T3: Transparent Thursday Topics

February 27, 2020: "The residents clearly stated that in order for them to feel that their concerns are heard and that their feedback is both useful and impactful, some kind of mechanism needs to be put in place."

Thank you so much we completely agree!!

There are some kind of feedback loops, which are challenging to close For example, when there is a complaint about a specific supervisor for confidentiality reasons it is difficult for us to let learners know about the result of a faculty review. However, learners are absolutely entitled to know virtually all other aspects of postgraduate functioning.  We already send important information and alerts via email. In addition, we have the monthly CBD newsletters. We have just agreed that all minutes from PRPC, PEAC and CBD operations committee will also be circulated to residents so that they can be aware of agenda items, discussions and decisions. In addition, we are working hard with PRAT, PGY representatives, and Chief Residents to make sure that they are regularly informed of any information that they can then pass on to the wider resident body.... and of course this very paragraph you are reading is meant to help as well.

March 5, 2020: ”EPA interfact difficult, having to log on with our phones – it’s very unnatural when discussing feedback; awkward to sit around and wait for supervisors to fill something out when they’ve already provided verbal feedback.”

This is a common concern in all specialties across the country. It is an absolute mandatory Royal College requirement. You should know that EPAs can be completed on a desktop computer, laptop, tablet, or phone, but the Royal College requires that the data be captured for review by the Competence Committee. This is an accreditation standard. In our experience so far, the competence committee is able to pick up on themes across rotations/EPAs that would not previously have been recognized. This is being fed back to residents to help them improve.

We also know that in most cases, faculty were already observing and providing feedback to residents on their performance but where this was previously not happening this new system will necessitate more observation and conversation which we think is to the benefit of learners.

As far as the useability/interface.... stay tuned as we're switching to Elentra July 1, 2020. This is the platform being used by all programs at U of T and about half of the Universities across the country. It's a little more pretty, a little more slick and has a few more features.

March 12, 2020: ”Why has the nature of the book allowance changed?”

The book allowance was a wonderful feature of our program for many years. It was entirely funded by psychiatrists out of their own pockets. It does not come from any university or AFP or any other source of funding. Recently, as we have tried to put into place all kinds of extra supports for residents including longitudinal coaching (which is  Royal College requirement), as well as the Competence Committees and increased observation, we have been asking more of our partner hospital sites. In addition, some aspects of patient flow and billing have changed as a result of the LAE. Sites were expressing reservations about continuing to contribute their own money to a resident book fund in the context of all these other accreditation/programmatic/curricular changes.

There was real risk that the book fund was going to disappear completely. Please note that book funds are not mandatory and not an accreditation standard but one of the many ways we have been delighted to voluntarily support residents. Rather than completely eliminating the book fund, we were able to negotiate with the psychiatrists in chiefs for them to take 75% of the book allowance money and reallocate it directly back into education. They continue to contribute the remaining 25% directly to residents, but, appropriately insisted that there be some kind of adjudication process for receiving the funds. We struck a joint committee between several residents and psychiatrists in chiefs to determine the terms of reference. In the end, we were delighted to offer academic awards which previously did not exist. Every year we receive requests for funding for conferences, seminars or research and we had no ability to fund those requests. Although it would have been nice to continue to have staff psychiatrists give money to residents - in a time of university, provincial, and OHIP cutbacks, which also coincides with the increased educational infrastructure it just was not possible. We are very happy to have preserved some funds to support the scholarly development of our learners. We have enough money to ensure that every single learner who has a viable application will receive a "resident scholarly development award" at least once over the course of their training.

March 19, 2020: "Why have you changed the format the PGY2 academic day? (hint: it wasn’t social distancing)"

The structure of the PGY2 academic day was changed for a number of important reasons.

1) There is loads of evidence to suggest that teaching and clinical experience should be aligned as closely as possible. In the old system you could have a lecture on a relevant topic in September but may not encounter a clinical situation until February. The new system allows us to better target lectures that relate specifically to the rotations on which residents are working. This is an evidence-based approach that we developed with consultation from educational scientists.

2) As the size of our residency program has grown, space and comfort has become an increasing issue. We did not have access to a room that was large enough to consistently accommodate all PGY2s for every week of the year. Furthermore smaller lectures promote better learning and participation. The new curriculum structure allows us to have groups of approximately 12-13 residents instead of 40 at each lecture.

