic Roles into their practice of medicine

Describe the CanMEDS Roles and how they relate to the practice of medicine

1.3 Apply knowledge of the clinical and biomedical sciences relevant to their specialty

Apply knowledge of the biomedical sciences to address common medical scenarios

Integrate knowledge of biomedical sciences and clinically relevant skills to identify, diagnose, and address common clinical problems

1.4 Perform an appropriately timed consultation, presenting well-documented assessments and recommendations in written or oral form

Perform an assessment of a patient and provide an interpretation of the clinical situation to the supervising physician

Document recommendations from the treating team accurately in the consultation record

1.5 Carry out professional duties in the face of multiple, competing demands

Recognize competing demands in professional duties and seek assistance in determining priorities

1.6 Recognize and respond to the complexity, uncertainty, and ambiguity inherent in medical practice

Recognize that there is a degree of uncertainty in all clinical decision-making

2. Perform a patient-centred clinical assessment and establish management plans

2.1 Identify and prioritize issues to be addressed in a patient encounter

Identify the concerns and goals of the patient or his or her family for the encounter

2.2 Elicit a history, perform a physical exam, select investigations, and interpret their results for the purpose of diagnosis and management, disease prevention, and health promotion

Elicit a history and perform a complete generic physical exam

Elicit a history and perform a physical exam that informs diagnosis

2.3 Establish goals of care with patients and their families, which may include slowing disease progression, achieving cure, improving function, treating symptoms, and palliation

Initiate discussions with simulated patients and caregivers about goals of care

Continued on next page.

Note: In the progression through medical school, residency training, and professional practice, competencies acquired at a given stage are sustained and developed further through subsequent stages. Where a specific milestone for the acquisition of an enabling competency is not specified for a given stage, it should be assumed that earlier milestones for that competency still apply.





2.4 Establish a patient-centred management plan

Develop an initial management plan for patients they have encountered

3. Plan and perform procedures for the purpose of assessment and/or management

3.1 Determine the most important procedure(s) for the purpose of assessment and/or management

Describe common procedures for the purpose of assessment and/or management of a given problem

Describe the potential harm from a given procedure

3.2 Obtain and document informed consent, explaining the risks and benefits of, and the rationale for, the proposed options

Describe the broad ethical and legal principles underlying informed consent

Describe the principles of obtaining and documenting informed consent

3.3 Prioritize procedures, taking into account clinical urgency, potential for deterioration, and available resources

3.4 Perform procedures in a skilful and safe manner, adapting to unanticipated findings or changing clinical circumstances

Perform simple procedures in a supervised, simulated environment

3.5 Establish and implement a plan for post-procedure care

4. Establish plans for timely follow-up and appropriate consultation

4.1 Establish the roles of the patient and all team members for follow-up on investigations, response to treatment, and consultation, and ensure that the agreed follow-up occurs

Discuss the importance of consultation and follow-up in patient care

5. Actively participate, as an individual and as a member of a team providing care, in the continuous improvement of health care quality and patient safety

5.1 Recognize and respond to adverse events and near misses

Describe the scope and burden of health-care–related harm

5.2 Seek opportunities to provide high-quality care

Describe the principles of continuous quality improvement

5.3 Contribute to a culture that promotes the continuous improvement of health care quality and patient safety

Describe the features of a fair and non-punitive approach to patient safety

Describe the domains of health care quality (safe, effective, patient-centred, timely, efficient, equitable)






5.4 Describe how human and system factors influence decision-making and the provision of patient care

Describe the individual factors (e.g., sleep deprivation, stress) that can affect human performance

Describe system factors (e.g., resources, physical environment) that can affect patient safety

5.5 Engage patients and their families in the continuous improvement of health care quality and patient safety



MEDICAL EXPERT MILESTONES: RESIDENCY

Transition to discipline Foundations of discipline Core of discipline Transition to practice



While engaging as a learner in the clinical environment, demonstrate a duty of care toward patients

Serve in the role of being the most responsible physician


Discuss the CanMEDS Framework and how the Intrinsic Roles need to be integrated in practice to deliver optimal patient care

Demonstrate integration of the CanMEDS Intrinsic Roles into their practice of medicine


Incorporate clinical and biomedical sciences to manage core patient presentations in their discipline

Incorporate a broad base and depth of knowledge in clinical and biomedical sciences to manage the breadth of patient presentations in their discipline


Perform consultations, presenting well-documented assessments and proposing recommendations

Recognize urgent problems that may need the involvement of more senior colleagues and engage them immediately

In response to the urgency of a situation, perform an appropriately timed consultation, presenting well-documented assessments and recommendations

Conduct well-documented assessments and communicate clear and useful recommendations

Prioritize consultations on the basis of clinical presentations


On the basis of patient-centred priorities, seek assistance to prioritize multiple competing tasks that need to be addressed

Maintain a duty of care and patient safety while balancing multiple responsibilities


Identify clinical situations in which complexity, uncertainty, and ambiguity may play a role in decision-making

Develop a plan that considers the current complexity, uncertainty, and ambiguity in a clinical situation

Adapt care as the complexity, uncertainty, and ambiguity of the patient’s clinical situation evolves

Continued on next page. Note: In the progression through medical school, residency training, and professional practice, competencies acquired at a given stage are sustained and developed

further through subsequent stages. Where a specific milestone for the acquisition of an enabling competency is not specified for a given stage, it should be assumed that earlier milestones for that competency still apply.







Reach agreement with patients and their families on priorities for each encounter at the outset

Consider clinical urgency, feasibility, availability of resources, and comorbidities in determining priorities for the patient encounter

Identify and prioritize which issues need to be addressed during future visits or with other health care practitioners

Iteratively establish priorities, considering the patient’s and /or caregiver’s perspective (including values and preferences) as the patient’s situation evolves


Consider how comorbidities may affect the patient’s presentation and how management plans may need to be modified

Adapt a clinical assessment in situations where evidence is uncertain

Focus the clinical encounter, performing it in a time-effective manner, without excluding key elements


Help patients and their families understand the options relevant to their specific context

Address the patient’s and/or caregiver’s ideas about the nature and cause of the health problem, their fears and concerns, and their expectations of health care providers

Address the impact of the medical condition on the patient’s ability to pursue life goals and purposes

Share concerns, in a constructive and respectful manner, with patients and caregivers about their goals of care when they are not felt to be achievable







Develop and implement initial management plans for common problems in their discipline

Ensure that patients and their families are informed about the risks and consequences of each choice of treatment in the context of best evidence and guidelines

Develop and implement management plans that consider all of the patient’s health problems and context in collaboration with patients and their families and, when appropriate, the interdisciplinary team



Independently select procedures for assessment of common clinical scenarios encountered in their specialty

Integrate planned procedures into global assessment and management plans

Integrate all sources of information to develop a procedural plan that is safe and patient-centred and considers the risks and benefits of all approaches


Demonstrate obtaining informed consent for a given procedure with a simulated patient

Obtain informed consent for commonly performed procedures and therapies

Document procedures accurately

Explain the risks, benefits, and rationale for procedures

Use shared decision-making in the consent process, taking risk and uncertainty into consideration


Recognize and discuss the importance of the triaging and timing of clinical procedures

Consider urgency, and potential for deterioration, in advocating for the timely execution of procedures for their patients

Recognize that resource limitations may necessitate triaging of patients

Triage procedures, taking into account clinical urgency, potential for deterioration, and available resources

Advocate for patients on the basis of urgency and available resources







Perform common simple procedures in a skilful and safe manner

Demonstrate effective procedure preparation, including the use of a pre-procedure time-out

Perform common procedures in a skilful, fluid, and safe manner with minimal assistance

Appropriately seek more supervision when unanticipated findings or changing clinical circumstances are encountered

Effectively position patients for common procedures

Competently and efficiently execute specialty-specific procedures

Appropriately set up and position patients for all procedures

Recognize uncertainty and the need for assistance in situations that are complex or new to the physician


Implement a post-procedure care plan that others have developed

Demonstrate a structured approach to post-procedure care

Establish and implement a plan for post-procedure care for commonly performed procedures within their discipline

Design and implement a comprehensive plan for all procedures in the scope of practice



Establish a follow-up plan for routine clinical situations

Ensure appropriate communication and follow-up through the primary care physician and/or health care team

Discuss with the patient the degree of uncertainty inherent in routine clinical situations

Determine the necessity and appropriate timing of consultation

Ensure follow-up on results of investigation and response to treatment

Establish detailed plans for follow-up for all patients, taking into consideration the patient’s clinical state and circumstances, the patient’s preferences and actions, available resources, best practices, and research evidence, and plan to deal with clinical uncertainty in partnership with the patient

Coordinate investigation, treatment, and follow-up plans when several consultants are involved








Discuss the potential for harm in care transitions from one provider to another or one setting to another

Recognize the occurrence of an adverse event or near-miss

Prioritize the initial medical response to adverse events to mitigate further injury

Include adverse events in their differential diagnosis

Disclose adverse events or near-misses to patients and families

Recognize near-misses in real time and respond to correct them, preventing them from reaching the patient

Identify potential improvement opportunities arising from adverse events and near-misses


Incorporate data and feedback from performance measurement to improve clinical practice


Describe the features of a high-reliability organization

Respond to feedback on their own practice and patient outcomes

Actively encourage all involved in health care, regardless of their role, to report and respond to unsafe situations

Engage in transparent and productive exchanges with colleagues on quality and safety issues


Describe common types of cognitive biases

Describe the principles of situational awareness and their implications for medical practice

Use cognitive aids (e.g., surgical checklists, structured communication) in enhancing patient safety

Apply the principles of situational awareness to clinical practice

Use strategies to mitigate the negative effects of human and system factors on clinical practice


Encourage patient and family involvement in patient safety and quality improvement

Use patient and family input to develop quality improvement goal

Modify their practice to address safety and quality concerns identified by patients and their families




MEDICAL EXPERT MILESTONES: LEARNING IN PRACTICE




Teach and role-model a commitment to high-quality patient care


Teach and assess the application of the CanMEDS competency framework to medical practice


Teach aspects of their discipline to other clinicians

Provide expert opinion to advise government or other organizations or to provide expert legal testimony


Develop system-level processes to facilitate appropriately timed consultations

Teach colleagues how to perform, document, and communicate consultations

Use technology to facilitate consultation for patients who may have limited or delayed access to specialist care


Teach and role-model how to prioritize professional duties


Conduct research relevant to clinical decision-making

Teach on complexity and clinical decision-making



Identify and prioritize issues to be addressed in patient encounters when there are communication barriers


Conduct a clinical assessment in challenging or unusual situations

Conduct a clinical assessment when a second opinion is requested or when a high degree of diagnostic uncertainty has already been established


Establish goals of care in patient encounters when there are communication barriers or difficult patient or family dynamics, etc.


