the future of medical education in canada: a collective vision for

FMECPG_Cover_EN_Layout 1 12-04-03 7:31 AM

A HEALTH CANADA FUNDED PROJECT

1FMEC PG PROJECT REPORT 2012

TA B L E O F C O N T E N T S

EXECUTIVE SUMMARY ........................................2

Guiding Principles..............................................3

Recommendations..............................................3

INTRODUCTION ....................................................8

The Future of Medical Education in Canada Medical Doctor Education Project ..............................................9

The Future of Medical Education in Canada Postgraduate Project ........................9

A Collective Vision for Medical Education..........................................................10

The Context of Canadian Postgraduate Medical Education............................................10

From Medical School to Residency Training ..........................................10

From Residency Training to Practice in Canada............................................11

The Unique Roles of the Resident as Student, Teacher, and Care-Provider ..............11

Stakeholders Involved in the CanadianPostgraduate Medical Education System ........11

From Shared Vision to Collective Action................................................................12

RECOMMENDATIONS..........................................13

1: Ensure the Right Mix, Distribution, and Number of Physicians to Meet Societal Needs ..................................................13

2: Cultivate Social Accountability throughExperience in Diverse Learning and WorkEnvironments ..................................................16

3: Create Positive and Supportive Learning and Work Environments ..................17

4: Integrate Competency-Based Curricula in Postgraduate Programs ................................18

5: Ensure Effective Integration and Transitions along the Educational Continuum ......................................................20

6: Implement Effective Assessment Systems ............................................................22

7: Develop, Support, and Recognize Clinical Teachers ..............................................24

8: Foster Leadership Development ..................26

9: Establish Effective Collaborative Governance in PGME ......................................27

10: Align Accreditation Standards ..................28

CONCLUSIONS AND NEXT STEPS ....................29

METHODOLOGY ..................................................29

Environmental Scan Consulting Group................................................................29

Liaison and Engagement Consultant Group ............................................30

Public Opinion Poll ..........................................30

National Survey of Program Directors ............31

International Consultations ............................31

Public Panel ......................................................31

Reviewing the Inputs........................................31

ACKNOWLEDGEMENTS ......................................32

COMMITTEES AND CONTRIBUTORS ..............34

Steering Committee..........................................34

Advisory Committee of PGME Deans ............35

Strategic Implementation Group ....................36

Public Panel ......................................................37

Liaison and Engagement Consulting Group................................................................38

Environmental Scan Consulting Group ..........38

GLOSSARY ..............................................................40

FMEC MD RECOMMENDATIONS ......................41

2

The Future of Medical Education in CanadaPostgraduate (FMEC PG) Project sets out avision for educating the kind of doctors

Canada needs—today and in the future. Part of thisvision is for all physicians, by the end of their training,to possess the clinical expertise necessary to practicemedicine based on the principles of quality, safety,professionalism, and patient-centred and team-basedcare.

The Canadian medical education system is interna-tionally recognized; however, there is more that it canand must do. Recognizing this, a consortium of four organizations—the Association of Faculties of Medicine of Canada (AFMC), le Collège desMédecins du Québec (CMQ), the College of FamilyPhysicians of Canada (CFPC), and the Royal Collegeof Physicians and Surgeons of Canada (RCPSC)—came together with other key stakeholders to reviewCanada’s postgraduate medical education (PGME)system and develop critical recommendations forchange.

Building on the work of the Future of MedicalEducation in Canada Medical Doctor (FMEC MD)Education Project, the FMEC PG project examinedPGME as part of the learning continuum for physi-cians, focusing on medical students as they move intopostgraduate training and, later, into practice. Manyof the reforms it recommends echo those identifiedin the FMEC MD project, emphasizing the impor-tance of making consistent changes across theeducational continuum.

The foundation of the FMEC PG project has been theidentification of a comprehensive base of evidence,including a literature review, stakeholder interviews,and an examination of international best practices.Recommendations and action plans were drafted andrefined through an iterative process involving exten-sive consultations with many stakeholders.

The project culminated in 10 recommendations forchange, each one backed by a key transformativeaction and other actions that will require a collectivewill to implement. These changes are needed to moreeffectively transform our PGME system and to act asan anchor for others to come in the future.

The action items also identify key stakeholders (listedin alphabetical order) whose involvement as leadersis essential. The leadership of these critical playersimplies ongoing dialogue and collaboration as well asthe creation of specific plans for the implementationphase of this project. In all cases, there is an open invi-tation for involvement by others, where interest orneed arises.

This report is intended to be considered in its entirety,as effective, sustainable change will require the implementation of each and every one of its 10 recommendations. This can only be accomplishedwith the engagement of all stakeholders, includingresident learners and their national representativeorganizations.

E X E C U T I V E S U M M A R Y


GUIDING PRINCIPLESThe recommendations are grounded in four guidingprinciples that encapsulate the strongly held viewsthat emerged from both the FMEC MD and PG projects and provide the lens through which the recommendations in this report are to be interpreted:

1. Align Physicians’ Learning around the Health andWell-Being of Patients and Communities

2. Ensure Patient Safety and Quality Patient Care

3. Value, Model, and Integrate Interprofessionalismand Intraprofessionalism into Resident Learningand Practice

4. Integrate State-of-the-Art Technology

RECOMMENDATIONS

#1 Ensure the Right Mix, Distribution, andNumber of Physicians to Meet SocietalNeeds

The recommendation states:

In the context of an evolving healthcare system, the PGME system must continuously adjust its training programs to produce the right mix, distri-bution, and number of generalist and specialistphysicians—including clinician scientists, educators,and leaders—to serve and be accountable to theCanadian population. Working in partnership withall healthcare providers and stakeholders, physiciansmust address the diverse health and wellness needsof individuals and communities throughout Canada.

This recommendation, and the concept that we mustadjust our physician workforce for the future, is fundamental. We need physicians in all corners of ourcountry who have the right skill sets; and we need abalance of generalists and specialists, including clinician scientists, educators, and leaders. In map-ping the right mix, distribution, and number ofphysicians needed across the country against societalneed, several key factors must be kept in mind. These

include the increasing importance of team-based care,changing scopes of practice of physicians and otherhealthcare providers, and how the professions interactin generating and disseminating information.

KEY TRANSFORMATIVE ACTIONS

Create a national approach, founded on robust data,to establish and adjust the number and type of specialty positions needed in Canadian residencyprograms in order to meet societal needs.

and

Establish a national plan to address the training andsustainability of clinician scientists.

Implementation of this recommendation must be ledby the Association of Canadian Academic HealthcareOrganizations (ACAHO), AFMC (Committee onPGME, Canadian Post-M.D. Education Registry[CAPER]), Canadian Academy of Health Sciences(CAHS), CFPC, CMQ, federal/provincial/territorial(F/P/T) governments, and RCPSC.

#2 Cultivate Social Accountability throughExperience in Diverse Learning and WorkEnvironments


Responding to the diverse and developing healthcareneeds of Canadians requires both individual and collective commitment to social accountability.PGME programs should provide learning and workexperience in diverse environments to cultivate socialaccountability in residents and guide their choice offuture practice.

Health care is becoming more ambulatory and community-based. During their training, residentsneed to experience different types and contexts ofpractice, including and extending beyond AcademicHealth Science Centres. These different settings willhelp inform career decisions.

4

KEY TRANSFORMATIVE ACTION

Provide all residents with diverse learning environ-ments that include varied practice settings, andexpose them to a range of service delivery models.

Implementation of this recommendation needs to beled by ACAHO, AFMC (Committee on PGME),CFPC, CMQ, Medical Council of Canada (MCC),and RCPSC.

#3 Create Positive and Supportive Learningand Work Environments

This recommendation states:

Learning must occur in collaborative and support-ive environments centred on the patient and basedon the principle of providing the highest quality ofcare in the context of teaching and learning the necessary competencies.

There needs to be a focus on professionalism andteam-based care. Both the privilege of being a physi-cian and the responsibilities that accompany it needto be emphasized. A careful balance is required toensure that our future physicians combine the best ofscientific knowledge and its application with exem-plary, patient-centred care.


Provide residents with adequate opportunities to learn and work in environments that foster respect among professions and are reflective of aninterprofessional and intraprofessional, collabora-tive, patient-centred approach to care.

1 Competency is defined as “an observable ability of a health professional, integrating multiple components such as knowledge, skills,values and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition.” Frank JR, SnellL, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher.2010;32:638-45.

2 Competency-based education (CBE) is an approach to preparing physicians for practice that is fundamentally oriented to graduateoutcome abilities and organized around competencies derived from an analysis of societal and patient needs. It deemphasizes time-based training and promises greater accountability, flexibility, and learner centredness. Medical teacher: 2010; 32: 631–637

Implementation of this recommendation needs to beled by ACAHO and the medical schools (PGMEDeans and PGME programs).

#4 Integrate Competency1-Based Curriculain Postgraduate Programs


Develop, implement, and evaluate competency-based, learner-focused education to meet the diverselearning needs of residents and the evolving health-care needs of Canadians.

Competency-based education2 is still in its infancy. Itinvolves moving away from a strictly time-basedtraining model towards one that identifies the specific knowledge, skills, and abilities needed forpractice. Some of these competencies will be genericand needed by all physicians; some will be specific tospecialties or groups of specialties; and others will bespecific to the needs of particular communities. Eachneeds to be identified, explicitly taught, and assessed.


Develop and implement competency-based trainingprograms.

Implementation of this recommendation needs to beled by the AFMC (Committee on PGME), CFPC,CMQ, and RCPSC.


#5 Ensure Effective Integration andTransitions along the EducationalContinuum


The Canadian PGME system prepares physicians forpractice. This requires development through theincrease of responsibility across the medical educa-tion continuum and effective transitions fromUGME into PGME, within PGME, and from PGMEinto practice.

The transitions from medical school to residency and,later, into practice are key opportunities for learning;however, they need to be managed and used moreeffectively. In particular, entry to residency and thefinal year of residency training need to be betterstructured to maximize learning and readiness topractice. The different phases of training also need tobe better integrated.


Develop smoother and more effective transitionsfrom medical school to residency and from PGMEinto clinical practice:

a. Review and redesign current practices and sys-tems (e.g., the entry-into-residency process).

b. Link the individual learner competencies devel-oped in MD training with the educationalobjectives set for the resident.

c. Review the timing of national examinations.

d. Develop strategies to increase flexibility toswitch disciplines while in training or when re-entering residency training.

Implementation of this recommendation needs to beled by ACAHO, AFMC (committees on PGME andUGME), Canadian Association of Internes andResidents (CAIR), Canadian Resident MatchingService (CaRMS), Canadian Federation of MedicalStudents (CFMS), CFPC, CMQ, Féderation médicaleétudiante du Québec (FMEQ), Féderation desmédecins résidents du Québec (FMRQ), MCC, medical schools, and RCPSC.

#6 Implement Effective Assessment Systems


Assess competence and readiness to practice througha combination of formative and summative feedbackand assessments.

The science of assessment is continually evolving, andthere is increasing recognition that new assessmenttools are required as we further develop competency-based medical education. Assessments need to beappropriately timed to provide ongoing feedback tolearners and to maximize all learning opportunitieswithin a residency program.


Provide residents with regular and adequate forma-tive feedback from multiple sources on both theirindividual and team performance, including theidentification of strengths and challenges, to supportprogressive attainment of competence along thelearning continuum.

Implementation of this recommendation needs to beled by the AFMC (Committee on PGME), CFPC,CMQ, Federation of Medical Regulatory Authoritiesof Canada (FMRAC), MCC, and RCPSC.

#7 Develop, Support, and Recognize Clinical Teachers


Support clinical teachers through faculty develop-ment and continuing professional development(CPD), and recognize the value of their work.

Teaching of residents in medicine now occurs in awide range of clinical settings, with instruction by avariety of physicians and other healthcare profes-sionals—all of whom possess varying levels ofteaching skills. Clinical teachers should be supportedto provide excellent instruction, responsible role-modelling, and effective feedback and assessment.

6

Teachers must be provided with effective and appro-priate faculty/professional development support inorder to optimize educational outcomes and recogni-tion (e.g., remuneration, academic merit/promotion,awards).


Develop a national strategy for faculty developmentand CPD that is accessible, comprehensive, and supports the spectrum of clinical teaching activities,including the teaching, assessment, and role model-ling of CanMEDS and CanMEDS-FM roles.

