Guidelines for Educational Responsibilities in Clinical Fellowships

Postgraduate Medical Education
Fellowship Education Advisory Committee

Guidelines for Educational Responsibilities in Clinical Fellowships

Background

The Guidelines for Educational Responsibilities in Clinical Fellowships (“the Guidelines”) is a resource for Fellows and education leaders working with Fellows.

In this document, Clinical Fellows are physicians who are acquiring post-certification training.

The relationship between the University of Toronto (UofT) and a Clinical Fellow is educational. As such, these Guidelines focus on the educational components of Clinical Fellowships. The clinical aspects of the Clinical Fellows’ learning are all subject to the policies, rules, and regulatory compliance of the hospital or other clinical settings.

A Clinical Fellowship is an opportunity for a physician to obtain advanced training, and/or to acquire more specialized expertise than would typically be available during a residency.

To be eligible the applicant must meet the educational requirements for certification as a specialist by:

• the Royal College of Physicians and Surgeons of Canada (Royal College), or
• College of Family Physicians of Canada (CFPC), or
• the American Board of Medical Specialties (ABMS), or
• be recognized as a medical specialist in the jurisdiction where the applicant practices medicine immediately before the appointment as a Clinical Fellow.

In Ontario, Clinical Fellowships are conducted under the auspices of the College of Physicians and Surgeons of Ontario (CPSO) through which fellows are granted educational licenses. The CPSO requires Clinical Fellowships to have:

• goals and objectives against which fellows are to be evaluated, and
• a structured program that adheres to supervision guidelines and professional responsibility policies.

Educational Guiding Principles

The University, through the Postgraduate Medical Education (PGME) Office, Academic Departments, and supervising and collaborating clinical faculty members, work together to provide a safe and positive learning opportunity for the Clinical Fellow to attain the written goals and objectives of the fellowship.

Meeting Professional Responsibilities for Medical Education Learners
Clinical Fellows and their supervising clinical faculty member are to meet their professional responsibilities with respect to care and supervision per the CPSO policy Professional Responsibilities in Medical Education and the advice included Companion Document.

Structuring Clinical Fellowship Offer Letters
Each offer for a Clinical Fellowship shall be in writing, signed by the Clinical Fellow and Supervisor. A copy of the offer letter shall be filed with the PGME Office and with the Academic Department Chair.

In every case the offer must be in writing. Each offer letter shall include the following:

• A written statement that the fellowship supervisor will provide the Clinical Fellow with a copy of the educational goals and objectives of the fellowship, as approved by the
• Postgraduate Medical Education Associate Dean.
• A statement of the duration of the fellowship, including the start and end dates.
• A statement which clarifies if the Clinical Fellowship has been accredited by the Royal College as an Area of Focused Competence (AFC) diploma program or if it meets the Royal College’s criteria for the Subspecialty Examination Affiliate Program (SEAP)
• A statement that the relationship between the fellow and the University is educational only and does not constitute an employment relationship with the University.
• A statement that the fellowship is subject to legal, policy, and professional requirements of the clinical site.
• A statement which clarifies the form that evaluation will take during the fellowship and how the Clinical Fellow will be evaluated.
• A statement that successful completion of the fellowship’s goals and objectives shall entitle the fellow to a Certificate of Completion, issued by the University of Toronto and the Postgraduate Medical Education office.
• A statement that the fellow may be placed on probation or be subject to remediation.
• A statement that the fellowship may be terminated earlier for cause for performance reasons.
• Written acknowledgment section for both parties (i.e., Supervisor, Clinical Fellow) to note acceptance of the contents of the offer including educational Goals and Objectives.
• Other terms may be developed as required by the institutions involved.

Assessments

Assessments are important to inform learners and supervisors about educational performance and identify educational needs.

Assessments should be guided by the educational goals and objectives of the fellowship as well as the CPSO required assessments. CPSO requires a period of assessment (up to 12 weeks for IMGs), called a PEAP (i.e., Pre-Entry Assessment Program) to determine if the Clinical Fellow can function at their appointed level of training prior to full acceptance in the program. See details about the PEAP.

Clinical Fellows and Supervisors should plan for quarterly assessments, verbally and in writing, including a follow up meeting to review feedback, progress, and strategies to meet educational needs with the aim of satisfying the program goals and objectives. Areas of strength and areas for improvement should be documented and verbally communicated.

A semi-annual written summary of progress should be completed by the Fellowship Program and uploaded into POWER. For one-year fellowships, the final report should be completed in the final month of the fellowship.