Establish managment plans in patient encounters when there are communication barriers or disagreements about what is achievable





MEDICAL EXPERT MILESTONES: LEARNING IN PRACTICE




Teach clinical reasoning regarding procedures to colleagues and learners

Conduct research on the risks and benefits of particular procedures

Develop novel procedures while respecting ethical standards for experimentation


Teach colleagues the principles and application of informed consent


Make triage and timing decisions in complex situations, demonstrating a collaborative approach when competing for limited resources


Complete procedures in an automated, efficient, timely, and technically proficient manner while demonstrating advanced intra-procedure decision-making in complex situations that have not been encountered before

Perform specialized procedures that extend beyond routine practice in the discipline, in a manner that peers identify as highly skilled

Teach the procedures of the discipline to others


Adapt the post-procedure plan to unique clinical, health system and/or patient characteristics that may require unconventional approaches



Develop a novel system of follow-up that is flexible and adaptable to the patient, families, and community resources



Teach about the impact of adverse events and near misses and how to improve patient care


Teach about quality improvement in the clinical environment


Teach others about promoting a health care culture that enhances safety and quality

Evaluate the culture of a given institution or group with respect to health care safety and quality


Teach others about the impact of human and system factors on patient care


Design quality improvement and safety initiatives on the basis of needs and concerns identified by patients and their families

Measure health care safety and quality using metrics identified as important by patients and their families



COMMUNICATOR MILESTONES: MEDICAL SCHOOL


1. Establish professional therapeutic relationships with patients and their families

1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy and respect

Describe the key components of the patient- centred approach to medical care

Outline the evidence that effective physician–patient communication enhances patient and physician outcomes

Demonstrate the key components of a patient-centred approach in routine clinical encounters

1.2 Optimize the physical environment for patient comfort, dignity, privacy, engagement, and safety

Describe elements of the physical environment that affect patient comfort, privacy, engagement, and safety (e.g., curtains, background noise, time standing or sitting, lighting, heating)

1.3 Recognize when the values, biases, or perspectives of patients, physicians, or other health care providers may have an impact on the quality of care, and modify the approach to the patient appropriately

Describe how patient and physician values, biases, and perspectives affect clinical encounters and suggest appropriate modifications to patient care

1.4 Respond appropriately to patients’ non-verbal communication and use appropriate non-verbal behaviours to enhance communication with patients

Identify nonverbal communication (facial expression, eye contact, gestures, intonation, body position, etc.) on the part of patients and their families and its impact on physician–patient communication

Describe how to apply non-verbal communication to build rapport

Recognize when non-verbal communication facilitates or interferes with rapport (e.g., in working with standardized patients)

1.5 Manage emotionally charged conversations and conflicts

Describe physician, patient, and contextual factors that lead to strong emotions

Describe how strong emotions may affect the patient–physician interaction

Critically reflect upon emotional encounters and identify how different approaches may have affected the interaction

1.6 Adapt to the unique needs and preferences of each patient and to his or her clinical condition and circumstances

Describe models of decision-making along the spectrum from paternalistic, to shared, to autonomous

Discuss the advantages and risks of actively involving patients in decisions about their care

Discuss the importance of capacity assessment

Assess patients’ preferred involvement in decisions about their care

2. Elicit and synthesize accurate and relevant information, incorporating the perspectives of patients and their families

2.1 Use patient-centred interviewing skills to effectively identify and gather relevant biomedical and psychosocial information

Describe the basic elements of the patient-centred interview

Conduct a patient-centred interview, gathering relevant biomedical and psychosocial information in the context of an uncomplicated presentation of a common medical problem







2.2 Inquire about and explore the patient’s beliefs, values, preferences, context, expectations, and health care goals

Incorporate questions about patient preferences, health care goals, etc. into the patient-centred interview

2.3 Provide a clear structure for and manage the flow of the entire encounter

Use a checklist to guide the patient interview Conduct a patient interview without using a checklist

2.4 Seek and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent

Identify relevant information about a patient from other sources

3. Share health care goals and plans with patients and their families

3.1 Provide explanations that are clear and adapted to the patient’s level of understanding and need

Describe the biopsychosocial model of illness and disease

Describe the social and cultural determinants of health

Describe ethical principles of truth-telling in the physician–patient relationship

3.2 Disclose adverse events to patients and their families accurately and appropriately

Define the terms “close call,” “no-harm event,” “potential harm event,” and “adverse event“

Describe the ethical, professional, and legal obligations, and policies for, disclosure of reporting adverse events

Differentiate complications or expected outcomes of diseases from adverse events

Participate with a health care team in planning disclosure according to the recognized steps

Describe the steps in providing disclosure after an adverse event

4. Engage patients and their families in developing plans that reflect the patient’s health care needs and goals

4.1 Facilitate discussions with patients and their families in a way that is respectful, non-judgmental, and culturally safe

Describe principles of cross-cultural interviewing

List relevant questions to ask patients, families, and partners in care to elicit an understanding of health care goals and needs

Demonstrate interviewing techniques for encouraging discussion, questions, and interaction

Conduct culturally safe interviews with close supervision

Describe steps for conducting an interview with a translator

4.2 Assist patients and their families to identify, access, and make use of information and communication technologies to support their care and manage their health

Identify communication technologies to support and manage patient care

Describe the various technologies available to enhance patients’ understanding and management of their health care

4.3 Use appropriate communication skills and strategies to help patients and their families make informed decisions regarding their health

Describe elements of informed consent Describe principles of behaviour change






5. Document and share written and electronic information about the medical encounter to optimize clinical decision-making, patient safety, confidentiality, and privacy

5.1 Document clinical encounters in an accurate, complete, timely, and accessible manner, in compliance with legal and regulatory requirements

Describe the functions and principal components of a medical record

Describe the regulatory and legal requirements, including privacy legislation, for record keeping

Identify potential difficulties and errors in medical record keeping that have a negative impact on patient care or patient safety

Document the essential elements of a clinical encounter using a structured approach

Maintain accurate and up-to-date problem lists and medication lists

Include as appropriate in the medical record the patient’s narrative* of his or her illness experience

5.2 Communicate effectively using a written health record, electronic medical record, or other digital technology

Describe how to effectively use an electronic medical record (EMR) while interviewing patients

Demonstrate effective communication skills with a simulated patient while documenting the encounter in a written or electronic record

Demonstrate reflective listening, open-ended inquiry, empathy, and effective eye contact while using a written record or EMR

Use EMRs proficiently

5.3 Share information with patients and appropriate others in a manner that respects patient privacy and confidentiality

Describe the principles and legal requirements for privacy and confidentiality of written and electronic communication

Describe the different levels of written and electronic health literacy of patients and their implications for patient care

Describe the advantages, limitations and risks of using electronic communication directly with patients (including telehealth) and strategies to reduce these risks

Assess patients’ needs and preferences with respect to methods of information sharing

* The patient’s narrative is the story of the patient’s illness. It includes his or her feelings about the illness and ideas about what may be wrong or what might be causing it, how the illness affects the patient’s day-to-day functioning, and the patient’s expectations of his or her health care providers.



COMMUNICATOR MILESTONES: RESIDENCY




Demonstrate the key components of a patient-centred approach in complex clinical encounters

Communicate using a patient-centred approach that facilitates patient trust and autonomy and is characterized by empathy and respect

Assess a patient’s health literacy

Demonstrate flexibility in applying the key components of a patient-centred approach in the context of complex clinical encounters


Mitigate physical barriers to communication to optimize patient comfort, privacy, engagement, and safety

Optimize the physical environment for patient comfort, privacy, engagement, and safety


Recognize when patient and physician values, biases, or perspectives threaten the quality of care, and appropriately modify the approach to patient care according to the context of the discipline

Teach learners to recognize situations in which patient and physician values, biases, or preferences may threaten the quality of care, and how to appropriately modify the approach to patient care


Identify, verify and validate non-verbal cues on the part of patients and their families

Use appropriate non-verbal communication to demonstrate attentiveness, interest, and responsiveness to patients and their families

Make use of non-verbal communication to enhance verbal communication


Recognize when strong emotions (e.g., anger, fear, anxiety, and sadness) are interfering with an interaction and respond appropriately

Establish boundaries as needed in emotional situations

Use their own feelings in interactions with patients as valuable clues to the patient’s emotional state

Continued on next page. Note: In the progression through medical school, residency training, and professional practice, competencies acquired at a given stage are sustained and developed

further through subsequent stages. Where a specific milestone for the acquisition of an enabling competency is not specified for a given stage, it should be assumed that earlier milestones for that competency still apply.