Implementation of this recommendation needs to beled by ACAHO, AFMC (committees of PGME,Faculty Development, and CPD), the CanadianAssociation for Medical Education (CAME), CFPC,the Canadian Medical Association (CMA), CMQ, andRCPSC.

#8 Foster Leadership Development

This recommendation states:

Foster the development of collaborative leadershipskills in future physicians, so they can work effectively with other stakeholders to help shape ourhealthcare system to better serve society.

Both the FMEC MD and PG projects recognize thatcollaborative MD leadership is essential. Leadershipdevelopment must begin in medical schools and befurther developed through residency and into practice.


Develop, in close collaboration with UGME programs, a national core leadership curriculum forall residents that is focused on professional respon-sibilities, self-awareness, providing and receivingfeedback, conflict resolution, change management,and working as part of a team as a leader, facilitator,or team member.

Implementation of this recommendation needs to beled by AFMC (committees on UGME and PGME),CAIR, CFPC, CMA, CMQ, FMRQ, and RCPSC.

#9 Establish Effective CollaborativeGovernance in PGME


Recognizing the complexity of PGME and the healthdelivery system within which it operates, integratethe multiple bodies (regulatory and certifying col-leges, educational and healthcare institutions) thatplay a role in PGME into a collaborative governance structure in order to achieve efficiency, reduce redun-dancy, and provide clarity on strategic directions anddecisions.

There is widespread acknowledgement that thePGME system in Canada is complex and, at times,somewhat inefficient. There are many stakeholders,decision points, governance challenges, and vestedinterests involved. Some of these interests must berecognized and supported, while others require re-evaluation and reconceptualization in order to create more effective governance.


Identify organizations that have decision-makingauthority in PGME and define roles that could betterstreamline and enhance their collaboration throughthe study of governance models and the implemen-tation of the one that promotes the greatest efficiencyand effectiveness.

Leadership for the implementation of this recom-mendation needs to come from ACAHO, AFMC,CAIR, CFPC, CMQ, F/P/T governments, FMRAC,FMRQ, hospitals, MCC, and RCPSC.


#10Align Accreditation Standards


Accreditation standards should be aligned across thelearning continuum (beginning with UGME andcontinuing through residency and professional practice), designed within a social accountabilityframework, and focused on meeting the healthcareneeds of Canadians.

Much of the same information is gathered severaltimes over. The standards of accreditation can be setby the appropriate body, but the conduct of accredi-tation can be shared and aligned. Standards oftraining and accreditation systems are in place toensure that quality physician are trained. It is up tothese systems to ensure that physicians in training areprepared for practice and maintain their competencethroughout their careers.


Facilitate and enable a more integrated PGME system by aligning accreditation standards andprocesses across the continuum of learning in theUGME, PGME, and CPD environments.

This recommendation must be led by the accreditingagencies of UGME, PGME, and CPD, AFMC, CFPC,CMA, CMQ, FMRAC, and RCPSC.

The challenge for us all is to achieve a collectivevision, including not only learners and teachers butalso provincial governments and the broaderCanadian public. We hope that this report and recommendations will accomplish this.

8

Over the last century, major changes have created increasing demands on the delivery ofhealth care in this country. Canadians are

living longer. Many people are experiencing multiplechronic diseases, which has generated the need formore community-based services. Ongoing healthcarechallenges continue and new threats to public healtharise, while scientific discoveries and the rapid evolu-tion of medical technologies have a profoundinfluence on the way in which medicine is practiced.Expectations on the parts of patients, their families,and their communities are continuously changing,and demands are growing that the healthcare systembe accountable for safety, quality, timeliness, andequitable access to services. Scopes of practice are alsoevolving. Team-based care is becoming the norm.Better service delivery models are being developed.The healthcare needs of Canadians are being moreclearly defined, and the education of providers mustrespond to them.

Physicians of the future “need a broad knowledgebase and strong clinical competencies to enter practice. Through lifelong learning the physician ofthe 21st century will be a skilled clinician, able toadapt to new knowledge and changing patterns ofillness as well as new interventions, personalizedtherapeutics, and rapidly changing medical scienceand healthcare systems. Physicians will need to beindependent and critical thinkers, capable ofappraising evidence free from personal bias andinappropriate influence.”3

The education of Canada’s future physicians is critical to addressing Canadians’ changing needs andexpectations. Governments across the country arefacing significant budgetary challenges, resulting in more demand being placed upon healthcare organizations and providers to demonstrate fiscal

accountability. The reality of provincial responsibil-ity for health care must be acknowledged as we moveforward with changes to our healthcare system andmedical education.

Collective planning and action is central to addressingthese challenges. Medical education plays a vital rolein developing the different types of physicians neededby Canadians. Physicians, as products of the medicaleducation system, must be ready to practice within anintegrated healthcare system that is designed todeliver the highest quality of care to the people itserves.

Physician training in Canada is recognized worldwidefor its high standards. The excellence that exists in this country can be attributed to the thousands ofmedical educators and leaders who believe in theircollective responsibility for educating the physiciansneeded now and in the future. To ensure that medicaleducation remains responsive to what Canadiansexpect of their physicians, a comprehensive review ofphysician education in Canada is timely.

The first initiative of this kind in recent years was theFuture of Medical Education in Canada MedicalDoctor (FMEC MD) Education Project. Building onthe work of the FMEC MD project, the Future ofMedical Education in Canada Postgraduate (FMECPG) Project examined postgraduate medical educa-tion (PGME) as part of the learning continuum forphysicians, focusing on medical students as they moveinto postgraduate training and, later, into practice.Many of the reforms it recommends echo those iden-tified in the FMEC MD project, emphasizing theimportance of making consistent changes across theeducational continuum.

I N T R O D U C T I O N

3 The Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada: A Collective Vision for MDEducation. Ottawa, ON: The Association; 2010.


THE FUTURE OF MEDICAL

EDUCATION IN CANADA

MEDICAL DOCTOR

EDUCATION PROJECT The FMEC MD project, led by the Association ofFaculties of Medicine of Canada (AFMC), was initi-ated by medical educators and leaders as an update tothe 1910 Abraham Flexner Report,4 which examinedmedical education in Canada and the United States.The project, which ran from 2007 to 2010, focused onenhancing the delivery of undergraduate medicaleducation (i.e., training towards the attainment of amedical degree) in Canada.

Ten main recommendations and five enabling rec-ommendations were made in the project report, TheFuture of Medical Education in Canada: A CollectiveVision for MD Education.5 Regional, national, andinternational interest has been garnered since therelease of the recommendations, which identified howundergraduate medical education (UGME) needed tobe enhanced to produce the type of physician collec-tively envisioned for the future (for more details onthe recommendations, please refer to page 41):

RECOMMENDATIONS:

1. Address Individual and Community Needs

2. Enhance Admissions Processes

3. Build on the Scientific Basis of Medicine

4. Promote Prevention and Public Health

5. Address the Hidden Curriculum

6. Diversify Learning Contexts

7. Value Generalism

8. Advance Interprofessional and IntraprofessionalPractice

9. Adopt a Competency-Based and FlexibleApproach

10. Foster Medical Leadership

ENABLING RECOMMENDATIONS:

A. Realign Accreditation Standards

B. Build Capacity for Change

C. Increase National Collaboration

D. Improve the Use of Technology

E. Enhance Faculty Development

THE FUTURE OF MEDICAL

EDUCATION IN CANADA

POSTGRADUATE PROJECT The Health Canada-funded FMEC PG Project wasundertaken in February 2010 by a consortium of fourorganizations: the AFMC (which served as theSecretariat), le Collège des Médecins du Québec(CMQ), the College of Family Physicians of Canada(CFPC) and the Royal College of Physicians andSurgeons of Canada (RCPSC). The initiative focusedon enhancing postgraduate residency education (i.e.,training to the point of independent practice) inCanada.

The FMEC PG project linked to and built upon thework of the FMEC MD project. With the vision of thephysician of the future defined, this second phase captured the collective wisdom and aspirations of theCanadian public, leaders in health professionals’ education, decision-makers, and policy-makers onhow PGME in Canada needed to change to fulfill thisvision.

The FMEC PG project was designed to examine andassess the systems, programs, and processes of thePGME environment. Building on the successful

4 Flexner, A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching.Bulletin No. 4. New York: Carnegie Foundation; 1910.


10

model used by the FMEC MD project, a rigorousreview was undertaken from February 2010 to March2012, involving hundreds of stakeholders (a fulldescription of this process is described in theMethodology section of this report).

As a result of this work, 10 recommendations weredeveloped to enhance the strong PGME systemalready in place. The changes suggested aim tostrengthen the role of medical educators and leadersin producing the type of physicians needed for thefuture—and are intended as a call to action. Thegreatest hope for the FMEC PG project lies in itsopportunity to influence the production and distribution of the right number, mix, and type ofpractice-ready physicians across Canada.

A COLLECTIVE VISION FOR

MEDICAL EDUCATION The FMEC PG project shares the same vision of medical education as its predecessor:

Medical education in Canada must ensure that keycompetencies are attained by every physician whilesimultaneously providing a variety of learningpaths and technologies that prepare students fordiverse roles in their future careers.6

The seamless integration of MD training and PGMEis critical in order to respond to the evolving needs ofCanadians. It is, therefore, not surprising that many ofthe themes that emerged through the FMEC MDproject have resurfaced as important issues for thefuture of PGME. In both educational environments,the primacy of medical education’s social accounta-bility role in health care emerged as its coreraison-d’être. Social accountability must informphysician training, with the health and well-being ofpatients and their communities providing theunequivocal focal points for medical education.Equally, it is held that physicians must work within ahealthcare system founded on quality, patient safety,

and patient-centred care. The medical education sys-tem must create physicians who are both competentand committed to practicing medicine in this way.

Advancing interprofessional and intraprofessionalcare and the abilities of physicians to work effectivelyin healthcare teams have emerged as other stronglyheld views on the manner in which physicians mustbe trained to provide effective, patient-centred care.Another area of emphasis is the need to ensure thatphysicians practice medicine in an evidence-informedmanner.

THE CONTEXT OF CANADIAN

POSTGRADUATE MEDICAL

EDUCATION To understand how the recommendations in thisreport are interrelated and aligned with the FMECMD recommendations, it is important to understandthe context within which residents are educated.Medical education is a lifelong learning journey. It ishelpful to consider the points of transition along whatis described as the continuum of medical education,as medical students develop into practicing physi-cians.

FROM MEDICAL SCHOOL TO

RESIDENCY TRAINING In their last year of medical school, medical studentschoose and are then matched to a specialty residencyprogram affiliated with one of the 17 CanadianFaculties of Medicine. Each of these university-baseddegree programs is responsible for providing resi-dency programs that meet accreditation standards setby either the CFPC or the CMQ (in Quebec) for thespecialty of family medicine; or by the RCPSC or theCMQ (in Quebec) for all other specialty programs.



Once residents complete their training, they mustprovide evidence of satisfactory completion of theirresidency program and pass the CFPC or RCPSCexamination in order to become certificants of theirrespective colleges. The CMQ no longer has separateexams and recognizes those of the CFPC and RCPSC;however, CMQ certification is necessary to practicein Quebec. To practice medicine in a province inCanada, graduates must also successfully pass theNational Licensing Examinations (Licentiate of theMedical Council of Canada - parts I and II). Withthese qualifications obtained, a resident is ready forpractice upon completion of a residency program.

For some residents, the learning journey continuesinto a subspecialty area. For others, a choice is madeto undertake enhanced skills training with a certifi-cate or diploma of added competence. Theseadditional qualifications are recognized in variousways within different healthcare organizations.

FROM RESIDENCY TRAINING

TO PRACTICE IN CANADAOnce in practice, all physicians must maintain a levelof competence that meets the needs of their practicepopulation in order to retain their medical licence topractice. The pursuit of continuing professionaldevelopment has become a mainstay of practice forall physicians.

THE UNIQUE ROLES OF THE

RESIDENT AS STUDENT,

TEACHER, AND CARE-

PROVIDERResidents are learners throughout their residencytraining. Residents are also clinical service providersthrough their affiliation with the healthcare organi-zations in which they train. They also play an

important role in teaching and as role models to med-ical students and other trainees. Each of these roles isessential to the development of competence—in par-ticular, the ability to function as a member of anintegrated healthcare delivery system. Residents aresupervised by staff physicians but also provide directpatient care. As such, they receive monetary compen-sation for their clinical service duties from theirprovincial ministries of health and belong to a resi-dent-specific employee union or professionalassociation in their respective provinces.