Clinical Fellows in Difficulty, Remediation, Probation, or Suspension

This section outlines the different levels of management for Clinical Fellows who are in difficulty with respect to the established fellowship Goals and Objectives. Fellowship Directors should contact PGME for any learners in difficulty, remediation, probation, or suspension. PGME can assist with the development of an education support plan. There are many resources available for Fellowship Directors, including assessment tools, access to educational consultants, learning specialists and experienced coaches.

Clinical Fellows in Difficulty

Sometimes Clinical Fellows struggle academically or personally. When this occurs, finding timely support for both the Clinical Fellow and the Supervisor is beneficial. Information is available on the PGME website (weblink to be inserted). Clinical Fellows and Supervisors are encouraged to access resources as early as possible if a Clinical Fellow may benefit from discussing wellness, accommodations, leaves of absence, or issues with the learning environment.

Remediation

The supervisor shall propose a learning plan when, in their opinion:

• there are significant and/or ongoing deficiencies in progress towards the goals and objectives that are not being remedied through usual educational activities, and/or
• there is a reasonable prospect of improvement with additional measures being put in place.

The learning plan will include specific written measures that are designed to assist the fellow in achieving the goals and objectives. Note that, as per above, consideration should be given to potential personal, family, or learning environment issues that may be contributing to a learner’s inability to meet objectives and there is an obligation for the program to direct the learner to appropriate supports and resources to optimize chances for the fellow’s success.

The drafted learning plan is to be discussed with the Vice-Chair Education (or delegate) and is subject to their approval. Where remediation involves additional costs (e.g., tutoring, coaching, textbooks, etc.) the responsibility for such costs are between the funder of the fellowship and/or the Clinical Fellow and the supervisor’s Academic Department and shall be detailed in the drafted learning plan.

The drafted learning plan shall be discussed with the Clinical Fellow. The decision as to whether the learning plan has been successfully completed is to be made by the supervisor and the Vice-Chair Education (or delegate) based on the learning plan including the outlined assessments and criteria for completion.

The learning plan should specify the assessments and criteria for completion. The learning plan outcomes and impact of successful or unsuccessful completion of remediation should be clearly outlined.

A Clinical Fellow who disagrees with the drafted learning plan may ask that the Associate Dean, PGME to review the learning plan proposal and/or request that there be further discussion with the supervisor. The decision as to the appropriate learning plan remains that of the supervisor, in consultation with the fellowship committee if applicable, after such review and discussion has occurred.

If the Clinical Fellow does not agree to participate in the learning plan that has been approved by the supervisor, following consultation with the fellowship committee if applicable, and the Vice-Chair Education (or delegate), the Fellowship is subject to termination for cause.

A second remediation may be entered, but only in exceptional circumstances.

Successful completion of remediation results in the resumption of regular educational program.

Probation

The supervisor, following consultation with the fellowship committee if applicable, and the Vice-Chair Education (or designate) shall propose “probation” when in their opinion:

• there are significant and/or ongoing deficiencies in progress towards the goals and objectives, or
• there are more serious deficiencies in meeting the requirements of the Clinical Fellow role at any point in time (i.e., ones that are not viewed as being amenable to being dealt with via a learning plan).

Probation is a time-limited period where performance is closely monitored, assessed, and documented. Note that, as per above, consideration should be given to potential personal, family, or learning environment issues that may be contributing to a learner’s inability to meet objectives and there is an obligation for the program to direct the learner to appropriate supports and resources to optimize chances for the fellow’s success.

The draft probation plan is to be discussed with the Vice-Chair Education (or delegate) and is subject to their approval. The approved drafted probation plan shall then be discussed with the Clinical Fellow prior to them signing off.

The probation plan should include the criteria for successful completion. The probation plan outcomes and impact of successful or unsuccessful completion of probation should be clearly outlined.

If the Clinical Fellow does not agree to participate in the probation plan that has been approved by the supervisor and the Vice-Chair Education (or delegate), the Fellowship is subject to termination for cause.

A second probation period may be entered, but only in exceptional circumstances.

Successful completion of probation results in the resumption of regular educational program.

Suspension

The supervisor shall propose “suspension” or immediate stop to the fellowship, when in their opinion:

• the Clinical Fellow has committed a critical error and/or there is a concern for patient safety or the safety of the learning environment.