Assess patients’ decision-making capacity

Tailor approaches to decision-making to patient capacity, values, and preferences



Conduct a patient-centred interview, gathering all relevant biomedical and psychosocial information for any clinical presentation

Actively listen and respond to patient cues to facilitate efficiency

Integrate, summarize, and present the biopsychosocial information obtained from a patient-centred interview


Integrate and synthesize information about the patient’s beliefs, values, etc. with biomedical and psychosocial information


Conduct a focused and efficient patient interview, managing the flow of the encounter while being attentive to patient cues and responses

2.4 Seek and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent

Seek and synthesize relevant information from other sources after obtaining patient consent



With supervision, communicate the plan of care clearly and accurately to patients and their families

Recognize when to seek help in providing clear explanations to patients and their families

Use strategies to verify and validate patient understanding of the diagnosis, prognosis, and management plan

Communicate clearly with patients and others in the setting of ethical dilemmas

Skillfully share information and explanations that are clear, accurate, timely, and adapted to the patient’s level of understanding






(3.1 continued) Adapt medical expertise and experience to context in developing a shared plan of care with patients

Share information related to the patient’s health status, care, and needs in a timely, honest, and transparent fashion


Anticipate and respond to the patient’s emotional reaction with compassion and ensure support

Participate in disclosing the reasons for unanticipated outcomes and patient safety incidents

Plan and document follow-up to an adverse event

Express regret for the adverse event and apologize appropriately

Adapt disclosure to the specific patient and situation



Conduct an interview, demonstrating cultural awareness

Explore the perspectives of patients and others when developing care plans

Communicate with cultural awareness and sensitivity

Engage patients and others in shared decision-making

Engage patients in a way that is respectful and non-judgmental and provides cultural safety


Help patients and their families identify and make use of information and communication technologies to support care and manage health







Demonstrate steps to obtaining informed consent

Answer questions from patients and their families about next steps

Demonstrate the ability to apply principles of change in conversations with patients

Use appropriate communication skills to help patients and their families make informed decisions regarding health



Describe the record keeping guidelines for their discipline

Demonstrate proficiency in using the vocabulary and appropriate abbreviations specific to their discipline and workplace

Organize information in appropriate sections within an electronic or written medical record

Document information about patients and their medical conditions in a manner that enhances intra- and interprofessional care

Adapt record keeping to the specific guidelines of their discipline and the clinical context

Participate in an analysis of patient safety incidents involving poor written, verbal, or electronic communication

Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Seek feedback and self-assess the quality of their own medical records and implement changes to improve medical record quality

Identify and correct vague or ambiguous documentation

Document clinical encounters in an accurate, complete, timely and accessible manner, and in compliance with legal and privacy requirements


Use reminders and clinical practice guidelines built into the electronic medical record (EMR) to enhance care

Share information in the EMR with patients to enhance collaboration and joint decision-making

Adapt use of the EMR to the patient’s health literacy and the clinical context

Use electronic tools appropriately to communicate with patients, protecting their confidentiality


Describe systemic and institutional policies on electronic communication with patients

Adapt written and electronic communication to the specificity of the discipline and to the expectations of patients

As appropriate, use teaching aids, provide handouts, and suggest online resources to patients, tailored to their questions or need for information and their health literacy



COMMUNICATOR MILESTONES: LEARNING IN PRACTICE




Teach students a patient-centred approach to communication


Participate in institutional/system initiatives to improve the physical environment for patients



Demonstrate advanced non-verbal communication skills in difficult situations

Teach how to use non-verbal communication to enhance physician–patient rapport


Teach others to anticipate, recognize, and manage emotions in routine clinical encounters


Teach senior residents to tailor approaches to decision-making to patient capacity, values, and preferences

Teach students and junior residents how to assess patients’ decision-making preferences



Role-model for learners various approaches to the patient-centred interview


Intervene when a learner ignores the patient’s beliefs, values, etc. during the patient interview


Role-model to learners how to provide structure and manage the flow of challenging patient encounters, e.g., with angry, distressed, or garrulous patients





COMMUNICATOR MILESTONES: LEARNING IN PRACTICE


2.4 Seek out and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent

Help learners identify when information needs to be sought from sources other than the patient and to understand that patient consent must first be obtained




Lead disclosure teams

Conduct peer review and practice assessments

Contribute to the improvement of the system of disclosure



Teach others and assess their ability to engage patients in a way that is respectful and non-judgmental and that provides cultural safety


Contribute to the development of communication technologies to enhance patient care and medical knowledge




Teach or conduct peer review and practice assessment regarding record keeping practices

Use medical record review to assess student and resident clinical reasoning and their understanding of their patients as persons

Develop improvements in the use of electronic medical records (EMRs)


Model effective communication while using an EMR

Teach others how to effectively communicate with patients while using an EMR

Contribute to the improvement of electronic tools of communication with patients


Teach medical students how to effectively and safely use written and electronic communication with patients

Teach patients how to use electronic communication effectively and safely to protect their confidentiality



COLLABORATOR MILESTONES: MEDICAL SCHOOL


1. Work effectively with other physicians and other health care professionals

1.1 Establish and maintain healthy inter- and intraprofessional working relationships for collaborative care

Describe the stages of group development

Describe relationship-centred care

Identify the stages of group development in health care settings

Introduce themselves and their role to intra- and interprofessional colleagues

Identify a variety of opportunities for collaboration among health care providers along the continuum of care

Give examples of the benefits of relationship-centred collaborative care

1.2 Negotiate overlapping and shared responsibilities with inter- and intraprofessional health care providers for episodic or ongoing patient care

Describe to others the roles and responsibilities of generalist and consultant physicians

Using case examples, describe the importance of professional role diversity in high-quality and safe patient care

Clarify clinical role responsibilities (e.g., on call, consults)

1.3 Engage in effective and respectful shared decision-making with inter- and intraprofessional care providers

Recognize and respect the patient as central to the health care process

Identify examples in clinical practice of the patient being central to the health care process within a collaborative care context

Transition smoothly into new team

2. Work with inter- and intraprofessional colleagues to prevent misunderstandings, manage differences, and resolve conflicts

2.1 Demonstrate a respectful attitude toward collaborators, including inter- and intraprofessional colleagues

Demonstrate a respectful attitude toward faculty and peers

Demonstrate respect for the diversity of perspectives and expertise among other health care providers

2.2 Work with others to prevent misunderstandings, manage differences, and resolve conflicts

Lists factors that contribute to misunderstandings, differences, and conflicts in the health care setting

Demonstrate understanding of the difference between intention and impact

List different approaches to preventing misunderstanding and managing differences

Discuss connections between collaboration, conflict, and patient safety

3. Effectively and safely hand over care to an appropriate health care professional

3.1 Recognize when care should be transferred to another physician or health care provider

Identify how scope of expertise can trigger transfer of care

Communicate with the primary health care provider (e.g., family physician) when the treating team assumes care for hospitalized patients





COLLABORATOR MILESTONES: MEDICAL SCHOOL


3.2 Demonstrate effective and safe handover, both verbal and written, during a patient transition to a different setting or stage of care

Describe common transitions in health care and the influence of effective collaboration among health care providers on safe handover

Use structured communication tools to facilitate safe and effective handover during patient transition to a different setting or stage of care

3.3 Demonstrate effective and safe handover, both verbal and written, during a transition of responsibility for care

Describe elements of safe and effective handover during a transition of physician responsibility for care

Identify examples in clinical practice of safe and effective handover between physicians



COLLABORATOR MILESTONES: RESIDENCY




Identify regular inter- and intraprofessional collaborators in their discipline

DIfferentiate between task and relationship issues after observing interactions between health care providers

List ground rules for collaboration

Compare and contrast enablers of and barriers to collaboration between colocated teams and in other health care situations

Demonstrate respect for established rules of team function (team norms)

Demonstrate receptivity to input from other health care providers

Analyze interactions among health care providers

Consistently scan for patient safety concerns relating to team function, anticipate issues that could degrade situational awareness, and respond to mitigate potential harm to patients

Establish and maintain healthy working relationships to support relationship-centred collaborative care

Institute strategies (tools and approaches) in daily practice to enhance relationship-centred collaborative care


Discuss the role and responsibilities of a specialist in their discipline

Describe the roles and scopes of practice of other health care providers related to the discipline

After case discussion, identify other health care providers, including other physicians or surgeons, required for consultation

Appropriately consult with other health care providers, including other physicians or surgeons

Negotiate role overlap and shared responsibilities with inter- and intraprofessional health care providers for episodic or ongoing care of patients


Describe strategies to promote engagement of inter- and intraprofessional colleagues in shared decision-making

Identify referral and consultation as opportunities to improve quality of care and patient safety by sharing expertise

Discuss the aspects or components of referrals and consultation reports that support collaborative or shared decision-making processes

Partner with inter- and intraprofessional colleagues in addition to the patient and his or her family to integrate the patient’s perspective and context into the care plan

Consistently discuss with patients and their families any plan for involving other health care professionals, including other physicians, in their care and their expectations of such involvement

Respectfully engage in shared decision-making with inter- and intraprofessional care providers in addition to the patient and his or her family







2. Work with inter- and intraprofessional colleagues to prevent misunderstandings, manage differences, and resolve conflicts


Actively listen to and engage in interactions

Convey information considerately

Build trust through actions (e.g., arriving on time, pitching in)

Acknowledge others’ viewpoints

Use reflective listening Provide timely and necessary written or verbal information to colleagues to enable effective relationship-centred care

Delegate tasks and responsibilities in an appropriate and respectful manner

Proactively identify problems and help others

Maintain positive professional relationships outside of meetings


Communicate clearly and directly to resolve a conflict

Listen in order to understand and to find common ground

Be responsive to requests and feedback

Describe their beliefs, biases, values, and perspectives related to collaboration and patient safety

Identify communication barriers

Recognize their role in contributing to differences and act in a professional manner to resolve them

Identify potentially problematic team dynamics

Reflect on actions

Recognize communication challenges

Manage differences to achieve solutions acceptable to colleagues

Gather the information and resources needed to resolve conflict

Use strategies for managing differences

Analyze team challenges with respect to assumptions, intentions, and the impact of behaviours

Implement strategies to resolve conflict in a manner that supports a collaborative culture

Gain consensus among colleagues in resolving conflict








Discuss with their clinical supervisors the appropriateness of transferring patients to other physicians or services

Include patient safety concerns in the discussion of transfer of care

Plan the transfer of care to the most appropriate health care provider

Communicate verbally with the receiving team to facilitate transfer of care

Summarize ongoing clinical concerns in the transfer summary, including plans to deal with ongoing issues

Organize the transfer of care to the most appropriate health care provider

In complex situations, coordinate the safe transfer of care to the most appropriate health care provider.