STAKEHOLDERS INVOLVED IN

THE CANADIAN

POSTGRADUATE MEDICAL

EDUCATION SYSTEMThe multiple roles of the resident as learner, teacher,and service-provider result in a complex network ofstakeholders who represent a diversity of interests andare involved in many different aspects of PGME inCanada. They include, but are not limited to, univer-sities, accrediting colleges, specialty societies,provincial regulatory licensing bodies, provincialministries of education and health, healthcare organ-izations, national and provincial residents’associations, national and provincial associationsinvolved in care or medical education issues, resi-dents, faculty, clinical providers, patients,government, and policy-makers.

The interconnectivity of these groups helps to definea system of players—all of whom support and have arole to play in the delivery of PGME. The recommen-dations in this report are aimed at all stakeholders,because a coordinated approach, anchored in a col-lective vision for medical education in Canada, is vitalto success.

12

FROM SHARED VISION TO

COLLECTIVE ACTIONThe FMEC PG project reflects collaboration at itsbest. The ideas and interests of those inside and outside medicine and medical education have beencollected through an extensive consultation processand rigorous literature review. This report capturesthe many ideas, aspirations, and commitments ofCanadians who are directly and indirectly connectedto medical education and health care. The 10 recom-mendations in this report encompass the collectivewisdom of constituents and educational leadersacross Canada.

Acknowledged as a highly iterative project, furtherinput from the community is anticipated as the recommendations move forward and discussions areheld on how implementation will take place. Theremust be commitment from and shared accountabilityby all stakeholders in order to succeed. Leadershipwill be required by certifying bodies, regulators, governments, hospitals, the AFMC, the MedicalCouncil of Canada (MCC), and Canada’s medicalstudent and resident organizations. The establish-ment of realistic timelines for implementation of the recommendations is a critical step.

Each recommendation identifies at least one keytransformative action, along with other actions thatrequire implementation in order to effectivelyimprove the system. The action items also identify keystakeholders (listed in alphabetical order) whoseinvolvement as leaders is essential. The leadership ofthese critical players implies ongoing dialogue andcollaboration as well as the creation of specific plansfor the implementation phase of this project. In allcases, there is an open invitation for involvement byothers, where interest or need arises.

This report is intended to be considered in its entirety,as effective, sustainable change will require the implementation of each and every one of its 10 rec-ommendations. This can only be accomplished withthe engagement of all stakeholders, including residentlearners and their national representative organiza-tions.

The consortium partners and committee mem-bers involved in this initiative are excited by thepossi b i lities contained in this report and its recom-mendations. It is shared with enthusiasm with allwho have a role in shaping the future of PGME inCanada.


R E C O M M E N D AT I O N S

Ten priority areas emerged from the evidence gathered during the FMEC PG project. They are encapsulatedin the 10 recommendations presented on the following pages. Each recommendation also includes transfor-mative actions and a brief rationale.

E N S U R E T H E R I G H T M I X ,D I S T R I B U T I O N , A N D N U M B E R O FP H Y S I C I A N S T O M E E T S O C I E TA L N E E D S

1:

ACTIONS: 1. Create or gather evidence-based data to assess

provincial and health human resource (HHR)needs.

2. Create a national approach, founded on robustdata, to establish and adjust the number and typeof specialty positions needed in Canadian resi-dency programs in order to meet societal needs.Leadership: Association of Canadian AcademicHealthcare Organizations (ACAHO), AFMC(Committee on PGME, Canadian Post-M.D.Education Registry [CAPER]), CFPC, CMQ, federal/provincial/territorial (F/P/T) governments,RCPSC.7

3. Establish a national plan to address the trainingand sustainability of clinician scientists.Leadership: AFMC, Canadian Academy of HealthSciences (CAHS), CFPC, CMQ, RCPSC.

4. Building on the experience of other countriesand the province of Quebec, develop and implement a pan-Canadian HHR strategy thatrecognizes and respects jurisdictional issues andenables the F/P/T process to respond effectivelyto the health and wellness needs of society.Leadership: AFMC (Committee on PGME), CFPC,CMQ, F/P/T governments), RCPSC.

RECOMMENDATION

In the context of an evolving healthcare system, the PGME system must continuously adjust its training programs to produce the right mix, distribution, and number of generalist and specialist physicians—including clinician scientists, educators, and leaders—to serve and be accountable to the Canadian population.Working in partnership with all healthcare providers and stakeholders, physicians must address the diversehealth and wellness needs of individuals and communities throughout Canada.

7 A complete list of abbreviations is provided in the Glossary on page 40. Organizations identified under the “Leadership” section ofeach action item are listed in alphabetical order. Groups listed are not seen as having exclusive responsibility for implementing theaction; rather, it is suggested that they lead the discussion in this regard, in collaboration with other relevant stakeholders.

14

5. Continually adjust medical schools’ residencytraining programs and resources to anticipateand respond to local, provincial, and nationalHHR needs. Leadership: CFPC, CMQ, F/P/T governments, medical schools, RCPSC.

6. Effectively integrate international medical graduates (IMGs) as part of the Canadian HHRstrategy. Leadership: AFMC (Committee onPGME), CFPC, CMQ, F/P/T governments,RCPSC.

7. Provide career- and workforce-planning infor-mation to medical students and residents toensure better alignment with HHR needs.Leadership: AFMC (committees on UGME andPGME), F/P/T governments.

RATIONALE: Canadians deserve a healthcare system that respondsto their evolving and diverse healthcare needs. Yet,gaps in health services exist. Marginalized individuals,such as those living in remote communities,Aboriginal and refugee populations, the urban home-less, and increasing numbers of the elderly, facesignificant barriers to accessing the care they need.Although family physicians are trained to providefront-line health care to meet most people’s needs,other generalists, such as general internists, generalpaediatricians, general psychiatrists, and general sur-geons, are also needed in many communities. Whilespecialists with focused areas of practice will alwaysbe required, the complement ratio of generalistsshould be higher than that of specialists. But that bal-ance is askew. Even though generalist physicians couldprovide care to many underserved populations andhelp close the current gap in services, there are notenough physicians graduating from residency train-ing programs who are continuing to practice asgeneralists. More important than the actual numberof practitioners is the effective scope of practice of thespecialist. Residency training must instill in residents

the importance of maintaining a generalist scope ofpractice (regardless of their specialist title) and equipthem to meet this mandate.

To be socially accountable, the PGME system mustproduce the right mix, number, and distribution ofphysicians across the country in order to meet theidentified healthcare needs of Canadians. Socialaccountability requires us to be good stewards ofHHR and financial resources. By committing to acoordinated and strategic planning process, leadersacross the PGME system can propel this accountabil-ity agenda forward. Strategic planning, combinedwith collaborative stewardship among stakeholders,is vital. Canada also needs to remain at the forefrontof scientific advancements and, as such, must con-tinue to train research physicians as clinicianscientists. It also needs to produce clinician educatorsand leaders.

While we advocate for the development of a pan-Canadian agenda in facilitating socially accountablehealth care, we also recognize the inherent need forthe flexible adaptation and implementation of suchan agenda in different jurisdictions across Canada.Whereas national consensus may be reached on principles, their application will necessarily hinge onlocal needs and capacities. We expect that, through anational dialogue, shared interests for PGME will bearticulated to address such topics as the movement ofphysicians across provincial boundaries; remunera-tion structures; the differing needs of rural and urbanhealth care; job security; and changing scopes of practice (subspecialties and diploma programs), jux-taposed with geographic disparities and demographicchanges. Flexibility and adaptability will be requirednot only in adjusting the type, location, and numberof residency training programs and positions but alsoto facilitate career choice changes. Opportunities for transfers during residency training, as well asretraining over physicians’ careers and practicechanges, must be available and supported.


Canadian medical schools are the main source ofCanadian physicians and have increased their enroll-ment by approximately 50 percent over the pastdecade to address physician shortages. IMGs will continue to play an important role in the Canadianhealthcare system: Integrating them effectively will befundamental to achieving the right mix, number, anddistribution of physicians. This will require concertedaction by governments, including immigrationauthorities, licensing authorities, universities, andhealth systems. The Canadian PGME system providestraining for many IMGs (the number of IMGs entering PGME in Canada has increased by morethan 400 percent over the past decade). All traineesmust have an understanding of the healthcare system,culture, and regulations. Since those receiving MDtraining in another jurisdiction may be disadvantagedin this regard, introductory programs should bedeveloped to enable them to enter and progressthrough their PGME program and take full advantageof learning opportunities.

16

ACTIONS:1. Provide all residents with diverse learning envi-

ronments that include varied practice settings,and expose them to a range of service deliverymodels. Leadership: ACAHO, AFMC (Committeeon PGME), CFPC, CMQ, MCC, RCPSC.

2. Provide and support experiences for all residentsthat focus on improving the health and healthcare of underserved and disadvantaged popula-tions. Develop residents’ understanding of andrespect for variations in the health, well-being,and needs of different patients and communities.Leadership: AFMC (Committee on PGME), CFPC,CMQ, RSPSC.

3. Develop career-planning resources and supports,including mentors and positive role models.Leadership: CFPC, CMQ, medical schools (PGMEprograms), RCPSC.

C U LT I VAT E S O C I A L A C C O U N TA B I L I T YT H R O U G H E X P E R I E N C E I N D I V E R S EL E A R N I N G A N D W O R K E N V I R O N M E N T S

2:

RATIONALE: Twenty-first century health care is becoming increasingly ambulatory and community-based innature and can only be delivered effectively by well-functioning, multi-professional teams. As such,residents need to experience diverse learning envi-ronments that reflect changing realities, including theneed for more generalists.

Disadvantaged populations require special attentionfrom the healthcare system and provide a focus fortraining residents to better understand the determi-nants of health and the differing needs of patients,communities, and health service delivery models. Theinvolvement of residents in projects to improve thehealth and health care of underserviced and disad-vantaged populations can have an immediate impacton health care and inspire residents’ future service.There are also changing healthcare delivery models:Family Health Teams in Ontario, the CFPC’s PrimaryMedical Care Home, the utilization of physicianassistants in both primary and specialty settings, andalternate funding plans for academic centres, to namea few. Learners need experience in these models andto understand their potential impact on access andquality.

Given the complexities and uncertainties of predict-ing Canada’s future needs for particular types ofphysicians, career planning is daunting not only forresidents but also for medical educators and healthsystem planners. More collective planning and analysis is needed to ensure the provision of appro-priate resources and supports, including mentoringto residents as they make career decisions.

RECOMMENDATION

Responding to the diverse and developing healthcare needs of Canadians requires both individual and collective commitment to social accountability. PGME programs should provide learning and work experiencein diverse environments to cultivate social accountability in residents and guide their choice of future practice.


ACTIONS: 1. Provide resident training that models and reflects

patient-centred care and that ensures quality,safety, and accountability. Leadership: ACAHO,AFMC (Committee on PGME).

2. Provide residents with adequate opportunities tolearn and work in environments that fosterrespect among professions and are reflective ofan interprofessional and intraprofessional, collaborative, patient-centred approach to care.Leadership: ACAHO, medical schools (PGMEDeans and PGME programs).

3. Advance and apply knowledge to gain a betterunderstanding of the factors that optimize performance, learning, and wellness. Leadership:AFMC (Committee on PGME), CFPC, CMQ,medical schools, RCPSC.

4. Research and address issues of resident fatigue,sleep deprivation, and other factors affectingpatient safety, quality of care, resident learning,and resident health. Leadership: ACAHO, AFMC(committees on PGME and Physician and StudentHealth), Canadian Association of Internes and Residents (CAIR), Canadian Federation of Medical Students (CFMS), CFPC, CMQ,Féderation médicale étudiante du Québec(FMEQ), Féderation des médecins résidents duQuébec (FMRQ), RCPSC.

5. Identify and address both positive and negativeaspects of the hidden curriculum in learning andwork environments. Leadership: CFPC, CMQ,RCPSC, medical schools.

C R E AT E P O S I T I V E A N D S U P P O R T I V EL E A R N I N G A N D W O R K E N V I R O N M E N T S3:

RATIONALE:The main learning and work environment for residents is our complex healthcare system. In addition to contributing to patient care, the servicethat residents provide is a source of foundational,experiential learning that fosters their developmentas the doctors of tomorrow. Patient-centred care thatensures quality, safety, and accountability is vitallyimportant to both the care of patients and the preparation of residents for practice.