3) Despite years of effort, resident attendance at core lectures and in large groups has been extremely poor. This led to a sense of inequity amongst residents. In addition, we were routinely receiving complaints from faculty who had taken the time to prepare lectures only to have 1-2 residents show up in the room. Some of our expert faculty were refusing to teach under these conditions.

 

4) The "new" structure for PGY2 lectures mirrors the structures we have always had in PGY3 and 4. Those have always been well-received and well-attended.

5) With the introduction of a longitudinal clinic (which was strongly requested by previous resident cohorts, more to come in a future question) having a full additional academic day would mean that residents were only present on their core rotations 3 days a week. We considered the possibility of half days of either LAE or teaching but that would absolutely necessitate significant travel for a large majority of residents, and we received feedback that this would not be well-received.

While this new structure is different for the PGY2 year it has been tried and tested in PGY3 and 4. It allows for an LAE that was requested by residents and is aligned with educational principles and literature. We do understand that some social aspects of the day have been lost - but we continue to protect and support a weekly resident lunch. We continue to protect and support 2 PRAT retreats. We are certainly open to other ideas that may promote friendship and collegiality in our program - send those ideas to us directly!

March 26, 2020: ”Why isn’t the Longitudinal Ambulatory Experience standardized across all our hospital sites? It seems there are drastically different expectations around documentation, frequency of new assessments, level of supervision etc."

We understand that there is bound to be variability in a program of our size. To some extent, this is desirable. We want sites to offer slightly different experiences. We also appreciate that different residents learn and perform at different rates. The goal of CBD is actually to allow for more individualization of the educational curriculum.

However, we also want to have some shared standards and "floors". There is already a document available on our Departmental Website (Longitudinal Rotation Structure under Departmental Policies and Guidelines: https://www.psychiatry.utoronto.ca/policies-and-guidelines) that outlines how an LAE should function. In addition, our LAE Working Group surveyed PGY1 and 2 residents as well as supervisors at our sites in January 2020. The group is currently reviewing the data to provide recommendations to the LAE sites so we can change those guidelines in accordance with feedback or help sites come into alignment with them.

Please remember that we started 6 brand new PGY2 clinics about 7 months ago. Some amount of learning and adjustment is to be expected. Bear with us, we're on it!

April 2, 2020: "Residents want clear communications/transparency over what will happen on rotation."

All site directors and administrators have been asked to contact learners 1 month before the scheduled start of their rotation to provide them with relevant information pertaining to their start. This includes access to office space, orientation, registration and when/where to meet. We regularly remind sites of this expectation. If you are starting a rotation and have not heard from anyone about the details, please reach out to Mark Fefergrad (mark.fefergrad@sunnybrook.ca).

 

April 9, 2020: "Why was the curriculum structure changed?"

A diverse group of departmental members and residents, met for two years to debate any changes to the previous rotation structure. The three biggest factors were: 1) community/societal need, 2) resident input, and 3) the wish to create more PLEX (elective) time. For example, we previously had 1 month of addictions in PGY1 and a brief PGY4 experience. Given the rate of substance use disorders in the populations for whom we care and hearing from residents about their comfort level, we thought that experience was grossly inadequate. As a result there is now 2 month experience in each of PGY2 and PGY4. This experience includes training in acute withdrawal, methadone, partial agonists/anti-craving medications and motivational interviewing - all of which we think will make for better prepared clinicians who can meet the needs of their patients.

As an another example, previously no rotation lasted longer than 6 months (other than psychotherapy) which meant there was never any longitudinal patient care. Numerous stakeholders across the system including patients and residents, have advocated for some mechanism to follow chronically unwell patients over a longer duration. The kind of care and relationships associated with that longitudinal model are more similar to actual practice and require a different skill set. Those factors along with the wish to provide one on one observation and feedback to learners, were important factors in the decision to create a longitudinal ambulatory experience.

We also reduced the duration of almost all rotations on the basis of resident feedback. We are a broad specialty and we want people to have the latitude to explore and invest in areas of interest. We also wanted PLEX (elective) time to be spread across training to facilitate research and so that any resident behind on their competencies/EPAs would have an opportunity built into the curriculum structure to catch up without needing to extend their training.

April 16, 2020: "Why isn't the child on-call experience completed during the PGY2 Child and Adolescent psychiatry rotation?"