Remain available to the new treating team after transfer of care to help clarify issues as needed


Identify specific information needs for safe and effective handover at different stages of care within their specialty

Demonstrate effective information exchange with health care providers during transitions in care

Analyze gaps in information exchange with health care providers during transitions in care

Apply structured communication strategies within clinical practice to facilitate safe and effective handover during transitions in care


Describe specific information needs for safe and effective handover between physicians

Demonstrate safe and effective handover communication with physician colleagues to ensure transfer of accountability for patient care

Describe and defend a rationale for particular structured communication strategies for safe and effective handover between physicians

Maintain safe and effective handover communication



COLLABORATOR MILESTONES: LEARNING IN PRACTICE




Analyze interactions among health care providers for the purpose of providing feedback to improve collaboration

Advocate for organizational structures that support relationship-centred collaborative care

Contribute to policy discussions related to collaborative care


Teach, assess, and model the negotiation of role overlap and shared responsibilities with other health care providers for episodic or ongoing patient care


Seek feedback from other health care providers and patients on how successfully they have been engaged in the shared decision-making process and integrate results into a quality improvement process

Analyze, for the purposes of teaching others, decision-making processes shared among inter- and intraprofessional colleagues

Build a collaborative culture

2. Work with inter- and intraprofessional colleagues to prevent misunderstandings, manage differences, and resolve conflicst


Nurture a respectful approach among colleagues

Engage colleagues and health care professionals in constructive conversations when words or behaviours undermine a respectful culture


Consult to help others manage differences and resolve conflicts

Teach conflict management in health care

Assess others’ conflict management abilities

Coach others to explore their assumptions, values, and biases

Analyze enablers of and barriers to relationship-centred collaborative care



Develop a network of colleagues to enable the timely and safe transfer of care to the most appropriate resource

Teach and assess others with regard to transfer of care


Model effective handover and teach learners structured communication techniques to facilitate safe and effective handover

Contribute to process improvements to enhance the safety and effectiveness of handover


Analyze local handover practices and work on process improvements to enhance safety and effectiveness

Model safe and effective handover communication techniques




LEADER MILESTONES: MEDICAL SCHOOL


1. Contribute to the improvement of health care delivery in health care teams, organizations, and systems

1.1 Contribute to quality improvement and patient safety using the best available knowledge and practices

Describe system theories at the practice, organization, and health system levels

Discuss how practice processes are interdependent and fit together to form programs

Achieve a patient-centred understanding of a patient’s longitudinal experience in the health care system

Describe a recent local or national health system change and the basis for acceptance or resistance to this change

1.2 Engage others to work collaboratively to improve systems of patient care

1.3 Use and adapt systems to learn from adverse events and near misses

Describe the process for reporting adverse events and near misses

Describe the available supports for patients and providers when adverse events and near misses occur

Describe the elements of the system that facilitate or protect against adverse events or near misses

1.4 Use health informatics to improve the quality of patient care and optimize patient safety

Describe the benefits and limitations of electronic medical records (EMRs) in the delivery of patient care

Use an EMR for patient care and adhere to local information technology policies

Develop habits to ensure confidentiality when accessing or exchanging patient information

2. Engage in the stewardship of health care resources

2.1 Allocate health care resources for optimal patient care

Describe the ethical debate related to resource stewardship in health care

Describe cost-utility methodology

Identify costs of common diagnostics and therapeutics as well as factors affecting these costs

2.2 Apply evidence and management processes to achieve cost-appropriate care

Describe current health expenditures and the payment structure

Describe how evidence-informed medicine can be applied to optimize health care resource allocation

Describe potential changes in practice that could address rising costs

2.3 Contribute to strategies that improve the value of health care delivery

Explain health care spending and how it has changed over time

Discuss the differences between cost, efficacy, and value with respect to health care delivery

Analyze a clinical case to show how practice-related decisions affect service utilization and health-system sustainability

Discuss strategies to overcome the personal, patient, and organizational factors that lead to waste of health care resources





LEADER MILESTONES: MEDICAL SCHOOLMedical school fundamentals Early clinical activity

3. Demonstrate leadership in professional practice

3.1 Develop their leadership skills Describe leadership styles

Describe how self-awareness, self-reflection, and self-management are important to developing leadership skills

Discuss aspects of own style (including strengths, weaknesses, and biases) that are relevant to leadership

Reflect on the impact of their leadership style on clinical performance

3.2 Design and organize elements of health care delivery

Describe the history and current structure of the health care delivery system in Canada

Describe society’s perspective on the role of physicians and other health care professionals

Compare and contrast the Canadian health care system with other models around the world

Analyze how health care goals from a diversity of stakeholders help set the direction for health care delivery

3.3 Facilitate change in health care to enhance services and outcomes

Describe the key issues regarding the need to improve health care delivery and the role of physician leadership in this improvement

Analyze patient feedback to help improve patient experiences and clinical outcomes

4. Manage their practice and career

4.1 Set priorities and manage time to balance practice and personal life

Reflect on and set personal, educational, and professional goals

Examine the challenges in balancing medicine and personal life

Align short-, medium-, and long-term goals

Demonstrate time management skills

Balance personal life with participation in educational opportunities and provision of patient care

4.2 Manage career planning, finances, and health human resources in a practice

Use data, feedback, and experience to become informed about societal need and current and projected workforce requirements, aligning these with personal factors important to choosing a career

Participate in available career-counselling activities

Create a professional medical curriculum vitae

Prioritize practice choice factors, secure recommendations, and apply to residency programs on the basis of personal strengths and goals, the needs of society, and current and projected workforce needs

4.3 Implement processes to ensure personal practice improvement

Describe how practice standardization can improve quality of health care through specific case examples and reflection on personal experience

Develop systematic habits for practice management (e.g., checklists, prompts, to-do lists, and standard operating procedures)

Use tools and technologies to manage their own schedule



LEADER MILESTONES: RESIDENCY




Describe quality improvement methodologies

Seek data to inform practice and engage in a reiterative process of improvement

Compare and contrast the traditional methods of research design with those of improvement science

Demonstrate ability to employ a quality improvement methodology (e.g., LEAN or the Model for Improvement)

Conduct an improvement investigation (patient safety and/or quality improvement)

Analyze processes seen in one’s own practice, team, organization, and system

Provide feedback on processes seen in one’s own practice, team, organization, and system


Follow others’ lead to work with them to improve patient care

Engage junior learners to work together to improve patient care

Engage health professionals and others to collaborate in improving patient care


Report patient safety hazards and adverse events

Participate in analysis to generate change after an adverse event or near miss

Lead or actively engage in a process for change to prevent future adverse events or near misses

Participate in a blame-free culture to promote openness and increased reporting


Map information flow for patient care while maintaining principles of confidentiality

Map information flow in the care of patients in their specialty and suggest process changes for quality improvement

Discuss options for adopting health information technology in their specialty

Use informatics for quality improvement by improving information flow into, within, and out of their practice









Describe models for resource stewardship in health care used at the institution level

Account for costs when choosing care options

Use clinical judgment and assessment of probability to minimize wasteful practices

Model practice patterns after senior colleagues who deliver a high standard of service

Design practice patterns for cost-effectiveness and cost control

Use local practice and patient flow patterns to influence access to care and system costs


Determine cost discrepancies between best practice and their current practice

Apply evidence and guidelines with respect to utilization relevant to common clinical scenarios

Apply available evidence or recommendations for cost-appropriate care

Develop plans to change areas of wasteful practice within their discipline


Analyze a proposed practice innovation to determine its cost impact in the clinical microsystem

Develop practice-based and system-based rules for resource allocation


3.1 Develop their leadership skills

Describe techniques to motivate themselves and others

Actively engage in change initiatives led by others

Use techniques to motivate themselves and others

Participate in activities and educational programs that develop self-awareness, self-reflection, and self-management as a leader and a follower in health care organizations

Use self-awareness, self-reflection, and self-management to improve practice


Describe key health policy and organizational issues in their area of practice or setting of care

Use management or performance information to monitor service delivery against accepted targets or goals

Use data on measures of clinical performance during team discussions and to support team decision-making


Present a recommendation for a change in health care delivery at a team meeting

Develop a strategy for implementing change with patients, colleagues, and staff

Critique an ongoing change occurring in health care delivery








Organize work using strategies that address strengths and areas to improve in personal effectiveness and efficiency

Align priorities with expectations for educational and clinical work

Identify and approach potential mentors

Balance personal life with availability for education, research, and patient care

Adjust workload to include preparation for examinations

Balance personal life with responsibilities in education, research, administration, and patient care

Align goals with opportunities for participation in unanticipated work and other activities

Develop time management skills in specific contexts, such as for delegation, in meetings, and for teamwork

Build relationships with mentors and mentees


Review opportunities for practice preparation, including choices available for further training

Reconcile projected residency expenses against expected income

Maintain a portfolio of performance

Examine personal interests and seek mentorship and career counselling

Seek performance assessments and reflect on how they modify future performance

Reconcile expectations for practice with job opportunities and workforce needs

Adjust educational experiences to gain competencies necessary for future independent practice

Outline remuneration models as they pertain to discipline

Align early practice with career goals and current opportunities.