While patient care is a core service provided by resi-dents and is foundational to their learning, residentfatigue is a significant phenomenon that can have anegative effect on patient safety, resident learning,and resident health. More research is needed toinform the development of training programs thatbalance duty hours with other learning modalities,including simulation, needed to develop competence.

The hidden curriculum is defined in Recom -mendation 5 of the FMEC MD Education ProjectCollective Vision as a “set of influences that functionat the level of organizational structure and culture,affecting the nature of learning, professional interac-tions, and clinical practice.” Role-models, attitudes,and conversations all affect daily working conditionsand also have an important long-term influence on the approach that young professionals take totheir lives, practices, and career choices. A criticalexamination of the impact of the hidden curriculumon residents’ learning and work environments is afirst step in addressing this.

Positive learning and work environments contributeto better learning and patient care.

RECOMMENDATION

Learning must occur in collaborative and supportive environments centred on the patient and based on theprinciple of providing the highest quality of care in the context of teaching and learning the necessary competencies.

18

ACTIONS:1. Conduct a thorough, evidence-based review of

competency-based training model options thatmost effectively develop readiness to practice byspecialty. Leadership: CFPC, CMQ, RCPSC.

2. Develop and implement competency-based training programs. Leadership: AFMC (Committeeon PGME), CFPC, CMQ, RCPSC.

3. Show evidence that program standards and resi-dent competencies are relevant to society’sevolving healthcare needs. Leadership: AFMC,CAIR, CFPC, CMQ, FMRQ, RCPSC.

4. Share curricular innovations and best practicesamong medical schools and residency training programs. Leadership: AFMC, CAIR, FMRQ.

I N T E G R AT E C O M P E T E N C Y 8 - B A S E DC U R R I C U L A I N P O S T G R A D U AT EP R O G R A M S

4:

RATIONALE: According to the latest census data, nearly 80 percentof Canadians live in urban areas. Serving the health-care needs of all Canadians, however, means that wemust adapt our training of doctors to meet theunique healthcare interests of both the minority andmajority of the population. To adequately meet theneeds of rural and remote communities, as well asmarginalized groups, curricula must be adapted toprovide residents with exposure to different popula-tions and service delivery models, both within andoutside urban and large tertiary-care centres.

Canadians’ evolving healthcare needs must drive and guide the competence9 required of physicians. As society’s healthcare needs shift, the requisite com-petencies for physicians will also shift. In other words,competencies must be defined on the basis of indi-vidual and community health needs. By workingtogether, medical schools, the CFPC, CMQ, andRCPSC can establish a process whereby competenciesare periodically reviewed and articulated to ensurethat the right generalist and specialist skills are devel-oped for quality patient care in all settings.

RECOMMENDATION

Develop, implement, and evaluate competency-based, learner-focused education to meet the diverse learningneeds of residents and the evolving healthcare needs of Canadians.

8 Competency is defined as “an observable ability of a health professional, integrating multiple components such as knowledge, skills,values and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition.” Frank JR, SnellL, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher.2010;32:638-45.

9 Competence is defined as “the array of abilities across multiple domains or aspects of physician performance in a certain context…multi-dimensional and dynamic… changes over time, experience, and setting. (Frank JR, Snell L, Cate OT, Holmboe ES,Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45.)


Residency training should provide learning experi-ences that support the development of definedrequisite competencies. We also recognize that a flexible, learner-centred curriculum is critical todeveloping competent physicians. Flexibility requiresthat we use a blend of time-based milestones andcompetency assessment to guide learning and progression through residency programs.

We have made significant strides in integrating theCanMEDS10 and CanMEDS-FM11 competencyframeworks into the PGME curricula. Undergra -duate and continuing professional developmentcurricula are also incorporating CanMEDS, providing greater fluidity and uptake of identifiedcompetencies. Readiness to practice is an essentialmarker for successful completion of resident training. Curriculum and assessment should be fashioned around this objective, with time-basedmilestones and demonstration of competencies ascomplementary markers of success. Residency training must equip residents with the tools for self-reflection and self-assessment, so they maintaincompetence throughout their careers.

10 Frank, JR. (Ed). The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: TheRoyal College of Physicians and Surgeons of Canada. (http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf).Revised 2005. Accessed January 5, 2012.

11 CanMEDS – Family Medicine. Working Group on Curriculum Renewal. The College of Family Physicians of Canada. (http://www.cfpc.ca/WGPCResources/). Accessed January 5, 2012.

20

ACTIONS:1. Develop smoother and more effective transitions

from medical school to residency and fromPGME into clinical practice:

a. Review and redesign current practices andsystems (e.g., the entry-into-residencyprocess).

b. Link the individual learner competenciesdeveloped in MD training with the educa-tional objectives set for the resident.

c. Review the timing of national examinations.

d. Develop strategies to increase flexibility toswitch disciplines while in training or whenre-entering residency training.

Leadership: ACAHO, AFMC (committees onUGME and PGME), CAIR, Canadian ResidentMatching Service (CaRMS), CFMS, CFPC, CMQ,FMEQ, FMRQ, MCC, medical schools, RCPSC.

2. Review and determine the ideal length and con-tent of PGME training based on competenciesrequired for readiness to practice, including theskills needed to maintain competency in thebreath of the specialty, rather than on traditionaltime-based models. Leadership: AFMC(Committee on PGME), CFPC, CMQ, RCPSC.

3. Provide current information regarding careeropportunities to students and residents prior totheir residency selection with CaRMS.Leadership: AFMC (committees on UGME andPGME), medical schools, F/P/T governments.

E N S U R E E F F E C T I V E I N T E G R AT I O N A N DT R A N S I T I O N S A L O N G T H EE D U C AT I O N A L C O N T I N U U M

5:

4. Facilitate collaboration between PGME andUGME programs to ensure that the latter appropriately prepare students for entry into residency (e.g., through a rigorous and flexibleuse of the final year of medical school that placesemphasis on the acquisition of the skills neededfor residency). Leadership: AFMC (committees onUGME, PGME).

5. Develop a pan-Canadian approach to residentorientation that includes assessment and supple-mentary learning modules for IMGs, as needed,to ensure their readiness to begin PGME.Leadership: AFMC (Committee on PGME), CAIRCFMS, FMEQ, FMRQ.

RATIONALE: The overarching mandate of PGME is to preparephysicians—intellectually, technically, and emotion-ally—for professional practice as members ofinterprofessional teams. Residents’ development,however, begins before and continues beyond postgraduate education. PGME plays an integral rolein supporting residents’ progress along this develop-mental path, a role that involves collaborativeplanning with other leaders in medical education tofacilitate smoother and more effective transitions. Toimprove transitions, a number of focal areas at boththe system and program level deserve attention.

Collaborative planning among medical educationstakeholders is a prerequisite to more effective transitioning to and from residency. Length of train-ing and timing of national examinations are criticalfactors for medical schools, the MCC, CFPC, CMQ,

RECOMMENDATION

The Canadian PGME system prepares physicians for practice. This requires development through the increaseof responsibility across the medical education continuum and effective transitions from UGME into PGME,within PGME, and from PGME into practice.


RCPSC, and others to review. National examinations,which are but one tool for assessing competence,must be considered within the context of an entireassessment process. The UGME and PGME systemsmust also collaborate to devise a plan whereby graduating medical students are optimally preparedfor residency. Similarly, dedicated resources andattention must be applied to the development ofeffective assessment tools. Ensuring the effective integration of IMGs into Canadian residency programs and their transition into practice must bea priority. The development of a national orientationprogram for all graduating MDs and IMGs couldprovide the necessary infrastructure for standardiz-ing entry into residency training. The CanadianPGME system must also improve the sign-off processfor indicating readiness to practice, such that the exitramp for graduating trainees ensures both compe-tency and accountability in the breadth of theirspecialty. The role of mentorship for new graduatesneeds to be developed and promoted.

22

ACTIONS:1. Provide residents with regular and adequate

formative feedback from multiple sources onboth their individual and team performance,including the identification of strengths andchallenges, to support progressive attainment ofcompetence along the learning continuum.Leadership: AFMC (Committee on PGME), CFPC,CMQ, MCC, Federation of Medical RegulatoryAuthorities of Canada (FMRAC), RCPSC.

2. Build a broad framework of assessment tools and methodologies that can be used to provideformative longitudinal feedback. Leadership:AFMC (Committee on PGME), CFPC, CMQ,MCC, RCPSC.

3. Develop summative assessment methodologiesand tools for providing evidence of readiness toenter practice that reflect the integration of allCanMEDS and CanMEDS-FM roles. Leadership:AFMC (Committee on PGME), CFPC, CMQ,MCC, RCPSC.

4. Ensure that adequate funding and flexibility areavailable for residents who require remediation,and develop strategies for the sharing of bestpractices in effective, structured remediation.Leadership: AFMC (Committee on PGME).

I M P L E M E N T E F F E C T I V E A S S E S S M E N TS Y S T E M S 6:

RATIONALE:Residents are expected to develop core competenciesthroughout their residency. The current process ofIn-Training Evaluation Reports (ITERs) is not necessarily reliable for ensuring the quality and rigorof non-medical expert CanMEDS roles. Assessmentprovides mechanisms for focusing attention on staying “on track and on target” to develop practice-ready residents. We should only measure whatmatters. CanMEDS and CanMEDS-FM, for example,emphasize the importance of the interlinked compe-tencies associated with the seven roles that ensure thedevelopment of the complete physician. Patientswant and deserve a medical expert who embodies andintegrates all of the CanMEDS and CanMEDS-FMroles.

Assessment often results in value-laden scores thatideally constitute valid and reliable data. Assessmentis also about a process that must be unequivocallyfair. The major rationale for providing supportive, in-the-moment evaluation and feedback is to developthe competencies to improve patient care. A lesserreason for the need for reliable, valid, and fair assess-ments is increased legal challenges by residents whoassert unfair evaluations. Robust assessment and aproper process are essential to ensure equity amonglearners. More medical education research and faculty development in this area is crucial for bothproper assessment and process.

Educational scholarship has shown that multipleindependent observations enhance validity, and thatdirect observation is the best means of assessing residents’ competencies in providing patient care.

RECOMMENDATION

Assess competence and readiness to practice through a combination of formative and summative feedback andassessments.


While many valuable assessment tools and methodsare currently available, there are opportunities forinnovative new practices in this area. Assessmentmust be based in both simulated and actual clinicalenvironments. Evaluating competencies that appearinherently subjective, such as “effective and appro-priate collaboration,” requires special attention.Furthermore, tools and methods offer utility ifapplied in a consistent fashion. Future improvementsto assessment practices should enhance regular formative feedback in a safe environment, lead tosummative tools and methods, and encourage consistent application. Remediation programs, oftencustomized around specific learner needs, deservegreater attention. Medical education scholarshipshould develop best practices in remediation programming that can be shared through facultydevelopment channels.

On a day-to-day basis, we assess trainees to improvetheir ability to care for patients. In a broader sense,we assess learners and faculty as a means to ensurethe best quality of health care to meet the needs ofCanadians. As a self-regulating profession, we havemade a commitment to the Canadian public to beexpert, professional, and patient-centered. Withsocial accountability as a driver, all stakeholders inthe Canadian PGME system must shift the culture ofmedical education to value assessment as a tool forthe continuous quality improvement of individuallearners, faculty, and the learning environment.

24

ACTIONS:1. Develop a national strategy for faculty develop-

ment and CPD that is accessible, comprehensive,and supports the spectrum of clinical teachingactivities, including the teaching, assessment, androle modelling of CanMEDS and CanMEDS-FMroles. Leadership: ACAHO, AFMC (committees onPGME, Faculty Development, and CPD),Canadian Association for Medical Education(CAME), CFPC, CMA, CMQ, RCPSC.

2. Advocate for university structures that recognizethe promotion of clinical teachers on the basis ofexcellent teaching and scholarship in education.

3. Recognize the issues of clinical teachers in all settings—including community-based, non-ter-tiary care settings—and provide them with themeans to carry out their many roles, includingcaring for patients and taking on increasing clinical teaching responsibilities. Leadership:AFMC (committees on UGME, PGME, CPD),CFPC, CMQ, RCPSC.