1. There were several reasons that the program decided to move the core child rotation to PGY-2, largely based on resident feedback. These include earlier exposure to an area of potential interest, more opportunity for elective time in general and an opportunity to decide earlier whether or not to apply for the sub-specialty.

[Addendum (April 21, 2020): There were several reasons that the program decided to move the core child rotation to PGY-2, largely based on resident feedback. Earlier exposure to children and adolescents emphasizes that most mental disorders start early in life; this developmental perspective will be essential for all the following rotations and for your psychotherapy and other LAE patients. Also, it provides more opportunity for elective time in general and to decide earlier whether or not to consider the sub-specialty.]

2. In consultation with faculty and residents, it wouldn’t make sense to move child call to PGY-2 (i.e., recoupling it, more or less, with the core child rotation), because the nature of CAP call (a subspecialty population, more often having to navigate family/systems issues, working more independently) makes it more suitable for a more senior resident. Furthermore, it's possible that this could be a resident's first ever on-call experience which seemed unwise. 

3. An advantage of doing adult call during the core CAP rotation is that residents continue to have experience assessing adults, which is likely helpful with respect to STACER preparation and keeping up knowledge/skills with adults more generally. 

4. An advantage of doing the core child rotation in PGY-2 followed by child call in PGY-3 is that residents have the opportunity to see kids at 2 different stages of their training. Thus, in PGY-3 they can consolidate and build on what they learned in PGY-2. This is an approach we've taken (again based on resident feedback) with inpatients, ER and addictions.

5. We continue to believe that some child call is an advantage to a robust training program. Downtown Toronto is very unique. In virtually every other call experience, it's likely that you will be called upon to assess kids in the ER.

April 23, 2020: “4 months is not long enough for the Inpatient Psychiatry rotation – can we have the 6 month rotation back?”

In the old curriculum, residents had a six-month inpatient block in PGY2. Residents consistently gave us feedback that this was too long on the most intense rotation early on in training. Many residents asked for a shorter experience saying that it would support their wellness and that the bulk of the learning occurred in the first 2/3 of the rotation. Furthermore, in the old system, it was possible to do an inpatient rotation until December of PGY2 and then graduate without ever again being on an inpatient unit.

 

By shortening the PGY2 inpatient rotation by two months and instead providing PLEX (elective time) we are hoping to allow residents the opportunity to explore potential areas of interest including the subspecialties early in training before any decisions need to be made. In addition, we believe the creation of a CTU like team with the PGY4 rotation will give all residents an opportunity to be a senior resident on the team. It will also allow the PGY4s to focus on other competencies like leader/manager, teacher, and other more senior/staff activities.

April 30, 2020: "Can the program please explain what efforts are being made to make the call accommodations system more fair?"

Up until recently the program took the stance that we would recognize and adhere to all accommodations supported by a medical note. In fact, we believe this is best for resident well-being and it is our legal obligation. However, over the last one to two years several residents have expressed concerns that some people may be misusing the generosity of that system. In principle, we would rather err on the side of a small number of residents getting accommodations that they don’t entirely need, rather than make the process for accommodations more challenging for a resident who is genuinely unwell. However, we also recognize the impact that this system can have on the rest of our hardworking call pools.

As a result, we are working with the University to implement a specific accommodation form. This is based on the kinds of forms that other large institutions or insurance companies use. This form will necessitate a specific description of any disabilities that need to be accommodated. In our current system, any physician can essentially write a note "this resident cannot do call" and we immediately take that resident out of the call pool. We are hopeful that the specificity required in the new form will diminish any misuse of medical notes.

In addition, it is important to note that rumors of widespread accommodations are overblown. In the current academic year, we have had a total of 28 residents with some form of call accommodations (for some period of time) out of 197 residents which works out to 14%. The numbers of residents requiring accommodation for 6 months or less is substantially smaller. While we always strive to improve our processes, this is not a number that suggests that multiple people are misusing the system, rather a few outliers.

Residents should also be aware that on occasion, when it has come to the program's attention that people are misusing call accommodations, we have acted swiftly. More than one resident has gone to the Faculty of Medicine Board of Examiners on the basis of these professionalism issues. If you are concerned about any professionalism issue with any of your colleagues, please feel free to bring it to our attention and we will not hesitate to follow-up.

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