Plan practice finances, considering short- and long-term goals

Hire according to defined capabilities and their own long-term goals

Consider legal requirements when hiring and practising in teams


Use their institution’s and/or discipline’s practice management tools

Analyze potential facilitators of and barriers to implementation of practice management tools and process improvement

Create a personal organized approach for practice management to improve patient care

Complete a plan for practice improvement, including evaluating a problem, setting priorities, executing the plan, and analyzing the results

Solicit feedback and external practice audits to drive practice improvement



LEADER MILESTONES: LEARNING IN PRACTICE




Participate in systemic programs that achieve improvement in outcomes affecting population health, patient and provider experience, or health care system sustainability

Lead quality improvement initiatives or patient safety reviews

Design processes to mitigate the impact of human and system factors on performance


Improve the ability of physicians and others to influence health care delivery at a systems level


Implement systems-level improvements in processes for identification of and response to patient safety hazards and adverse events

Champion a blame-free culture to enhance patient safety


Participate in systems-based informatics development and improvement

Engage others in the adoption and refinement of health information technology



Teach stewardship to junior learners and colleagues

Assess performance of learners in providing high-value care

Advocate providing value in care to learners, colleagues, and patients

Attempt to eliminate zero-value care from practice


Collect utilization data and compare practices with colleagues and other institutions to revise activities that are inefficient or unnecessary


Engage health care administration and leadership to reduce waste

Design processes that balance standardization and variability to reduce errors in the delivery of health care

Experiment with care delivery models that may improve care, value, or efficiency


3.1 Develop their leadership skills Actively engage in change initiatives led by others

Provide mentorship and guidance to help others develop leadership and motivational skills

Demonstrate the maintenance and development of leadership competencies


Align the performance of staff within their area of responsibility with overall health care delivery goals

Seek leadership roles to engage in global health care planning and delivery

Decide on target goals and timelines

Ensure that structures are in place to continue to meet target goals and improve upon them





LEADER MILESTONES: LEARNING IN PRACTICEContinuing professional development


Engage with a multidisciplinary team to implement a change in clinical care delivery using a specific change framework

Provide advice and guidance from a clinical perspective to managers and policy-makers

Ensure that failures to achieve health care goals or targets are identified and addressed



Adjust priorities to enable participation in clinical care, the profession, and institutional, provincial, national, or international activities

Teach and assess time and personal management skills


Teach others about career and financial planning


Engage regulatory bodies to improve standards of practice

Engage others to develop a culture of continuous practice improvement



HEALTH ADVOCATE MILESTONES: MEDICAL SCHOOL


1. Respond to the individual patient’s complex health needs by advocating with the patient within and beyond the clinical environment

1.1 Work with patients to address determinants of health that affect them

Explain the determinants of health and their implications

Describe the role of health professionals in patient advocacy

Identify with patients and their families the obstacles they face with respect to health care and related resources

1.2 Work with patients and their families to increase their opportunities to adopt healthy behaviours

Recognize the value and limitations of promoting healthy behaviours

1.3 Incorporate disease prevention, health promotion, and health surveillance into interactions with individual patients

Describe the processes of disease prevention, health promotion, and health surveillance

2. Respond to the needs of a community or population they serve by advocating with them for system-level change

2.1 Incorporate disease prevention, health promotion, and health surveillance activities into clinical practice

2.2 Work with a community or population to identify the determinants of health that affect them

Describe communities or populations facing health inequities

2.3 Participate in a process to improve health in the community or population they serve

Note: In the progression through medical school, residency training, and professional practice, competencies acquired at a given stage are sustained and developed further through subsequent stages. Where a specific milestone for the aquisition of an enabling competency is not specified for a given stage, it should be assumed that earlier milestones for that competency still apply.



HEALTH ADVOCATE MILESTONES: RESIDENCY




Demonstrate an approach to working with a patient to advocate for beneficial services or resources

Analyze a patient’s complex health needs

Facilitate timely patient access to services and resources

Work with patients to address the determinants of their health


Identify community resources or agencies that address the health needs of patients

Select patient education resources

Work with patients and their families to increase opportunities to adopt healthy behaviours

1.3 Incorporate disease prevention, health promotion, and health surveillance into interactions with individual patients

Work with patients and their families to identify opportunities for disease prevention, health promotion, and health protection

Evaluate with a patient the benefits and potential harms of health screening investigations

Incorporate disease prevention, health promotion, and health surveillance activities into interactions with individual patients



Participate in local and national health promotion and disease prevention programs relevant to their practice

Identify patients or populations that are not being served optimally in their clinical practice

Report epidemics or clusters of unusual cases seen in practice, balancing patient confidentiality with the duty to protect public health

Improve their clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities


Identify communities or populations they serve who are experiencing health inequities

Analyze current policy or policy developments that affect the community or population they serve

Work with a community or population to identify the determinants of their health





HEALTH ADVOCATE MILESTONES: RESIDENCY



Partner with others to identify health needs in a community or population they serve

Appraise available resources to support the communities or populations they serve

Distinguish between the potentially competing health interests of the individuals, communities, and populations they serve

Participate in a process to improve health in the communities or populations they serve



HEALTH ADVOCATE MILESTONES: LEARNING IN PRACTICE




Advocate before administrative or governing bodies on behalf of a patient

Champion the development, implementation, and promotion of health advocacy teaching


Create health promotion and education resources

1.3 Incorporate disease prevention, health promotion, or health surveillance into interactions with individual patients

Champion education programs for disease prevention, health promotion, and health surveillance



Collaborate with national organizations and surveillance programs to identify populations in need


Contribute to policy discussions relevant to the determinants of health

Communicate with the communities or populations they serve about ways to improve health


Partner with others to support, plan, or lead the implementation of a program to improve the health of the communities or populations they serve




SCHOLAR MILESTONES: MEDICAL SCHOOL


1. Engage in the continuous enhancement of their professional activities through ongoing learning

1.1 Develop, monitor, and revise a personal learning plan to enhance professional practice

Describe principles of effective learning relevant to medical school

Describe physicians’ obligations for lifelong learning and enhancement of competence

Create a learning plan, using a provided template and input from a supervisor, identifying goals related to Faculty of Medicine outcomes, clerkship, and longer- term career goals

Describe learning opportunities, resources (people and information sources), and assessment and feedback opportunities relevant to learning in the clinical setting

Demonstrate a structured approach to monitoring progress with respect to learning in the clinical setting

1.2 Regularly analyze their performance, using various internal and external data sources to identify opportunities for learning and improvement

Identify and prioritize, with guidance, personal learning needs based on formal curriculum learning objectives

Define reflective learning as it relates to medicine

Compare, with guidance, self-assessment with external assessments

1.3 Engage in collaborative learning to continuously improve personal practice and contribute to collective improvements in practice

Participate effectively in collaborative group learning

2. Facilitate the learning of students, residents, other health care professionals, the public, and other stakeholders

2.1 Recognize the power of role-modelling and the impact of the hidden curriculum on learners

Describe the concepts of formal, informal, and hidden curricula

Identify behaviours associated with positive and negative role-modelling

2.2 Promote a safe learning environment

Describe factors that can positively or negatively affect the learning environment

Describe strategies for reporting and managing mistreatment experienced or witnessed

2.3 Ensure patient safety is maintained when learners are involved

Work within their limitations, seeking guidance and supervision when needed

2.4 Collaboratively identify the learning needs of others and prioritize learning outcomes

2.5. Demonstrate effective teaching to facilitate learning

Describe the characteristics of effective teachers in medicine







2.6 Seek and provide meaningful feedback

Use exam results and feedback from teachers and peers to enhance self-assessment and improve learning

Describe the features of effective feedback and its importance for teaching and learning

Seek and respond to feedback from supervisors, peers, and others

2.7 Use assessment tools and evaluation practices that are appropriate and relevant to the teaching and learning context

Evaluate teachers and programs in an honest, fair, and constructive manner

3. Integrate best available evidence, contextualized to specific situations, into real-time decision-making

3.1 Recognize practice uncertainty and knowledge gaps in clinical and other professional encounters and generate focused questions that can address them

Describe the different kinds of evidence and their roles in clinical decision-making

3.2 Demonstrate proficiency in identifying, selecting, and navigating pre-appraised resources

Describe the advantages and limitations of pre-appraised resources

Demonstrate how various sources of clinical information (studies, expert opinion, practice audits) contribute to the evidence base of medical practice

Select appropriate sources of knowledge as they relate to addressing focused questions

3.3 Integrate evidence into decision-making

For a given clinical case, demonstrate the application of evidence during clinical decision-making

4. Critically evaluate the integrity, reliability, and applicability of health-related research and literature

4.1 For a given professional scenario, formulate well-structured scholarly questions

Formulate structured clinical or scholarly questions using a specific question architecture that can inform a critical appraisal exercise

For a given professional scenario, formulate well-structured clinical or scholarly questions

4.2 Identify one or more studies or scholarly sources that shed light on a given professional question

Contrast the various study designs used in medicine and the quality of various pre-appraised resources

Identify the study design best suited to address a given clinical question

4.3 Interpret study findings, including a discussion and critique of their relevance to professional practice

Describe the various ways that studies can communicate their results

4.4 Determine the validity and risk of bias in a wide range of scholarly sources

Demonstrate the use of critical appraisal frameworks to evaluate common study designs






4.5 Describe study results in both quantitative and qualitative terms

Outline the core concepts related to measures of association, relative and absolute effects, and precision

4.6 Evaluate the applicability (external validity or generalizability) of evidence from a wide range of biomedical research products

Describe the threats to external validity or generalizability of a study or synthesis of studies

4.7 Apply study findings to professional practice and discuss the barriers and facilitators to achieving this

4.8 Use automatic information-delivery services that highlight new evidence appropriate to their scope of professional practice

5. Contribute to the dissemination and/or creation of knowledge and practices applicable to health

5.1 Describe the principles of research and scholarly inquiry and their role in contemporary health care

Describe the principles of research and scholarly inquiry and their role in health and health care

5.2 Discuss and interpret the ethical principles applicable to health-related research

Describe the ethical principles applicable to scholarly inquiry and research

5.3 Discuss the roles and responsibilities of researchers, both principal investigators and research collaborators, and how they differ from clinical and other practice roles and responsibilities

5.4 Pose medically and scientifically relevant and appropriately constructed questions that are amenable to scholarly investigation