4. Identify effective incentives to encourage theongoing professional development of clinicalteachers, including systemic mechanisms (e.g.,licensing, certification, hospital privileges, fund-ing models) and recognition (e.g., remuneration,academic merit/promotion, awards). Leadership:ACAHO, AFMC (Committee on PGME), CMA,CFPC, CMQ, FMRAC, P/T governments, RCPSC.

5. Develop valid, fair, and reliable assessment toolsthrough which residents can safely provide form-ative feedback to clinical teachers to support theirongoing professional development. Leadership:CFPC, CMQ, medical schools (PGME programs),RCPSC.

D E V E L O P, S U P P O R T, A N D R E C O G N I Z EC L I N I C A L T E A C H E R S 7:

6. Recognize the role of residents as teachers andfuture clinical teachers and create and implementa national competency-based curriculum at theresidency level.

RATIONALE: Quality teaching is the sine qua non of resident train-ing, yet the development and recognition of teachingexcellence has not been prioritized accordingly.Greater support for professional development of clinical teachers is required to enable excellent teach-ing and responsible role-modelling. The limitedfinancial resources allocated to CPD, coupled withthe scarcity of medical education mentors, presentschallenges to developing the necessary skills ininstruction, leadership, and role modelling for thosewho teach. While several institutions across the country offer best practices in CPD for clinical teachers, the lack of a national-level partnership ordialogue means that these practices are not wellshared, thereby creating variability across residencyprograms.

The CanMEDS and CanMEDS-FM frameworks offeruseful structures and a range of resources that can beadapted and implemented by teaching sites and universities for targeted faculty development.Through further partnership with the AFMC, CFPC,CMQ, and RCPSC, a national competency-based curriculum and standardized assessment mechanismfor teaching faculty could be developed that leveragesthe tools built through CanMEDS and CanMEDS-FM. Teaching and assessing the competencies withinthese two frameworks requires faculty development.Faculty must be supported to incorporate the latesttechnologies, such as simulation and web-based

RECOMMENDATION

Support clinical teachers through faculty development and continuing professional development (CPD), andrecognize the value of their work.


media, alongside more traditional teaching practicesthat, together, enhance resident learning. Clinicalteachers outside the academic tertiary-care environ-ment must also be supported to deliver thecurriculum through effective role-modelling thatreflects and influences behavioural and practicenorms.

Assessment provides a valuable method to encourageexcellence in teaching. To fully embrace this dual roleof teacher and learner, all clinical teachers must beevaluated on their competencies in teaching and rolemodelling. It is important that assessment and feedback to clinical teachers is collaborative betweenteaching environments, hospitals, academic centers,community offices, and other venues. Faculty assess-ment should be conducted in the spirit of continuousquality improvement: aimed at the professionaldevelopment of the faculty member and also sup-portive of improving the learning environment as awhole. As is the case with assessing residents, theassessment of faculty must be valid, fair, and reliable—affording both formative and summativefeedback to clinical teachers.

To excel at teaching goes beyond natural talent andintellect. It also requires a dedication of time andeffort, patience, self-awareness, empathy, and leader-ship. Excellence in teaching is a valuable contributionto the development of emerging physicians and, inturn, to patients and communities. It should beacknowledged. To provide recognition for teaching isespecially important considering the volunteerism ofmany clinical teachers who teach because of theircommitment to develop the next generation of doctors and clinical educators. With this in mind,proportionate recognition of faculty contributionsshould be further explored, both locally and nation-ally, as a means of encouraging and rewardingteaching excellence.

Residents are important teachers for other residents,as well as for medical students and other healthcarelearners. Accreditation requirements at both theUGME and PGME levels articulate this importantrole. There is a need for PGME programs to addresslearners’ needs as teachers by identifying the specificteaching competencies that can be taught by all.

26

ACTIONS:1. Develop, in close collaboration with UGME

programs, a national core leadership curriculumfor all residents that is focused on professionalresponsibilities, self-awareness, providing andreceiving feedback, conflict resolution, changemanagement, and working as part of a team as aleader, facilitator, or team member. Leadership:AFMC (committees on UGME and PGME), CAIR,CFPC, CMA, CMQ, FMRQ, RCPSC.

2. Tailor leadership development to personal needs,including by making opportunities available forhigher education in leadership through formaldegree programs. Leadership: AFMC (Committeeon PGME).

3. Ensure that all residents are given the opportu-nity to participate in administrative, clinical,educational, and scientific leadership duringtraining. Leadership: ACAHO, AFMC (committeeson UGME and PGME), CAIR, CFPC, CMA,CMQ, FMRQ, provincial residents organizations,RCPSC.

4. Working with national CPD initiatives, developprograms to enhance the teaching of leadershipin UGME and PGME and build on the leadershipcurriculum for those in practice. Leadership:AFMC, CFPC, CMA, CMQ, RCPSC.

5. Encourage the integration of interprofessionaland intraprofessional education leadershipopportunities in PGME environments to supportteam skills and teaching across disciplines andprofessions. Leadership: ACAHO, AFMC (com-mittees on UGME and PGME), CAIR, CFPC,CMA, CMQ, FMRQ, provincial residents’ organi-zations, RCPSC.

F O S T E R L E A D E R S H I P D E V E L O P M E N T 8:

RATIONALE: There are various definitions of leadership. The com-mon thread among them is a process of intentionalinfluence between the leaders and followers to worktowards a shared goal. In our society, physicians are often perceived as leaders. Every resident mustunderstand that leadership is an enabling componentfor all CanMEDS and CanMEDS-FM roles and is relevant to patient care, education, research, andadministration. Residents must be provided withopportunities to attain competencies related to collaborative leadership. Today’s leadership trainingmust be focused on the current environment inwhich physicians work in interprofessional teams asfacilitators, team members, or team leaders. Residentsshould learn to exercise leadership choices in theirdaily work, irrespective of whether they have a formal leadership position. Residents must also havethe opportunity to receive feedback on their per-formance on interprofessional collaborative teams.All residents should become engaged in improvingthe health care of patients and populations and thehealthcare system in general. To this end, residentsmust be supported in developing their collaborativeleadership skills during training and have the oppor-tunity to create positive change in our healthcaresystem.

RECOMMENDATION

Foster the development of collaborative leadership skills in future physicians, so they can work effectivelywith other stakeholders to help shape our healthcare system to better serve society.


ACTIONS:1. Identify organizations that have decision-making

authority in PGME and define roles that couldbetter streamline and enhance their collabora-tion through the study of governance models andthe implementation of the one that promotes thegreatest efficiency and effectiveness. Leadership:ACAHO, AFMC, CAIR, CFPC, CMQ, F/P/T governments, FMRAC, FMRQ, hospitals, MCC,RCPSC.

2. Establish terms of reference, align strategic directions, and establish a collective governanceprocess. Leadership: ACAHO, AFMC, CAIR,CFPC, CMQ, FMRAC, F/P/T governments,FMRQ, hospitals, MCC, RCPSC.

E S TA B L I S H E F F E C T I V E C O L L A B O R AT I V EG O V E R N A N C E I N P G M E9:

RATIONALE: Effective governance—in this context, the institu-tions, policies, and processes that support theadministration and delivery of resident training—isessential to the administration of the CanadianPGME system. The PGME system is composed of acomplex array of players, including educators, government bodies, and health authorities, that have multi-directional accountabilities. Within this complexity lies the profound challenge of finding theclarity and collaboration required for effective governance, which has, to date, resulted in a lack ofalignment towards a common vision for residenttraining. To ensure effective governance withinPGME, two things must be in place: clear roles andresponsibilities for the many stakeholders involvedand a practice of collaborative dialogue.

Partners in the Canadian PGME system must assumea leadership role in beginning a dialogue with othermedical education stakeholders to articulate a common vision and their particular interests, respon-sibilities, and accountabilities in meeting Canadians’health and wellness needs. If sustainable healthcarein Canada is to be achieved, effective governancemust be put into practice to enable careful forecast-ing of the number and types of physicians required inour system. This will enable effective HHR decisionsthat will streamline the training process and avoidredundancy.

RECOMMENDATION

Recognizing the complexity of PGME and the health delivery system within which it operates, integrate themultiple bodies (regulatory and certifying colleges, educational and healthcare institutions) that play a rolein PGME into a collaborative governance structure in order to achieve efficiency, reduce redundancy, and provide clarity on strategic directions and decisions.

28

ACTIONS:1. Facilitate and enable a more integrated PGME

system by aligning accreditation standards andprocesses across the continuum of learning in the UGME, PGME, and CPD environments.Leadership: Accrediting agencies of UGME, PGME,and CPD, AFMC, CFPC, CMA, CMQ, FMRAC,RCPSC.

A L I G N A C C R E D I TAT I O N S TA N D A R D S10:

RATIONALE: Current accreditation standards and processes focusexclusively on UGME, PGME, or CPD. The processesshare many common attributes and goals; however,they are very labour intensive and costly for the medical schools and accrediting agencies involved.Ways need to be found to reduce the burden of paper,time, and human resources that are devoted toaccreditation. There is increasing interest in anaccreditation process, be it at the UGME, PGME, orCPD level, that is more continuous, promotes continuous quality improvement, and is less focusedon summative visits at the end of each accreditationcycle.

A review of the recommendations in both the FMECMD report and this one highlights many areas thatrequire change but are interdependent betweenUGME and PGME. For example, addressing the hidden curriculum and developing clinical teachersare issues in both educational environments. Anaccreditation system that recognizes these issuesacross the continuum would well serve the medicaleducation system.

RECOMMENDATION

Accreditation standards should be aligned across the learning continuum (beginning with UGME and con-tinuing through residency and professional practice), designed within a social accountability framework, andfocused on meeting the healthcare needs of Canadians.


This action-oriented mandate for change hasbeen derived from extensive dialogue andengagement with the many stakeholders in the

PGME system and builds on much work that isalready underway. Our collective challenge in movingforward is to improve our healthcare system not onlyby implementing the recommendations in this reportbut also by retaining the many strengths that alreadyexist.

While leadership in the implementation of these recommendations will be provided by the four consortium partners, the participation of a numberof key stakeholders will also be required to ensure the success of this effort. For example, the implemen-tation of many of these recommendations will becontingent upon the active participation of ourprovincial governments. As such, we must be cognizant of today’s fiscal realities and strive to make

changes collectively, while minimizing any increasedfinancial responsibilities placed on our governments,medical schools, certifying bodies, and learners.

It is hoped that the completion of this report will notonly result in the implementation of its 10 recom-mendations but also lead to the next step in what isincreasingly referred to as “the FMEC process”: a comprehensive examination of the continuing medical education environment of practicing physicians. This, combined with our recent reviews ofthe undergraduate and postgraduate contexts, willround out an analysis of the entire medical educationcontinuum and lend an overarching perspective tothese highly interrelated learning environments. It isonly by reforming this continuum from end to endthat we will continue to ensure the capacity of ourphysicians to meet the needs of Canadians, now andin the future.

C O N C L U S I O N S A N D N E X T S T E P S

The FMEC PG project encompassed manyinputs, which formed the basis of evidencefrom which the recommendations were devel-

oped. These inputs came from a variety of sources:

ENVIRONMENTAL SCAN

CONSULTING GROUPThe Environmental Scan Consulting (ESC) Groupwas directed to gather evidence two ways: by prepar-ing commissioned papers on an approved list oftopics and by conducting interviews with key inform-ants. The project methodology was guided by theScientific Advisory Committee (SAC), which includededucational research scientists who provided bothcontent and process expertise. Research ethics board

approval for the interviews was sought and received atthe three participating universities (McGill University,University of British Columbia, and University ofToronto).

The initial inventory of research themes that eventu-ally led to commissioned papers was developedthrough an iterative consultation process thatincluded a literature review, consultation with theAdvisory Committee of PGME Deans and the FMECPG Steering Committee, a document analysis ofFMEC MD literature reviews, and review by the ESCGroup and the SAC.

Following an analysis for key themes in PGME, 24 papers were commissioned. Each paper included areview and analysis of relevant literature from the pastdecade, and many employed multiple methodologi-cal approaches (e.g., interviews, feedback from

M E T H O D O L O G Y

30

stakeholders, focus groups) to capture the currentissues in PGME, evidence and information about bestpractices, and innovations and options for the futureof PGME in Canada.

Twenty-seven key informant interviews were conducted. The ESC Group used the Towards Unityfor Health framework and purposeful sampling toensure input from multiple viewpoints. Interviewersused a common interview protocol, including consentforms, questions, audio recordings, submission of abrief summary field report, the review of transcripts,and the verification of transcripts with key inform-ants.