In such a case, the supervisor will promptly notify, in writing, the Clinical Fellow; the Chair of the Academic Department; the hospital or clinical site Vice-President Education (or equivalent); and the Associate Dean, PGME. The PGME Office shall inform the CPSO in writing of the suspension.

Authority for the needed review, investigation, and other handling of the case will depend on the organizations(s) having jurisdiction. Designation of jurisdiction shall be a matter of discussion between the University and hospital, clinical site, or other organizations(s), and may be subject to additional policies or guidelines. Decisions will be determined collectively by the University Academic Department, the Hospital, and PGME.

The decision regarding return to clinical training from suspension is dependent on the outcomes of review (in cases in which is a review or investigation is triggered) and would require re-activation of licensure by CPSO.

Contesting a Fellowship Learning Plan

A Clinical Fellow may appeal a Program Decision for a fellowship learning plan in writing within 14 days, to the Associate Dean’s office, PGME. The review shall be conducted by a designate appointed by the Associate Dean, PGME. The review shall consider whether there was a reasonable opportunity given to the Clinical Fellow to achieve the written goals and objectives of the fellowship.

If a Clinical Fellow’s appeal is rejected by the Associate Dean’s, PGME appointed designate, it is expected that the Clinical Fellow will resume the fellowship learning plan. If a Clinical Fellow refuses to commence a fellowship learning plan following an unsuccessful appeal, consideration for termination will be reviewed.

Termination and Review

A Clinical Fellow may be terminated from their Clinical Fellowship program for performance reasons prior to the scheduled completion.

The Vice-Chair Education (or designate) shall ensure that prior to the final decision, the Clinical Fellow has been advised in writing of the reasons for the proposed termination and has had an opportunity to respond.

Prior to any final decision to terminate, the Department Chair (or delegate) shall consult with the fellowship supervisor, the Associate Dean, PGME, and the hospital Vice-President Education.

Termination for cause may occur at any time in the fellowship depending on the performance reasons that exist, and is not dependent on whether remediation, probation, or suspension has occurred.

In all cases of early termination for cause for performance reasons, the University will alert the institution which has entered into the contract with the Clinical Fellow in advance of the termination being finalized, so that the institution may consider what contractual provisions, if any, including notice, may apply.

Where a Clinical Fellow has been terminated for cause for performance reasons, PGME will not issue a Certificate of Completion, but will only issue a letter which verifies the dates and duration of the trainee’s registration and includes a notation that the fellowship was terminated for cause.

The CPSO must be notified of a change in status following a withdrawal of the trainee from a Clinical Fellowship or the termination of the fellowship for cause for performance reasons.

The decision of the Vice-Chair Education (or delegate) regarding the termination of a fellowship for cause for performance reasons is not subject to appeal.

Concerning Fellowship Experiences

Where, in the opinion of the Clinical Fellow and/or the Fellowship Program, there are serious deficiencies in the efforts of the supervising and collaborating clinical faculty members to provide a safe and positive learning opportunity for the Clinical Fellow to attain the goals and objectives of the fellowship or serious deficiencies in those faculty members’ compliance with the CPSO policy Professional Responsibilities in Medical Education and Companion Document, a review of the progress of the Clinical Fellowship shall occur.

The review shall be conducted by an individual or individuals appointed by the Associate Dean, PGME. If deficiencies in the Clinical Fellowship are found, the case shall be referred to the Associate Dean, PGME for corrective action, to be undertaken in consultation with the relevant parties, including the Vice-Chair Education (or delegate). This may include removing learners from the environment or suspending the fellowship until appropriate corrective measures have been implemented, with a mechanism for near-term monitoring for compliance.

Where there is concern of learner mistreatment, the Clinical Fellow can access the resources to discuss, disclose or report through the Learner Experience Office.

Where, in the opinion of the Clinical Fellow and/or the Fellowship Program, there are potential wellness concerns the Clinical Fellow and/or Fellowship Program should contact the Office of Learner Affairs (OLA) for more information. Following consultation with OLA it may be determined that a recommendation be made for accommodation and/or referral to the Board of Medical Assessors (BMA) for further review.

Where, in the opinion of the Fellowship Program, there are patient safety issues the Fellowship Program should immediately contact the Associate Dean, PGME for direction. This may result in placing the Clinical Fellow on temporary leave until next steps are determined.

Attainment of Educational Goals and Objectives

Where a Clinical Fellow has successfully completed the fellowship goals and objectives, the PGME office issues a Certificate of Completion that includes the dates and duration of the trainee’s fellowship.