5.5 Discuss and critique the possible methods of addressing a given scholarly question

5.6 Summarize and communicate to professional and lay audiences, including patients and their families, the findings of applicable studies and reports



SCHOLAR MILESTONES: RESIDENCY




Create a learning plan in collaboration with a designated supervisor and others as needed, identifying learning needs related to their own discipline and career goals

Use technology to develop, record, monitor, revise, and report on learning in medicine

Review and update earlier learning plan(s) with input from others, identifying learning needs related to all CanMEDS Roles to generate immediate and longer-term career goals

Create a learning plan, incorporating all CanMEDS domains, targeting residency program completion and the transition to practice

Discuss a learning plan and strategy for ongoing self-monitoring with a mentor, faculty advisor, or learning coach


Demonstrate the habit of answering questions regularly to address personal learning needs identified in daily work

Seek help or pursue learning opportunities, as appropriate, when limits of current expertise are reached

Describe the implications of reflection in action (during) and reflection on action (after) for medical learning

Regularly engage in personal learning by drawing upon various sources (daily work, literature, scanning of literature, formal or informal education sessions) to identify and prioritize learning needs

Seek and interpret multiple sources of performance data and feedback, with guidance, to continuously improve performance

Define a performance assessment question

Demonstrate initiation and maintenance of performance improvements


Contribute to quality improvement and patient safety education initiatives with an interprofessional team

Identify learning needs of a health care team

Engage in collaborative learning to continuously improve personal practice and contribute to collective improvements in practice









Describe the link between role-modelling and the hidden curriculum

Use strategies for deliberate, positive role-modelling

Apply strategies to mitigate the tensions between formal, informal, and hidden curricula

2.2 Promote a safe learning environment

Explain how power differentials between learners and teachers can affect the learning environment

Ensure a safe learning environment for all members of the team


Speak up in situations in the clinical training environment where patient safety may be threatened

Recognize unsafe clinical situations involving learners and manage them appropriately

Balance the tension between direct clinical supervision and graduated responsibility


Describe sources of information used to assess learning needs

Define specific learning objectives for a teaching activity

2.5. Demonstrate effective teaching to facilitate learning

Demonstrate basic skills in teaching others, including peers

Describe a model of clinical teaching relevant to their discipline

Describe the basic principles of education planning

Choose appropriate content, teaching format, and strategies tailored to a specific educational context

2.6. Seek and provide meaningful feedback

Provide written or verbal feedback to other learners, faculty and other members of the team

Role-model regular self-assessment and feedback-seeking behaviour


Contribute to the assessment of other learners

Demonstrate appropriate assessment of junior learners








Recognize uncertainty and knowledge gaps in clinical and other professional encounters relevant to their discipline

Recognize practice uncertainty and knowledge gaps in clinical and other professional encounters and generate focused questions that can address them


Demonstrate proficiency in identifying, selecting, and navigating clinical information sources that provide or are based on pre-appraised evidence

3.3 Integrate evidence into decision-making

Demonstrate the use of an integrated model of decision-making that combines best evidence, resources, and clinical expertise in the context of patient values and preferences



Formulate clinical or scholarly questions in the categories of diagnosis and therapy

Formulate detailed scholarly questions in the categories of diagnosis, prognosis, prevention, therapy, harm reduction, and clinical prediction, incorporating outcomes important to the patient


Identify one or more scholarly sources that inform the clinical question at the centre of a structured critical appraisal activity

Demonstrate how various scholarly sources such as studies, expert opinion, and practice audits inform practice







Interpret study findings, including a discussion and critique of their relevance to professional practice


Determine the validity and risk of bias in a wide range of scholarly sources


Generate measures of association and diagnostic accuracy from 2 × 2 tables

Demonstrate an understanding of the role of qualitative research and analyze its limitations and applicability

Describe study results in both quantitative and qualitative terms as appropriate


Evaluate the applicability (external validity or generalizability) of evidence from a wide range of research


Demonstrate an understanding of the principles of knowledge translation and the Knowledge to Action Framework

Translate and apply the findings of studies into practice, and discuss factors that can impede or facilitate this


Describe the need for and benefits of evidence alerting services appropriate to one’s scope of professional practice

Use information delivery services that highlight new evidence appropriate to one’s scope of professional practice



Discuss the principles of research and scholarly inquiry and their role in addressing questions in their discipline

Apply the principles of research and scholarly inquiry to contribute to a scholarly investigation in their discipline







Discuss and provide examples of the ethical principles applicable to scholarly inquiry and research relevant to their discipline

Identify ethical principles for research and incorporate them into obtaining informed consent, considering harm and benefit, and considering vulnerable populations


Compare and contrast the roles and responsibilities of researchers, both principal investigators and research collaborators, and how they differ from and relate to clinical and other practice roles and responsibilities


Identify potential relevant questions that are amenable to scholarly inquiry in their discipline

Pose relevant, appropriately constructed questions that are amenable to scholarly investigation


Describe and compare the common methodologies used for scholarly inquiry in medicine

Select appropriate methods of addressing a given scholarly question


Summarize and communicate to peers the findings of applicable studies and reports

Summarize and communicate to professional and lay audiences, including patients and their families the findings of applicable studies and reports

Prepare a manuscript suitable for publication in a peer-reviewed journal



SCHOLAR MILESTONES: LEARNING IN PRACTICE




Develop a plan to enhance competence across all CanMEDS domains for practice and update it regularly

Coach others to enhance their own learning plans for practice


Access and summarize sources of performance data applicable to a scope of practice

Use performance data in dialogue with a peer or mentor to inform a performance improvement plan and continuing learning

Revise and monitor a performance improvement plan on the basis of changes to scope of practice

Coach another physician to use his or her performance data to inform a performance improvement plan and continuing learning


When appropriate, lead team-based learning activities to address patient safety and quality improvement



Address systemic issues that contribute to the hidden curriculum

2.2 Promote a safe learning environment Address systemic or institutional processes that may compromise the safety of the learning environment

Coach others about optimizing learning environments



Integrate formal and informal methods of needs assessment to guide the development and/or modification of learning activities

2.5 Demonstrate effective teaching to facilitate learning

Teach the public and other health care stakeholders

Use relevant learning theories to enhance the learning of others

Coach others to enhance their teaching

2.6 Seek and provide meaningful feedback Help learners and teachers manage the emotional impact of giving and receiving feedback

Work with recipients of feedback to develop plans for improvement

Coach others to enhance their ability to seek, provide, and use feedback








Plan programmatic approaches to assessment of learners or evaluation of programs




Coach others to find and select sources of evidence for a given practice-related question

3.3 Integrate evidence into decision-making Coach other health professionals on integrating evidence effectively into practice decision-making



Develop questions that address the cost-effectiveness of interventions or management strategies

Coach another physician to formulate clinical or scholarly questions based on a medical scenario


Coach another health professional on the selection of relevant sources of evidence for a given scholarly question


Participate in the development of an evidence synthesis for one’s peers


Demonstrate the use of research evaluation and reporting tools for specific study designs or scholarly sources

Coach another health professional to use critical appraisal frameworks to evaluate common study designs




Supervise a critical appraisal session (e.g., journal club)


Coach another health professional to use evidence alerting services







Research collaborator Principal investigator


Take responsibility for applying the principles of research and scholarly inquiry to scholarly investigations

Coach others to enhance their understanding of the principles of research and scholarly inquiry


Apply ethical principles relevant to research and scholarly inquiry

Apply ethical principles relevant to research and scholarly inquiry


Actively participate as a research team member, balancing the roles and responsibilities of a researcher with the clinical roles and responsibilities of a physician

Create and lead research teams

Serve as a role model and mentor for others with respect to the responsibilities of a researcher


Select and construct relevant, appropriately constructed questions to guide scholarly investigation

Take responsibility for the development of relevant, appropriately constructed questions to guide scholarly investigation

Coach others to pose relevant, appropriately constructed questions that are amenable to scholarly investigation


Determine the appropriate methods to address a given scholarly question and assist in their application and implementation

Determine and apply the appropriate methods to address a given scholarly question and take responsibility for their application and implementation


Take responsibility for summarizing and communicating study findings to stakeholders



PROFESSIONAL MILESTONES: MEDICAL SCHOOL


1. Demonstrate a commitment to patients by applying best practices and adhering to high ethical standards

1.1 Exhibit appropriate professional behaviours and relationships in all aspects of practice, reflecting honesty, integrity, commitment, compassion, respect, altruism, respect for diversity, and maintenance of confidentiality

Describe the importance of honesty, integrity, and confidentiality in medicine

Exhibit honesty and integrity in the classroom setting and clinical environment

Recognize and respect professional boundaries

Demonstrate sensitivity to issues concerning diversity with respect to peers, colleagues, and patients

Demonstrate caring and compassion

Consistently maintain confidentiality in the clinical setting and recognize the limitations of confidentiality

1.2 Demonstrate a commitment to excellence in all aspects of practice and to active participation in collaborative care

Examine experiences in the classroom and clinical setting and use reflection to identify personal deficiencies and consider behaviour changes

Examine experiences in the clinical setting and use reflection to identify personal deficiencies and make behaviour changes

1.3 Recognize and respond to ethical issues encountered in practice

Describe principles and theories of clinical ethics as well as core ethical concepts

Apply appropriate ethical concepts to address ethical issues encountered during clinical and academic activities

1.4 Recognize and manage conflicts of interest

Discuss potential personal, financial, and institutional conflicts of interest and the implications of conflicts of interest for the profession

Recognize their own conflicts of interest and demonstrate an approach to managing them

1.5 Exhibit professional behaviours in the use of technology-enabled communication

Explain the potential abuses of technology-enabled communication and their relation to professionalism

Demonstrate awareness of policies related to technology-enabled communication

Use technology-enabled communication, including their online profile, in a professional, ethical, and respectful manner

Consistently follow relevant policies, including with regard to the appropriate use of electronic medical records