For both the commissioned papers and key informantinterviews, the research team analyzed the resultsusing grounded theory methods over the course oftwo separate two-day workshops. For each researchtheme, a broad group of researchers, including repre-sentatives from the FMEC PG Steering Committee,developed a consensus view of the key messages fromeach of the commissioned papers and the themesfrom across the papers and key informant interviews.

A final report was submitted to the FMEC PGSecretariat in May 2011. The commissioned papers and synthesis report are available on the project website.

LIAISON AND ENGAGEMENT

CONSULTING GROUPDuring the first round of consultations (undertakenbetween August and December 2010), the Liaison andEngagement Consulting (LEC) Group conducted 108in-person and teleconference consultations with abroad range of stakeholders in the PGME community.The purpose of these consultations was to raiseawareness of the project and solicit opinions andideas for the FMEC PG Steering Committee’s consid-eration in formulating its recommendations. Allstakeholders were asked to describe the strengths, vulnerabilities, risks, and opportunities within PGME

and suggest ways to innovate or strengthen the current system. The LEC Group developed a standardized process to ensure that consistent messaging and common processes were used for allconsultations, including a step-by-step guide, an invitation to target stakeholders, and a reporting template for stakeholder feedback.

The second round of consultations took place inAugust and September 2011 in response to the firstversion of draft recommendations, which wasreleased on July 28, 2011. The FMEC PG ManagementCommittee directed the LEC Group to solicit feed-back on this first draft from 13 national stakeholders,through town hall meetings at 17 medical schools,and through a web-based survey. All individuals andorganizations who participated in the first round ofthe consultations were invited to submit their feedback on the draft recommendations using a web-based survey.

The project website provided a copy of the LECGroup's first report and a copy of the draft recom-mendations. A total of 107 individuals participated inthe national consultations and a further 579 in thetown hall meetings, for a total of almost 700 partici-pants (this underestimates the number of peopleinvolved, as many participants provided feedback on behalf of their executive or membership). An additional 18 submissions were provided through theweb-based survey or directly to the LEC Group.

Reports were submitted to the FMEC PG Secretariatafter both rounds of consultations and are availableon the project website.

PUBLIC OPINION POLLEKOS Research Associates conducted a survey thatexamined a number of important issues pertaining tohealth care and the medical education system inCanada—in particular, public confidence in thehealthcare system, public priorities, public literacy of the healthcare system, confidence in the medicaleducation system, and the growing role of technology.


The survey was conducted from January 24 toFebruary 4, 2011, using EKOS’s hybrid online-offlineresearch panel, Probit. A random sample of 1,720Canadians aged 18 and over responded to the survey(1,502 online and 218 by self-administered mail-outsurveys). A sample of this size provides a margin oferror of +/- 2.4 percentage points, 19 times out of 20.

NATIONAL SURVEY OF

PROGRAM DIRECTORSAn online survey was distributed to all 807 Specialtyand Family Physician Program Directors acrossCanada in December 2010. Recipients were asked torate the importance of a number of issues and chal-lenges they faced that could be affected by PGME.Both qualitative and quantitative data were collectedand analyzed collectively and according toSpecialty/Family Physician program. An overallresponse rate of 33% was achieved (56% FamilyPhysician and 32% Specialty).

INTERNATIONAL

CONSULTATIONSSite visits and key stakeholder interviews were conducted in the United States, United Kingdom, andFrance in the spring of 2011. The Steering Committeeidentified international institutions, locations, andindividuals able to contribute relevant informationand examples of innovative PGME programming andprocesses. Many environments outside the Canadiancontext were included to facilitate an understandingof the PGME response to societal shifts in differentbut comparable contexts, identify international trendsand drivers, and obtain evidence of exemplary practices in PGME.

PUBLIC PANELThe Public Panel was composed of members of the“informed lay public”: community members whopossess an understanding of and have some experi-ence with medical education but are not MDs ordirectly involved in the PGME environment. Manyparticipants were public members from the boards oforganizations represented on the Steering Committee.The panel met twice: initially in January 2011 to discuss their priorities for PGME, and again inNovember 2011 to provide feedback on the secondversion of the draft recommendations.

REVIEWING THE INPUTSAll of these inputs were considered in formulating thedraft recommendations. Members of the SteeringCommittee and Advisory Committee of PGME Deansmet in early February 2011 to develop preliminarythemes. The Management Committee then met in lateMarch 2011 to review the evidence and preliminarythemes and to formulate a list of key thematic areas.A meeting in June 2011 marked the final time that allcommittee members met before the first version ofthe recommendations was drafted. The first draft wasdistributed in July 2011 and reviewed through theLEC Group process and by committee members.Deans of Medicine provided feedback via webinar.Feedback on a refined version of the recommenda-tions, distributed in early November 2011, wasprovided by the Advisory Committee on HealthDelivery and Human Resources, the Deans ofMedicine, and the Public Panel. Following a meetingin early December 2011 of all committee members, athird version was drafted for review at the NationalForum on January 30 and 31, 2012.

32

On behalf of the four consortium partners—the AFMC, CFPC, CMQ, and RCPSC—wewould like to extend our thanks to many indi-

viduals for their roles in the FMEC PG project, whichwas truly collaborative in nature and far-reaching inbreadth.

First and foremost, we extend sincere thanks toHealth Canada for its generous funding over 25months, and a special thank you to Margo CraigGarrison for her presence and participation as amember of the project Steering Committee. We similarly acknowledge staff administrators at HealthCanada for their patience and collegial supportthroughout this initiative.

The FMEC PG project was truly a pan-Canadianeffort and would not have been possible without thededication and commitment of many medical educa-tors across the country. We formally acknowledge thesignificant contributions of our consortium partnerorganizations, which provided considerable in-kindsupport through our participation as lead represen-tatives and the involvement of our colleagues whoserved on the Steering Committee or StrategicImplementation Group, or were engaged in otherways in this project.

Several key groups carried this work forward.Members of the 33-person Steering Committee—with representatives from national medical education associations, decanal teams of Canadian medical education programs, governments, learner and resi-dent groups, national and provincial certifyingcolleges, and regulatory authorities—contributedtheir time and ideas through participation in multipleface-to-face meetings.

The Advisory Committee of PGME Deans, composedof the PGME Deans from all 17 medical educationprograms across Canada, worked in close collabora-tion with the Steering Committee throughout theproject to bring both philosophical and frontline perspectives to this work.

We four signatories, along with Drs. Pierre Leblanc,Geneviève Moineau, and James Rourke, constitutedthe project’s Management Committee. The commit-tee guided the day-to-day work of the project,working closely with Secretariat staff and the

consulting writer to shape the draft recommenda-tions. This was a major commitment involvingmonthly teleconferences, the chairing of meetings,and extensive on-line writing and editing of multipledrafts of this report.

The SIG, composed of members of the ManagementCommittee as well as Drs. Mathieu Dufour, TomFeasby, Kevin Imrie, Cathy MacLean, Jay Rosenfield,and Mark Walton, helped to edit later versions of this report and contributed strategic thinking as theproject shifted into its implementation phase.

The 20-member Public Panel met twice over theduration of this initiative. Their high level of engage-ment and critical feedback in reviewing drafts from apublic/patient perspective was imperative to thiseffort. The Deans of Medicine and many other keynational stakeholder groups held several focused discussions on this project and the draft recommen-dations as they emerged. Thank you all for yourconsideration and input.

International consultations revealed key innovationsand shed light on how PGME is carried out in com-parable environments. We recognize SteeringCommittee members Drs. Mathieu Dufour andJoshua Tepper, who undertook consultations inFrance, and Drs. Maureen Topps and Jerry Maniate,who visited multiple sites in both the United Statesand United Kingdom. Thanks, too, go out to thenumerous medical educators with whom they metand who took the time to share their wisdom andexperience.

The FMEC PG project benefitted tremendously fromthe involvement of a number of highly skilled con-sultants, whose contributions greatly enriched thiswork and facilitated the development of this report.

An environmental scan team from the University ofBritish Columbia, University of Toronto, and McGillUniversity provided a comprehensive and academi-cally rigorous evidence base for this work. Theseleading thinkers in medical education workedtogether to complete a thorough literature review, 27national key informant interviews, and a synthesisreport. The project owes a debt of gratitude to Drs.Sarita Verma, Sarkis Meterissian, Salvatore Spadafora,Joanna Bates, Kamal Rungta, Jean Jamieson, Susan

A C K N O W L E D G E M E N T S


Glover Takahashi, and their colleagues for theirexhaustive efforts in producing the high-qualityresearch that helped to inform this project.

The LEC Group from the same three universities, led by Dr. Sarita Verma, completed two rounds ofextensive national consultation on the draft recom-mendations as they emerged. This role was critical inthat it kept the Canadian PGME community apprisedof developments in the project and provided oppor-tunities for all project stakeholders to voice theiropinions and provide feedback on work to date.

We thank Frank Graves and his colleagues at EKOS,who collected and analysed highly relevant nationalpublic opinion data that also informed this report.

Bernard Gauthier and his associates from Delta Mediacoordinated e-newsletters and updates to the FMECPG project website to keep all stakeholders and thegeneral public informed of progress. They also helpedto create the FMEC PG project video and providedadvice and professional services for communicationsleading up to the National Launch of the projectreport.

Lori Charvat, of Sandbox Consulting, did a wonder-ful job of integrating input and feedback frommultiple voices into a coherent whole as the consult-ing writer. Working closely with the ManagementCommittee over many months, she drafted the firstthree iterations of this report, which were pivotal toits successful and timely completion.

Two comprehensive evaluations of the project, prepared by Blair Stevenson and his colleagues at SiltaAssociates, were each very helpful to our process.

The professional team at Strachan-Tomlinson provided overarching process design advice to thiscomplex project as well as superior meeting designand facilitation skill and liaison work with projectstaff, consultants, and stakeholders. It was a truepleasure to work with Dorothy Strachan.

On the important matter of language, we thank LeslieJones, of Leslie Jones Communications, who docu-mented the entire project with her outstandingnote-taking and report-writing skills at the manymeetings held over the course of the initiative. Shealso did a wonderful job of editing this report. We arevery appreciative of the efforts of Geneviève Denis,who provided superior translation services all the way from Harare, Zimbabwe, and Sylvie Leboeuf, ofthe CMQ, who generously reviewed and revisedtranslations of each major iteration of this report.

Last but not least, we extend a sincere thank you toproject manager Catherine Moffatt and project assis-tant Claire de Lucovich, of the AFMC, for their effortsin administering this multifaceted project. They werethe backbone of this team effort and the ones whoensured the delivery of a high-quality product. AFMCsenior management team members Irving Gold, Dr.Geneviève Moineau, and Steve Slade also contributedtheir time and unique talents to this initiative, and forthis we are very grateful.

It is our sincere hope that the multiple parties whoparticipated in this collaborative initiative will con-tinue to carry forward this collective vision throughthe implementation of its recommendations.

