Guidelines on Conflict of Interest for Competence Committees

Date of original approval: October 23, 2025
Date of last revision and approval: October 23, 2025
Date for next review: October 2029

Purpose

The purpose of this guideline is to safeguard the fairness, integrity, and transparency of competence and promotions committees by clearly defining, identifying, disclosing and mitigating conflicts of interest (COIs). This guideline supports ethical decision-making, promotes equity, diversity, and inclusion, and ensures consistent governance across all programs.

This guideline applies to all voting and non-voting members of competence, assessment and promotions committees, including faculty, mentors, academic advisors, and any staff involved in trainee assessment or promotion processes.

For this guideline, competence, assessment and promotions committees will all be encompassed within the term ‘Competence Committee’ (CC). Governance of CCs occurs through the Residency Program Committee (RPC).

Identification and Disclosure

A conflict of interest (COI) arises when a committee member’s personal, professional, or financial interests have the potential to compromise – or appear to compromise – their impartiality in committee deliberations or decisions. Common types of COIs on CCs can include, but are not limited to:

• Dual roles (e.g., a voting CC member who is also a mentor, coach or academic / research advisor)
  • Note: Clinical Supervision is not generally considered a COI, though CC members may declare it as such if they feel they cannot review assessment data in an unbiased way.
• Familial, financial/business or personal ties (e.g., where a trainee’s relative or close family friend serves as a CC member)
• Committee overlap (e.g., membership on both selection and promotions panels)
• Research interests (e.g., reviewer evaluating a trainee whose work they fund)
• Personal Biases (e.g. race, ethnicity, gender-identify, sexual orientation, disability, political, and/or religious beliefs and affiliations)
• Professional engagements (e.g., CC members serving as external consultants for a project lead by a trainee)
• Program Directors (See below)

Processes

To maintain fairness and objectivity, it is essential for the CC to implement a structured approach for identifying and reducing potential conflicts of interest between its members and the learners they assess.

Initial Declaration: Upon joining the committee, CC members must submit a written declaration of current and foreseeable conflicts of interest to the CC Chair and/or Program Director, using the appended standardized attestation form.

Maintenance of Declarations: COIs are to be monitored on an ongoing basis and updated as roles and relations change. The CC agenda should include an opportunity to declare a COI at the beginning of each meeting, prior to trainee file review. Members can also disclose a COI privately to the CC Chair. Members are required to immediately disclose newly emerging COIs – such as anticipated roles on hiring or selection committees.

Recognition of COI: If a committee member is concerned about bias (including discriminatory bias) from another member, they may raise this confidentially with the Chair. Learners should be made aware that if they have concerns around a COI, they should bring this to the attention of their Program Director and/or the CC Chair.

The Chair (or designate) has a responsibility to actively monitor committee dynamics for potential COI and bias, including instances where power differentials (e.g., faculty seniority) may make self-identification difficult.

Ongoing Review: As part of a CC’s continuous quality improvement process, committee adherence to the COI guideline and practices to mitigate bias and discrimination should be periodically audited to identify and correct systemic biases.

Mitigation Strategies

If a COI is identified, the CC Chair must evaluate the risk of bias it presents and determine whether the affected member can continue participating. Depending on the nature of COI, CC’s may choose to discuss and resolve COIs in a committee format. In some cases, the conflict may be addressed with mitigation strategies; in others, the CC member may be recused from individual discussions or asked to step down from the committee.

The following are important factors to consider when deciding on how best to manage COIs:

• Assess the nature and severity of the conflict. This includes evaluating whether the conflict involves sensitive personal matters, professional dynamics (such as participation on an admissions committee), or collaborative work (like joint research)
• Determine whether the COI breaches any professional codes or regulations
• Confirm whether all relevant information about the COI has been fully disclosed Transparency is essential for fair decision-making
• Evaluate whether the committee and the affected CC member(s) believe the COI can be reasonably managed or resolved. This involves personal judgment and reflection on bias mitigation
• Consider whether recusal from decision-making is warranted. A COI might affect a particular issue, or it could influence wider responsibilities within the committee
• Review the necessity of the CC member’s continued involvement. If the conflict cannot be adequately managed, the committee should explore replacing the member with a suitable alternative

Mitigation strategies, implemented based on the conflict’s nature and severity, might include:

• Recusal from discussions and/or voting on affected trainees
  • Note: In small programs, where recusals may disproportionately affect marginalized or minority-identifying learners, additional safeguards should be used, such as:
    • Ensuring another faculty advocate is present
    • Seeking an external reviewer or committee member for balance
    • Documenting the rational for all decisions transparently
• Limited participation (e.g., presence allowed but person(s) with an identified COI is/are not permitted to vote on CC decisions)
• Replacement of the member, if the conflict is significant or persistent

Guidelines around Common COIs

• Hiring or Selection Committees: Faculty who sit on hiring or selection committees where information from the CC may bias their decision-making regarding future positions, should not be members of CCs. Conversely, Faculty may sit on the CC if they choose to discontinue their involvement in the hiring or selection committee
• Residency Program Committee (RPC): Where possible, the committee membership of the CC and RPC should be distinct
  • Note: This is often a challenge in smaller programs. Where there is overlap between CC and RPC membership, it is important that the function and work of each committee member is clearly documented in the terms of reference and minutes of both committees
• Smaller programs with limited faculty resources may adapt these guidelines. Rationale for adaptations must be debated at the RPC, documented, and supported by Departmental leadership
  • Note: Consultation is available through Temerty Postgraduate Medical Education
• Program Directors (PD) are uniquely positioned to have additional information that is relevant to the interpretation of assessment data
  • While it is permissible for a PD to be a voting member or Chair the CC, best practice is for the PD to serve as a non-voting member to minimize bias
  • The role of the PD on the CC is to act as a voice for the resident, to be the link between the CC and the RPC, and to provide educational guidance and leadership
  • Confidential information (e.g., mental health disclosures; disability accommodations; feedback from informal channels, shared in confidence; personal challenges shared with the PD in trust, etc.) known to the PD should not be disclosed to the CC unless it is required to support assessment decisions and express permission has been given by the trainee involved

Documentation:

All COI disclosures and management plans must be recorded in a centralized accessible system

• CC agendas and minutes should reflect opportunities to disclose, discussions around, and decisions related to COIs
• Members who disclose a COI privately to the CC Chair or Program Director should do so in advance of the CC meeting
• Once a plan for managing a disclosed COI has been approved, this plan should be documented by the CC Chair

Governance and Transparency:

This document should be reviewed by the RPC and CC, who are responsible for ensuring that its contents are understood and implemented. Additionally, RPCs and CCs are responsible for ensuring they understand and comply with all accreditation requirements related to assessment, including those pertaining to COIs, bias and discrimination.

Terms of Reference: The processes employed, from the point of COI disclosure to resolution, should be detailed in the committee’s Terms of Reference

• COI discussions should be led by the CC Chair, unless the Chair has a COI, in which case the discussion should be led by the PD or appropriate delegate

Accountability: The Committee Chair and RPC share oversight responsibility for Guideline adherence. CCs must be committed to ensuring that no resident is disadvantaged by bias or discrimination in assessment decisions. Where COI concerns or process challenges cannot be resolved within the CC, they will be referred to the RPC and/or Temerty PGME for impartial review.

Professionalism and Ethical Decision-Making

CC decisions must balance rules-based ethics (justice) with context-driven ethics (care), ensuring that policies are applied fairly and consistently while accounting for individual trainee circumstances. Professionalism, reflecting academic and clinical integrity, is the cornerstone of all deliberations.

Equity, Diversity, and Inclusion (EDI) and Bias Mitigation: This document partially satisfies the following institutional accreditation requirements: 5.1.1.5: The policies and processes governing assessment decision-making outline how to recognize and mitigate bias and discrimination.

Committee Composition: Membership should reflect institutional diversity goals, including gender, race, and discipline, wherever possible.

As many forms of bias are not always acknowledged or consciously recognized, members are expected to reflect on whether their perspectives may be influenced by such factors.

Training and Faculty Development

Training Requirements: All committee members must complete mandatory anti-racism and anti-discrimination bias training upon joining the committee, to be renewed every 3 years.

• Note: this requirement is set as part of the Institutional Standards for Accreditation (4.2.2.1), “individuals involved in residency education, including residents, teachers, program leaders, and administrative personnel must have access to and are required to engage in anti-racism and anti-discrimination training.”

To build competency in COI identification and management, Temerty PGME will provide:

• Formal workshops on COI principles and practical scenarios
• Case-based seminars illustrating complex or emerging conflicts
• Guidelines based on best-practice