2. Demonstrate a commitment to society by recognizing and responding to the social contract in health care

2.1 Demonstrate a commitment to the promotion of the public good in health care, including stewardship of resources

Explain how the concept of stewardship of resources relates to professionalism

Explain physician roles and duties in the promotion of the public good

Describe the tension between the physician’s role as advocate for individual patients and the need to manage scarce resources

2.2 Demonstrate a commitment to maintaining and enhancing competence

Accept and respond to feedback

Reflect on their own strengths and weaknesses in relation to academic or clinical performance

Demonstrate a commitment to identifying and addressing gaps in the knowledge and skills necessary for optimal performance as a trainee







2.3 Demonstrate a commitment to patient safety and quality improvement

Describe the link between professionalism and a commitment to patient safety and quality improvement

Demonstrate a consistent commitment to patient safety and quality improvement through adherence to institutional policies and procedures

2.4 Demonstrate accountability to patients, society, and the profession by recognizing and responding to societal expectations of the profession

Describe the relationship between medicine and society in terms of the social contract

Describe the levels of accountability of a medical student, a physician, and the profession to individual patients, society, and the profession

3. Demonstrate a commitment to the profession by adhering to standards and participating in physician-led regulation

3.1 Fulfill professional and ethical codes, standards of practice, and laws governing practice

Show awareness of the codes, standards of practice, and laws governing practice

Demonstrate accountability to relevant codes and institutional standards

Demonstrate awareness of how to access codes, standards, and laws, along with a basic understanding of what they contain

Demonstrate accountability to policies and professional guidelines

3.2 Recognize and respond to unprofessional and unethical behaviours in others

Respond on an individual level to peer- group lapses of professional conduct

3.3 Commit to participation in peer assessment and standard-setting

Identify aspects of professionalism in performance in standardized clinical scenarios

3.4 Maintain and promote a culture of collegiality and respect in professional relationships

Act respectfully toward peers and colleagues in learning and clinical environments

Identify situations in which personal boundaries may be at risk of being breached with colleagues

4. Demonstrate a commitment to physician health and well-being to foster optimal patient care

4.1 Exhibit self-awareness and effectively manage the influences on personal well-being and professional performance

Self-awareness: Identify the effects that attitudes, emotions, and behaviours can have on performance in school activities

Physical and environmental factors: Identify key factors in learning environments that can affect well-being and performance

Resilience: Identify personal capacity for resilience, specifically the ability to adapt and recover from challenges, and identify opportunities to expand skills where needed

Safe patient care: Describe the connection between self-care and patient safety

Self-awareness: Use strategies to improve self-awareness and regulate attention, emotions, thoughts, and behaviour to enhance performance

Resilience: Identify, and demonstrate the ability to apply, skills to adapt to and recover from challenges encountered in clinical environments

Safe patient care: Identify specific personal factors that may affect their care of patients






4.2 Manage personal and professional demands for a sustainable practice through the physician life cycle

Personal–professional integration: Identify current or potential examples of competing personal/academic responsibilities

Awareness of risks to physician health: Describe how physicians are vulnerable to physical, emotional, and spiritual illness and identify risks and opportunities with regard to sustainable well-being

Strategies to enhance and maintain health: Identify strategies to support personal well-being, implement healthy lifestyle choices, and engage in appropriate self-care, including with the help of a primary health care provider

Physician life cycle: Describe transitions through a physician’s life cycle that are periods of vulnerability and recognize periods of increased risk during the academic school year

Critical incidents/adverse events: Describe the effect that discrete experiences can have on their well-being during early medical training

Career choice / professional identity: Identify personal attributes and values that will contribute to appropriate career decision-making

Personal–professional integration: Develop approaches to managing competing personal, academic, and professional responsibilities

Awareness of risks to physician health: Identify the risks and barriers that inhibit the engagement of appropriate and timely access to existing resources for care and identify possible ways to address these barriers

Strategies to enhance and maintain health: Implement strategies to maintain personal well-being in the context of increased clinical demands

Physician life cycle: Use strategies to mitigate stressors during transitions and enhance professional development

Critical incidents/adverse events: Use strategies to mitigate the impact of critical incidents or adverse events

Career choice / professional identity: Integrate self-awareness with knowledge of clinical and environmental factors to inform career path decisions

4.3 Promote a culture that recognizes, supports, and responds effectively to colleagues in need

Mentoring: Describe the value of being mentored throughout professional development

Contribution to a positive work environment: Recognize behaviours that contribute to collegial and non-collegial work environments

Mentoring: Building on the experience of being mentored, begin to develop skills in mentoring others

Contribution to a positive work environment: Develop an approach to practising positive behaviours and dealing with negative behaviours to promote a collegial work environment

Support for colleagues in need: Describe the multiple ways in which poor physician health can present, including disruptive behaviour, and provide support to peers when needed



PROFESSIONAL MILESTONES: RESIDENCY




Exhibit honesty and integrity in the specialty-specific clinical and academic environments

Independently manage specialty-specific issues surrounding confidentiality

Demonstrate and role-model honesty and integrity in complex clinical and professional contexts

Coach and assess professional behaviours

Intervene when breaches of confidentiality occur

Manage complex issues while preserving confidentiality


Identify how the system of care supports or jeopardizes excellence

Examine their own experiences and explicitly state the assumptions that led to particular actions, with the aim of doing better in the future

Role-model a consistent commitment to excellence in practice


Recognize and manage specialty-specific ethical issues encountered in the clinical setting and during academic activities

Actively manage challenging ethical dilemmas encountered in practice


Manage conflicts of interest with reference to policies and guidelines, seeking help when needed

Proactively resolve real or potential conflicts of interest through courses of action designed to minimize the perception of or potential for conflicts of interest








Use appropriate professional behaviours in technology-enabled communication

Intervene when aware of online breaches of professionalism



In their own clinical encounters, recognize the tensions between the physician’s role as advocate for individual patients and the need to manage scarce resources

Discuss solutions to promote equity (fairness) in patients’ access to health care

Demonstrate the ability to balance their fiduciary duty to patients with the public good


Demonstrate a commitment to identifying and addressing gaps in the knowledge and skills necessary for optimal specialty practice

Demonstrate a commitment to the ongoing enhancement of competence as it relates to scope of practice

2.3 Demonstrate a commitment to patient safety and quality improvement

Identify and participate in quality improvement and patient safety initiatives

Initiate and carry out patient safety or quality improvement initiatives within their own practice environment


Respond to patient and societal expectations in clinical interactions

Recognize and manage tensions or differences between the expectations of society and the profession







3.1 Fulfill the professional and ethical codes, standards of practice, and laws governing practice

Describe the content of relevant codes, standards, and laws, and the structure and function of the regulatory structures governing individual residents, physicians, and the profession, including standard-setting and disciplinary and credentialing procedures

Describe how to respond to a College complaint or legal action

Demonstrate accountability to patients, the profession, and society with regard to the impact of decisions that are made


Describe the various functions of regulatory structures governing individual residents, physicians, and the profession, including standard-setting and disciplinary and credentialing procedures

Describe the regulatory codes and functions of review or disciplinary committees within their academic or health care institution

Respond on an individual level to colleagues’ lapses of professional conduct in all areas of practice

Describe and identify regulatory codes and procedures relevant to involving the provincial regulatory body in a case of serious unprofessional behaviour or practice


Participate in the clinical assessment of medical students

Prepare a morbidity and mortality report or chart review

Assess the clinical performance of junior trainees

Lead a debrief of a difficult clinical interaction


Role-model respectful behaviours with physician and non-physician colleagues in clinical, educational, and administrative settings

Intervene when behaviours toward colleagues and learners undermine a respectful environment








Self-awareness: Demonstrate an ability to regulate attention, emotions, thoughts, and behaviours while maintaining capacity to perform professional tasks

Physical and environmental factors: Identify strategies to manage the impact of physician and environmental factors that can affect performance

Resilience: Reflect on personal experiences with challenging situations and integrate skills that support adaptation and recovery

Physical and environmental factors: Effectively manage the impact of physical and environmental factors on performance

Resilience: Consistently demonstrate resilience in challenging situations and help others to use their own skills in adaptation and recovery

Safe patient care: Demonstrate an approach to dealing with personal factors arising in the care of patients and their families

Safe patient care: Integrate strategies to manage their own personal factors in order to enhance patient care

Physical and environmental factors: Demonstrate the ability to manage and mitigate environmental factors that affect professional performance

Resilience: Demonstrate the ability to adapt and recover from the challenges inherent in the transition to independent practice and recognize opportunities to expand skills where needed


Awareness of risks to physician health: Manage barriers to successful access to care for themselves

Strategies to enhance and maintain health: Adapt and practise strategies to maintain personal well-being, including ongoing relationships with appropriate health care providers, while recognizing responsibilities to patients and colleagues

Personal–professional integration: Manage competing personal and professional priorities consistently

Awareness of risks to physician health: Recognize and work to remove barriers for junior trainees

Strategies to enhance and maintain health: Encourage self-care in juniors and colleagues and promote a healthy work environment

Career choice / professional identity: Consider career options that will promote personal strengths and enhance well-being and long-term success

Personal–professional integration: Manage competing personal and professional priorities effectively

Awareness of risks to physician health: Recognize the barriers that may arise and adapt strategies to maintain personal well-being in the context of professional practice

Strategies to enhance and maintain health: Seek appropriate health care, incorporate self-care into work/life routines, and recognize and promote an appropriate standard of care to other health care professionals






(4.2 continued) Physician life cycle: Recognize evolving professional identity transitions and manage their inherent stresses

Career choice / professional identity: Discuss the influence of personal and environmental factors on their career path and integrate this information into the development of a career plan

Physician life cycle: Manage the multiple transitions of increased expectations and responsibilities

Physician life cycle: Effectively manage the increased professional responsibilities inherent in the transition to independent practice

Critical incidents / adverse events: Effectively manage the impact of adverse events inherent in the transition to independent practice