Sincerely,

Nick Busing, MDPresident & Chief Executive OfficerThe Association of Faculties of Medicine of Canada

Ivy Oandasan, MDConsulting Director, Academic Family MedicineThe College of Family Physicians of Canada

Anne-Marie MacLellan, MDSecrétaire adjoint, Directrice, direction des Études médicalesCollège des médecins du Québec

Ken Harris, MDDirector, Office of EducationThe Royal College of Physicians and Surgeons ofCanada

34

Ian Bowmer, MDExecutive DirectorMedical Council of Canada

(MCC)

Ford Bursey, MDAssistant Dean for Professional

AffairsFaculty of MedicineMemorial University of

Newfoundland

Nick Busing, MD *President and Chief Executive

Officer The Association of Faculties of

Medicine of Canada (AFMC)

Margo Craig GarrisonFederal ACHDHR Co-ChairSenior Director Health Care Programs and Policy

Directorate Health Canada

Frédérick D’Aragon, MDPresident - Comité des affaires

pédagogiques – SpécialitésLa fédération des médecins rési-

dents du Québec (FMRQ)

Mathieu Dufour, MDMember-at-LargeCanadian Association of Interns

and Residents (CAIR)

M. George Elleker, MDDivision of NeurologyFaculty of Medicine & DentistryUniversity of Alberta

Jason Frank, MDAssociate Director, Specialty

Standards, Policy andDevelopment

The Royal College of Physiciansand Surgeons of Canada(RCPSC)

Ken Harris, MD *Director of EducationThe Royal College of Physicians

and Surgeons of Canada(RCPSC)

Noura HassanPresidentCanadian Federation of Medical

Students (CFMS)

Jill KonkinRepresenting the Society of Rural

Physicians of Canada (SRPC)Associate Dean Rural and Regional

HealthFaculty of Medicine and Dentistry University Of Alberta

Pierre LeBlanc, MD *Directeur du Département de

médecineFaculté de médecineUniversité Laval

Anne-Marie MacLellan, MD *Secrétaire adjoint, Directrice,

direction des Études médicalesCollège des Médecins du Québec

(CMQ)

Jerry Maniate, MDRepresenting the Canadian

Association for MedicalEducation (CAME)

Markus Martin, MDExecutive Member, Board of

DirectorsCollège des Médecins du Québec

(CMQ)

Karen Mazurek, MD Representing the Federation of

Medical Regulatory Authoritiesof Canada (FMRAC)

Assistant Registrar (Complaints)College of Physicians and

Surgeons of Alberta (CPSA)

Shawn MondouxPresidentCanadian Federation of Medical

Students (CFMS)

Glenn MonteithACHDHR Co-ChairAssistant Deputy MinisterHealth Workforce DivisionAlberta Health and Wellness

Ivy Oandasan, MD *Consulting DirectorAcademic Family MedicineCollege of Family Physicians of

Canada (CFPC)

Eric PetersPresidentFédération médicale étudiante du

Québec (FMEQ)

Paul Rainsberry, PhDAssociate Executive DirectorAcademic Family MedicineCollege of Family Physicians of

Canada (CFPC)

Ira Ripstein, MDAssociate DeanUndergraduate Medical EducationUniversity of Manitoba

Jay Rosenfield, MDVice Dean, Undergraduate Medical

EducationFaculty of MedicineUniversity of Toronto

James Rourke, MD *Dean, Faculty of MedicineMemorial University of

Newfoundland

Anurag Saxena, MDAssociate DeanPostgraduate Medical EducationUniversity of Saskatchewan

C O M M I T T E E S A N D C O N T R I B U T O R S

STEERING COMMITTEE


Maureen Shandling, MDRepresenting the Association of

Canadian Academic HealthcareOrganizations (ACAHO)

Vice President, Medical AffairsMount Sinai Hospital

Josh Tepper, MDVice-President, EducationSunnybrook Hospital

Maureen Topps, MDAssociate Dean (Former)Post Graduate Medical EducationNorthern Ontario School of

Medicine

J. Mark Walton, MDAssistant DeanPostgraduate Medical EducationMcMaster University

W. Todd Watkins, MDDirector, Office of Professional

ServicesCanadian Medical Association

(CMA)

Bruce Wright, MD Associate Dean, Undergraduate

AffairsUniversity of Calgary

EX-OFFICIO MEMBERS

Irving GoldVP – Government Relations and

External AffairsThe Association of Faculties of


Geneviève Moineau, MD *Vice President, EducationSecretary for AccreditationThe Association of Faculties of


Steve SladeVP – Research and AnalysisThe Association of Faculties of


PROJECT STAFF

Catherine MoffattProject Manager The Association of Faculties of


Claire de LucovichProject AssistantThe Association of Faculties of


* Management Committee member

Paul Bragg, MDAssistant DeanPostgraduate Medical EducationFaculty of MedicineUniversity of Ottawa

Josée Dubois, MDVicedoyen aux etudes médicales

postdoctoralesFaculté de médecine - DirectionUniversité de Montréal

Martin Gardner, MDAssociate DeanPostgraduate Medical EducationDalhousie University

Mireille Grégoire, MDAdjointe au vice-doyen aux affaires

cliniquesBureau des études médicales post-

doctoralesFaculté de MédecineUniversité Laval

Ramona Kearney, MDAssociate DeanPostgraduate Medical EducationFaculty of Medicine and DentistryUniversity of Alberta

Jill Kernahan, MDAssociate DeanFaculty of Medicine, Dean's OfficePostgraduate Medical EducationUniversity of British Columbia

Serge Langevin, MDViceDoyenÉtudes médicales postdoctoralesFaculté de médecine et des sci-

ences de la santéUniversité de Sherbrooke

Sarkis Meterissian, MDAssociate DeanPostgraduate Medical EducationFaculty of MedicineMcGill University

Asoka Samarasena, MDAssistant DeanPostgraduate Medical EducationFaculty of MedicineMemorial University of

Newfoundland

Anurag Saxena, MDAssociate DeanPostgraduate Medical EducationCollege of MedicineUniversity of Saskatchewan

Sal Spadafora, MDVice DeanPostgraduate Medical Education

OfficeFaculty of MedicineUniversity of Toronto

Joanne Todesco, MDAssociate DeanPostgraduate Medical EducationFaculty of MedicineUniversity of Calgary

ADVISORY COMMITTEE OF PGME DEANS

36

Maureen Topps, MDAssociate Dean (Former)Post Graduate Medical EducationNorthern Ontario School of

Medicine

G. Ross Walker, MDAssociate DeanPostgraduate Medical EducationFaculty of Health SciencesQueen's University

J. Mark Walton, MDAssistant DeanPostgraduate Medical EducationSchool of MedicineMcMaster University

Chris Watling, MDAssociate DeanPostgraduate Medical EducationSchulich School of Medicine &

DentistryUniversity of Western Ontario

Michael West, MDAssociate Dean (Former)Postgraduate Medical EducationUniversity of Manitoba

Nick Busing, MDPresident and Chief Executive

Officer The Association of Faculties of


Mathieu Dufour, MDMember-at-LargeCanadian Association of Internes

and Residents (CAIR)

Tom Feasby, MDDean, Faculty of MedicineUniversity of Calgary

Ken Harris, MDDirector of EducationThe Royal College of Physicians

and Surgeons of Canada(RCPSC)

Kevin Imrie, MDPhysician-in-Chief, Sunnybrook

Health Sciences CentreVice-Chair, Education,

Department of Medicine,University of Toronto

Vice-President, Education, RoyalCollege of Physicians andSurgeons of Canada

Pierre LeBlanc, MDDirecteur du Département de

médecineFaculté de médecineUniversité Laval

Cathy MacLean, MDProfessor and HeadDepartment of Family MedicineUniversity of Calgary Past-President, College of Family

Physicians of Canada (CFPC)

Anne-Marie MacLellan, MDSecrétaire adjoint, Directrice,

direction des études médicalesCollège des Médecins du Québec

(CMQ)

Geneviève Moineau, MDVice President, EducationSecretary for AccreditationThe Association of Faculties of


Ivy Oandasan, MDConsulting DirectorAcademic Family MedicineCollege of Family Physicians of

Canada (CFPC)

Jay Rosenfield, MDVice Dean, Undergraduate Medical

EducationFaculty of MedicineUniversity of Toronto

James Rourke, MDDean, Faculty of MedicineMemorial University of

Newfoundland

J. Mark Walton, MDAssistant DeanPostgraduate Medical EducationMcMaster University

STRATEGIC IMPLEMENTATION GROUP


John G. Abbott, MAChief Executive Officer Health Council of Canada

Tracey M. Bailey, LL.B.Executive DirectorHealth Law InstituteLaw CentreUniversity of Alberta

Cheryl Cox, BSP, MBA Faculty of Pharmacy &

Pharmaceutical SciencesUniversity of Alberta

Thomas Dignan, MD, PhDA/Regional Community Medicine

SpecialistHealth Canada

Pierre Durand, MDProfesseur titulaire Faculté de médecine de

l'Université Laval et Centre d'ex-cellence sur le vieillissement deQuébec

CEVQ,CHA Hôpital du SaintSacrement

Nathalie Ebnoether, MAMembre du Conseil d'administra-

tion (représentant du public) Collège des médecins du Québec

Hon. Judith Erola P.C. Public Member, CFPCFm. Member of Parliament, Cabinet Minister (Mines, Status of

Women, Consumer andCorporate Affairs)

President, RxD

David A. Gass, MDProfessor, (post retirement), Department of Family MedicineDalhousie University

Hon. Gwen Haliburton E.C.N.S. Public Member, MCC

Glen A. Jones, B.Ed., M.Ed.,Ph.D.

Ontario Research Chair inPostsecondary Education Policy

University of TorontoOntario Institute for Studies in

EducationUniversity of Toronto

Marjolaine Lafortune, LL LMembre du Conseil d'administra-

tion (représentant du public) Collège des médecins du Québec

Tina Martimianakis, MA, MEd,PhD

Education Researcher & Lecturer,Dept. of Paediatrics

Affiliated Scholar, Wilson Centrefor Research in Education

Academic Educator, Centre forFaculty Development

Faculty of Medicine, University ofToronto

Hospital for Sick Children

Ian ParkerCommunications

Consultant/Former Network TVJournalist

President, P.B. CommunicationsInc.

Irene Pfeiffer, CMPresidentMoorgate HoldingsPast ChairCollege of Physicians and

Surgeons of Alberta

Shanthi RadcliffePublic Member, RCPSCRetired, former Executive DirectorLondon InterCommunity Health

Centre

Roseann O’Reilly Runte, CM,PhD

President and Vice-ChancellorCarleton University

Bernard Shapiro, MA, PhD Public Member, RCPSCPrincipal and Vice-Chancellor

Emeritus McGill University

Kevin Taft, PhDMLA, Edmonton Riverview

Geoff Tesson, PhD Senior Research Fellow Centre for Rural and Northern

Health Research Laurentian University

PUBLIC PANEL

38

Sarita Verma, MD (LeadConsultant)

Deputy DeanFaculty of MedicineUniversity of Toronto

Sarkis Meterissian, MDAssociate Dean, PGMEFaculty of MedicineMcGill University

Kamal Rungta, MD Associate Dean, PGME (Former)Faculty of MedicineUniversity of British Columbia

Salvatore Spadafora, MDVice Dean, PGME Faculty of MedicineUniversity of Toronto

LIAISON AND ENGAGEMENT CONSULTING GROUP

PRINCIPALINVESTIGATOR:

Sarita Verma

CO-INVESTIGATORS:

Kamal Rungta, Joanna Bates,Salvatore Spadafora, Susan GloverTakahashi, Sarkis Meterissian.

ENVIRONMENTAL SCANSYNTHESIS REPORTAUTHORS:

Susan Glover Takahashi, JoannaBates, Sarita Verma, SarkisMeterissian, Kamal Rungta,Salvatore Spadafora.

SCIENTIFIC ADVISORYCOMMITTEE:

Susan Glover Takahashi (Chair),Lilian Ardenghi, Joanna Bates,Sarah Dobson, Heather Frost,Brian Hodges, Jean Jamieson,Melissa Kennedy, Vicki LeBlanc,Sarkis Meterissian, Glenn Regehr,Mathieu Rousseau, Valerie Ruhe,Roona Sinha.

COMMISSIONEDPAPERS:

1. Health Disparities, SocialAccountability andPostgraduate MedicalEducation: Author(s): JeanJamieson*, David Snadden*,Sarah Dobson, Heather Frost,Stephane Voyer. Contributor(s):Joanna Bates, Jeannine Banack,Jane Buxton, Jean Parboosingh,Wayne Weston, Bob Woollard.

2. Generalism in PostgraduateMedical Education: Author(s):Kevin Imrie*, Wayne Weston*,Melissa Kennedy.Contributor(s): BonnieGranata.

3. Trends and issues inPostgraduate MedicalEducation: inputs, outputs &outcomes. Author(s): CarolineAbrahams*, Jean Bacon*.Contributor(s): Lawrence Loh,Danielle Frechette, James Ayles,Mariela Ruetalo.

4. Training residents to addressthe needs of a socially diversepopulation: Author(s): SaleemRazack*, Farhan Bhanji*. LilianArdenghi, Marie- Renée Lajoie.Contributor(s): JeffreyWiseman

5. International MedicalGraduates - Current Issues:Author(s): Allyn Walsh*,Sandra Banner*, Inge Schabort,Heather Armson, Ian Bowmer,Bonnie Granata.Contributor(s): LucianaRibeiro, Dale Dauphinee, KristaBreithaupt, Robert Lee, SteveSlade.

6. Future Of Health Care Trends:Impact On PostgraduateMedical Education: Author(s):Jean Jamieson*, Angela Towle*.Contributor(s): Carol Herbert,Dean Giustini.