Career choice / professional identity: Develop a plan for transition to practice that demonstrates knowledge of personal and environmental factors that promote or challenge health and well-being


Contribution to a positive work environment: Practise collegial interactions and serve as an example to medical students supervised

Support for colleagues in need: Describe the importance of early intervention for colleagues in need of assistance, identify available resources, and describe professional and ethical obligations and options for intervention

Mentoring: Seek out mentorship to address varied professional development needs

Contribution to a positive work environment: Describe the distinct roles of administrators and health care providers in creating a positive work environment

Support for colleagues in need: Describe the emotional impact of an adverse event on the individual physician and other health care providers

Mentoring: Develop skills to provide mentorship to junior colleagues

Contribution to a positive work environment: Behave in a way that creates and role-models collegiality for healthy workplaces that optimize patient care

Contribution to a positive work environment: Address, in a sensitive and supportive way, behaviours that undermine collegiality in the work environment

Physician life cycle: Support others in their professional transitions



PROFESSIONAL MILESTONES: LEARNING IN PRACTICE




Lead and advise on professionalism and professional behaviour

Role-model for colleagues a caring and compassionate nature, listening to patients, and putting others’ needs above their own

Demonstrate special expertise in conflicts of confidentiality and serve as a resource for others


Analyze how the system of care supports or jeopardizes excellence

Set up mechanisms to address barriers to excellence


Advise on complex ethical issues in practice

Teach and assess the management of ethical issues


Advise on conflicts of interest in practice and in institutions and on methods to resolve them


Lead and model the use of technology-enabled communication for the public good



Coach and assess other physicians’ ability to balance fiduciary duty to patients with the public good


Coach others to demonstrate a commitment to maintaining and enhancing competence

2.3 Demonstrate a commitment to quality improvement and patient safety


Influence the profession’s response to issues of societal accountability

Advise on social accountability and the medical profession





PROFESSIONAL MILESTONES: LEARNING IN PRACTICE



3.1 Fulfill the professional and ethical codes, standards of practice, and laws governing practice

Contribute to the development of professional codes, standards, or laws governing practice


Work to enhance the profession’s response to colleagues’ lapses of professional conduct


Participate in the regulatory procedures that govern the profession

Chair administrative committees


Lead initiatives that promote respectful work environments

Advise others regarding professional boundaries



Self-awareness: Role-model and teach the skills of self-regulation

Physical and environmental factors: Advise on strategies to mitigate negative effects of physical and environmental factors

Resilience: Role-model and coach others in resiliance


Personal–professional integration: Role-model and teach the management of competing personal and professional priorities

Awareness of risks to physician health: Actively work to eliminate barriers to physicians seeking needed care

Strategies to enhance and maintain health: Role-model a commitment to personal health and well-being

Support for colleagues in need: Encourage and support colleagues and junior trainees to pursue appropriate self-care

Contribution to a positive work environment: Advocate for learning and work environments that provide opportunities for a healthy lifestyle

Physician life cycle: Recognize important periods of vulnerability that accompany shifting priorities and goals, including when retirement approaches


Career choice / professional identity: Role-model and teach learners and colleagues about personal and professional choices to effectively manage practice

Mentoring: Establish and/or participate in a formal mentorship program to promote a culture of collegiality

Contribution to a positive work environment: Teach and positively influence the behaviour of others to promote a culture of wellness and address lapses in professional behaviour as necessary

Support for colleagues in need: Exhibit proficiency in providing support for physician colleagues and in educating learners

Critical incidents / adverse events: Manage and support others as they deal with the impact of critical incidents or adverse events



HEALTH ADVOCATE

ChairDr. Jonathan Sherbino

Core membersDr. Deirdre BonnycastleDr. Brigitte CôtéDr. Leslie FlynnDr. Andrea HunterDr. Daniel Ince-CushmanDr. Jill KonkinDr. Ivy OandasanDr. Glenn RegehrDr. Denyse RichardsonDr. Jean Zigby

AdvisoryDr. Marcia ClarkDr. Sherissa Microys

SCHOLAR

Chairs Dr. Denyse Richardson Dr. Anna Oswald

Scholar – Lifelong Learning

ChairDr. Denyse Richardson

Core membersDr. Nathalie Caire FonDr. Craig CampbellDr. Ian GoldstineMs. Jennifer GordonDr. Jocelyn Lockyer Dr. Karen MannDr. John ParboosinghDr. Mithu SenDr. Ivan Silver

AdvisoryDr. Robert BlumanDr. Dave DavisDr. François GouletDr. Brenna LynnDr. Jamie MeuserDr. Brian M Wong

Scholar – Teacher

ChairsDr. Anna OswaldDr. Ming-Ka Chan

Core membersDr. Karen MannDr. Wayne WestonDr. Elisa Ruano CeaDr. Constance LeBlancDr. Farhan BhanjiDr. James Goertzen Dr. Jennifer WaltonDr. Marcia ClarkDr. Brian M Wong

AdvisoryDr. Nick Busing Dr. Sal SpadaforaDr. Allyn Walsh Dr. Chris Watling

Scholar – Critical Appraisal

ChairDr. Eddy S Lang

Core membersDr. Roland GradDr. Martin DawesMs. Susan PowelsonDr. Jim HendersonMs. Lorie KlodaDr. Brian Haynes

AdvisoryDr. Lisa CalderDr. Julien PoitrasDr. Kent Stobart

Scholar – Research

ChairDr. Bart J Harvey

Core membersDr. Stacy Ackroyd-StolarzDr. Tanya HorsleyDr. Vivian R RamsdenDr. David Streiner




PROFESSIONAL

EditorsDr. Linda SnellDr. Leslie Flynn

Professionalism

ChairDr. Linda Snell

Core membersDr. Leslie Flynn Dr. Merril Pauls Dr. Ramona KearneyDr. Andrew WarrenDr. Robert Sternszus Dr. Richard CruessDr. Sylvia CruessDr. Maggy DupréDr. Rose Hatala

AdvisoryDr. Shiphra GinsburgDr. Sharon Johnston Dr. Yvette Lajeunesse

Physician Health

ChairDr. Leslie Flynn

Core membersDr. Linda SnellDr. Meri BukowskyjDr. Susan EdwardsDr. Jordan CohenDr. Anita ChakravartiDr. Leslie NickellDr. Janet Wright

AdvisoryDr. Jonathan DellaVedovaDr. Eva KnellDr. Derek PuddesterDr. Andrew Warren

PATIENT SAFETY AND QUALITY IMPROVEMENT

ChairDr. Brian M Wong

Core membersDr. Stacy Ackroyd-Stolarz Dr. Meri Bukowskyj Dr. Lisa CalderDr. Amir GinzbergDr. Sherissa MicroysDr. Antonia StangDr. Gordon Wallace

AdvisoryDr. Philip EllisonDr. Ward FlemonsMs. Abigail HainDr. Karen Hall BarberDr. Amy NakajimaDr. Kaveh ShojanaDr. Roger Wong

eHEALTH

ChairDr. Kendall Ho

Core members Dr. Rachel EllawayDr. Judith LittlefordDr. Robert Hayward Dr. Katrina Hurley

INTEGRATION COMMITTEE

ChairsDr. Jason R FrankDr. Linda Snell

MembersMs. Cynthia Abbott Dr. Craig Campbell




Dr. Kenneth HarrisDr. Farhan BhanjiDr. Andrée BoucherDr. Ming-Ka ChanDr. Lara CookeDr. Deepak DathDr. Sue DojeijiDr. Leslie FlynnMs. Danielle FrechetteMs. Jennifer GordonDr. Jolanta KarpinskiDr. Viren NaikDr. Anna OswaldDr. Denyse RichardsonDr. Jonathan SherbinoDr. Elaine Van MelleDr. Elizabeth Wooster

NATIONAL ADVISORY COMMITTEE

ChairsDr. Jason R FrankDr. Ivy Oandasan

MembersDr. Adele Atkinson Dr. Glen BandieraDr. Andrée BoucherDr. Ian BowmerMr. Ian BrasgDr. Ford Bursey Dr. Nick BusingDr. François Caron Dr. Charles FaubertDr. Lisa GravesDr. Ken Harris Dr. Kevin ImrieDr. Fleur-Ange LefebvreDr. Anne Marie MacLellanMr. Hugh MacLeod Dr. Ashley MillerDr. Geneviève MoineauDr. Julien Poitras

Dr. Charmaine RoyeDr. Kam RungtaDr. Asoka Samarasena Dr. Linda SnellDr. Kent StobartDr. Gordon WallaceDr. Parveen Wasi Dr. James WilsonDr. Roger Wong

INTERNATIONAL ADVISORY COMMITTEE

ChairsDr. Jason R Frank, Royal College of Physicians and

Surgeons of Canada, CanadaDr. Linda Snell, Royal College of Physicians and

Surgeons of Canada, Canada

MembersDr. Ducksun Ahn, KoreaDr. Esam Al Banyan, Saudi ArabiaDr. Andleeb Arshad, KuwaitDr. Sally Davies, United KingdomDr. Jean-François Denef, BelgiumDr. Peter Dieckmann, DenmarkDr. Richard Doherty, AustraliaDr. Robert Englander, United States of AmericaDr. Jaime Godoy, ChiliDr. Peter Harris, AustraliaDr. Jennie Kendrick, AustraliaDr. Scott Lang, Australia/CanadaDr. Mary Lawson, AustraliaDr. Haicho Li, ChinaDr. Tindal Magnus, AustraliaDr. Doris Ostergaard, DenmarkDr. Ingrid Philibert, United States of AmericaDr. Peter Raubenheimer, South AfricaDr. Fedde Scheele, NetherlandsDr. Stefanus Snyman, South AfricaDr. Marie-Louise Stokes, AustraliaDr. Tim Swanwick, EnglandDr. Olle ten Cate, NetherlandsMr. Patrick van Gele, SwitzerlandDr. Simon Williams, Australia


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