7. Integrating Patient Safety andQuality Improvement withPostgraduate MedicalEducation: Author(s): BrianWong*, Kaveh Shojania*, ElisaHollenberg, Edward Etchells,Ayelet Kuper, Wendy Levinson.

8. Governance in PostgraduateMedical Education in Canada:Author(s): Nathalie Saad*, AlimPardhan*. Contributor(s):Bonnie Granata, MelissaKennedy, Loreta Muharuma,Sharon Cameron.

9. Issues related to Residents asWorkers and Learners:Author(s): Patricia Houston*,Robert Conn*, Roona Sinha*,Maya Rajan. Contributor(s):Susan Glover Takahashi, ErikaAbner, Dawn Marin.

ENVIRONMENTAL CONSULTING GROUP


10. Length of training inPostgraduate MedicalEducation in Canada:Author(s): Sarkis Meterissian*,Mathieu Rousseau*, JoyceMaman Dogma, Marion Dove,Charo Rodriguez.

11. Accreditation of PostgraduateMedical Education: Author(s):Margaret Kennedy*, PaulRainsberry*, Melissa Kennedy,Erika Abner.

12. Distributed Education AndDistance Learning In PGME:Author(s): Joanna Bates*,Heather Frost, Brett Schrewe,Jean Jamieson, Rachel Ellaway.Contributor(s): Doug Schaad,Roy Schwarz.

13. Assessment in PGME: Trendsand issues in assessment in theworkplace: Author(s): GlennRegehr*, Kevin Eva, ShiphraGinsburg, Yasmin Halwani,Ravi Sidhu.

14. Information and educationaltechnology in PostgraduateMedical Education: Author(s):Rachel Ellaway*, MaureenTopps, Tamara Bahr.

15. Integration of CanMEDSexpectations & outcomes:Author(s): CynthiaWhitehead*, Andrée Boucher*,Dawn Martin, NicolasFernandez, Marika Younker,Remi Kouz, Jason Frank.

16. Innovations in teaching andlearning, in the clinical settingfor Postgraduate MedicalEducation: Author(s): LucasMurnaghan*, Milena Forte*,Ian Choy, Erika Abner.

17. Inter and Intra-ProfessionalCollaborative Patient-CentredCare in Postgraduate MedicalEducation: Author(s): LesleyBainbridge*, Louise Nasmith*.Contributor(s): Andrea Burton,Valerie Ball, Karen Ho.

18. Simulation in PostgraduateMedical Education: Author(s):Vicki LeBlanc*, Dylan Bould*,Nancy McNaughton, RyanBrydges, Dominique Piquette,Bharat Sharma.

19. Innovations, Integration AndImplementation Issues InCompetency-Based Training InPGME: Author(s): SusanGlover Takahashi*, BrianHodges*, Andrea Waddell,Melissa Kennedy.

20. Teaching, Learning andAssessing Professionalism at thePost Graduate Level: Author(s):Richard Cruess*, SylviaCruess*, Linda Snell*, ShiphraGinsburg, Ramona Kearney,Valerie Ruhe, SimonDucharme, Robert Sternszus.

21. Faculty Development – theRoad Ahead: Author(s):Yvonne Steinert*.

22. The Career Decision-MakingProcess Of Medical StudentsAnd Residents And The ChoiceOf Specialty And PracticeLocation: How DoesPostgraduate MedicalEducation Fit In?: Author(s):Nicole Leduc*, Alain Vanasse*,Ian Scott, Sarah Scott, MariaGabriela Orzanco, JoyceMaman Dogma, Sabina Abou Malham. Contributor(s):Kelly Dore.

23. Resident Wellness andWork/Life Balance inPostgraduate MedicalEducation: Author(s):*Susan Edwards.Contributor(s): DerekPuddester*, Erin Maclean,Bonnie Granata, MarielaRuetalo.

24. Supporting the Development ofResidents as Teachers: CurrentPractices and Emerging Trends:Author(s): Sandra JarvisSelinger*, Yasmin Halwani,Karen Joughin, Dan Pratt,Tracy Scott, Linda Snell, KileBrokop, Yolanda Liman.

CONSENSUS MEETINGON COMMISSIONEDPAPERS:

Susan Glover Takahashi (Co-facilitator), Joanna Bates (Co-facilitator), Lilian Ardenghi,Delphine Arweiler, Joyce Dogba,Melissa Kennedy, Vicki LeBlanc,Pierre LeBlanc, Carol-AnneMoulton, Glenn Regehr, ValerieRuhe, Marcella Sholdice, RoonaSinha, Salvatore Spadafora, JamesSzabo, Sarita Verma.

KEY INFORMANTINTERVIEW TEAM:

Delphine Arweiler, Joanna Bates,Heather Frost, Brian Hodges,Melissa Kennedy, Dawn Martin,Sarkis Meterissian, Carol AnneMoulton, Mathieu Rousseau,Roona Sinha.

CONSENSUS MEETINGON KEY INFORMANTINTERVIEWS:

Brian Hodges (Facilitator), ErikaAbner, Lillian Ardenghi, DelphineArweiler, Joanna Bates, HelenCaraoulanis, Sarah Dobson,Heather Frost, Susan GloverTakahashi, Irving Gold, YasminHalwani, Jean Jamieson, MelissaKennedy, Dawn Martin, Carol-Anne Moulton, Mathieu Rousseau,Valerie Ruhe, Kamal Rungta,Maureen Shandling, MarcellaSholdice, Roona Sinha, JamesSzabo, Sarita Verma, Mark Walton.

* Lead / Co-lead for paper

40

ACAHO Association of Canadian Academic Healthcare Organizations

ACHDHR Advisory Committee on Health Delivery and Human Resources

AFMC Association of Faculties of Medicine of Canada

CAHS Canadian Academy of Health Sciences

CAIR Canadian Association of Internes and Residents

CAME Canadian Association for Medical Education

CanMEDS Canadian Medical Education Directions for Specialists

CanMEDS-FM Canadian Medical Education Directions for Specialists-Family Medicine

CAPER Canadian Post-M.D. Education Registry

CaRMS Canadian Resident Matching Service

CFMS Canadian Federation of Medical Students

CFPC College of Family Physicians of Canada

CMA Canadian Medical Association

CMQ Collège des médecins du Québec

CPD Continuing Professional Development

ESC Environmental Scan Consulting

F/P/T Federal/Provincial/Territorial

FMEC Future of Medical Education in Canada

FMEQ Fédération médicale étudiante du Québec

FMRAC Federation of Medical Regulatory Authorities of Canada

FMRQ Fédération des médecins résidents du Québec

HHR Health Human Resources

IMG International Medical Graduate

ITER In-Training Evaluation Report

LEC Liaison and Engagement Consulting

MCC Medical Council of Canada

PGME Postgraduate Medical Education

RCPSC Royal College of Physicians and Surgeons of Canada

SIG Strategic Implementation Group

UGME Undergraduate Medical Education

G L O S S A R Y


RECOMMENDATION I: ADDRESSINDIVIDUAL AND COMMUNITYNEEDS

Social responsibility and accountability are core values underpinning the roles of Canadian physiciansand Faculties of Medicine. This commitment meansthat, both individually and collectively, physicians andfaculties must respond to the diverse needs of individuals and communities throughout Canada, aswell as meet international responsibilities to theglobal community.

RECOMMENDATION II: ENHANCEADMISSIONS PROCESSES

Given the broad range of attitudes, values, and skillsrequired of physicians, Faculties of Medicine mustenhance admissions processes to include the assess-ment of key values and personal characteristics offuture physicians—such as communication, interper-sonal and collaborative skills, and a range ofprofessional interests—as well as cognitive abilities.In addition, in order to achieve the desired diversity inour physician workforce, Faculties of Medicine mustrecruit, select, and support a representative mix ofmedical students.

RECOMMENDATION III: BUILD ONTHE SCIENTIFIC BASIS OF MEDICINE

Given that medicine is rooted in fundamental scien-tific principles, both human and biological sciencesmust be learned in relevant and immediate clinicalcontexts throughout the MD education experience.In addition, as scientific inquiry provides the basis foradvancing health care, research interests and skillsmust be developed to foster a new generation ofhealth researchers.

RECOMMENDATION IV: PROMOTEPREVENTION AND PUBLIC HEALTH

Promoting a healthy Canadian population requires amultifaceted approach that engages the full contin-uum of health and health care. Faculties of Medicinehave a critical role to play in enabling this require-ment and must therefore enhance the integration ofprevention and public health competencies to agreater extent in the MD education curriculum.

RECOMMENDATION V: ADDRESS THEHIDDEN CURRICULUM

The hidden curriculum is a “set of influences thatfunction at the level of organizational structure andculture,”10 affecting the nature of learning, profes-sional interactions, and clinical practice. Faculties ofMedicine must therefore ensure that the hidden curriculum is regularly identified and addressed bystudents, educators, and faculty throughout all stagesof learning.

RECOMMENDATION VI: DIVERSIFYLEARNING CONTEXTS

Canadian physicians practice in a wide range of insti-tutional and community settings while providing thecontinuum of medical care. In order to prepare physi-cians for these realities, Faculties of Medicine mustprovide learning experiences throughout MD educa-tion for all students in a variety of settings, rangingfrom small rural communities to complex tertiaryhealth care centres.

RECOMMENDATION VII: VALUEGENERALISM

Recognizing that generalism is foundational for allphysicians, MD education must focus on broadlybased generalist content, including comprehensivefamily medicine. Moreover, family physicians andother generalists must be integral participants in allstages of MD education.

F M E C M D R E C O M M E N D AT I O N S

42

RECOMMENDATION VIII: ADVANCEINTERPROFESSIONAL ANDINTRAPROFESSIONAL PRACTICE

To improve collaborative, patient-centred care, MDeducation must reflect ongoing changes in scopes ofpractice and health care delivery. Faculties ofMedicine must equip MD education learners with thecompetencies that will enable them to function effec-tively as part of inter and intra-professional teams.

RECOMMENDATION IX: ADOPT ACOMPETENCY-BASED AND FLEXIBLEAPPROACH

Physicians must be able to put knowledge, skills, andprofessional values into practice. Therefore, in thisfirst phase of the medical education continuum, MD education must be based primarily on the devel-opment of core foundational competencies andcomplementary broad experiential learning. In addition to pre-defined curriculum requirements,MD education must provide flexible opportunities forstudents to pursue individual scholarly interests inmedicine.

RECOMMENDATION X: FOSTERMEDICAL LEADERSHIP

Medical leadership is essential to both patient careand the broader health system. Faculties of Medicinemust foster medical leadership in faculty and students, including how to manage, navigate, and help transform medical practice and the health caresystem in collaboration with others.

ENABLING

RECOMMENDATIONS

ENABLING RECOMMENDATION A:REALIGN ACCREDITATIONSTANDARDS

Recognizing that accreditation is a powerful lever,Canadian medical leaders must review and realignexisting standards of the Committee on Accreditationof Canadian Medical Schools and the LiaisonCommittee on Medical Education and develop newones, as necessary, to respond to the recommenda-tions in this report. This may involve the alignmentof undergraduate and postgraduate accreditationstandards.

ENABLING RECOMMENDATION B:BUILD CAPACITY FOR CHANGE

Each Faculty of Medicine should carry out a reviewof its organizational systems, processes, and structuresto determine and build capacity, where required, tosupport a constructive response to these recommen-dations.

ENABLING RECOMMENDATION C:INCREASE NATIONALCOLLABORATION

Canadian Faculties of Medicine are continually inno-vating and have much to offer each other. Increasedcollaboration among schools is needed, including thesharing of teaching and learning resources, evaluationframeworks, tools for common curriculum develop-ment, innovations, and information technologies.


ENABLING RECOMMENDATION D:IMPROVE THE USE OF TECHNOLOGY

Based on rapid and evolving technological changesrelated to the way people communicate and learn,there must be increased understanding and use oftechnology on the part of both faculty and learners atall MD education sites.

ENABLING RECOMMENDATION E:ENHANCE FACULTY DEVELOPMENT

Recognizing that teaching, research, and leadershipare core roles for physicians, priority must be given tofaculty development, support, and recognition inorder to enable teachers and learners to respondeffectively to the recommendations in this report.

FMECPG_Cover_EN_Layout 1 12-04-03 7:31 AM Page 4

the future of medical education in canada: a collective vision for

Documents