Application

Effective 2017-18, these Guidelines apply to all students registered in the MD Program.

Overview

Being a professional is one of the key attributes of being a physician. These guidelines for the assessment of MD student professionalism are informed by the University of Toronto’s Standards of Professional Practice Behaviour for all Health Professional Students and the MD Program’s competency framework.

Assessment of student professionalism takes place through competency-based professionalism assessments and critical incident reports, as described below.

Suspected breaches of academic integrity are investigated and addressed in accordance with the MD Program’s Academic Integrity Guidelines.

Competency-based Professionalism Assessments

In selected teaching and learning settings where teachers are in a position to make meaningful observations about students’ professional behaviour, including small group settings and clinical learning environments, supervising teachers complete competency-based student professionalism assessment forms. This assessment exercise provides an opportunity for teachers to indicate both strengths and areas for improvement with respect to professionalism, with a primary goal being the provision of formative feedback to support medical students' professional identity formation through the development of their professional competencies. It also allows the program to monitor whether individual students are exhibiting a pattern of unprofessional behaviour, possibly across multiple courses or multiple learning contexts.

The Faculty Lead, Ethics and Professionalism plays a dual role with respect to these guidelines. They play a leadership role in ensuring that the processes to support the assessment of student professionalism and
processes to support students who are identified as being in professionalism difficulty are clearly articulated, fair, and informed by Temerty Medicine’s commitment to the principles and practices of equity, diversity, inclusion, Indigeneity, and accessibility (EDIIA). The Faculty Lead, Ethics and Professionalism also plays a consultative role with respect to medical students who have been identified as being in professionalism difficulty. This consultative role includes active participation in the development and assessment of focused professionalism learning plans and professionalism remediation plans. 

The assessment of demonstrated professional behaviours form is organized according to six professionalism domains. Each domain includes criteria that reflect specific behaviours that characterize the respective domain, as follows:

• Interactions with Patients and Essential Care Partners
  • Uses effective verbal and non-verbal communication
  • Shows respect for patients' time, space, and person (e.g., appropriate draping)
  • Takes time to comfort the patient 
  • Navigates difficult or complex situations with empathy and sensitivity to the patient's lived experience
  • Demonstrates respect for donated tissues/cadavers
  • Establishes and maintains appropriate boundaries
• Reliability and Responsibilities
  • Fulfills obligations in a timely manner
  • Manages transitions of care effectively
  • Informs supervisor/colleagues when tasks are incomplete, mistakes or medical errors are made, or when faced with a conflict of interest
  • Manages lateness or absence in accordance with policy/expectations
  • Arrives prepared for work, including maintaining an acceptable standard of appearance and hygiene (e.g., scrubs for OR)
  • Actively participates in patient care activities and learning activities (e.g., rounds, family meeting, CBL/HSR/Seminar, etc.)
  • Fulfills call duties and academic responsibilities (e.g, attending rounds, seminars, classes)
  • Timely completion of MD Program and hospital registration requirements
• Growth and Adaptability
  • Accepts and provides effective feedback
  • Incorporates feedback by demonstrating changes in behaviour 
  • Recognizes own limits and seeks appropriate help
  • Appropriately responds to unanticipated changes in schedules, clinical responsibilities, and other work/learning activities
  • Understands the importance of reconciling self-care and care for patients. Consults with others when challenges arise
• Relationships with colleagues
  • Maintains appropriate boundaries
  • Balances the needs of the learner and the group/team (e.g., group work, leaving early)
  • Collaborates effectively with team members (including physician colleagues, other health providers, other clinic/hospital staff, and patients/families/essential care partners)
  • Communicates effectively with Temerty Faculty of Medicine staff/faculty
  • Contributes to a psychologically and culturally safe learning environment
  • Demonstrates awareness and support for peers-in-need
• Upholding Student and Professional Codes of Conduct
  • Accurately represents qualifications
  • Uses appropriate language with patients, colleagues, and other staff
  • Acts with honesty and integrity
  • Employs effective conflict navigation strategies
  • Respects confidentiality, privacy, and data stewardship
  • Engages responsibly with social media and observes policies surrounding its use 
  • Promotes equity, diversity, and inclusion (e.g., race, gender, religion, sexual orientation etc.)
  • Uses appropriate strategies to access and identify supports and pathways to respond to unprofessional behaviour and unethical behaviours
• Recognize and Respond to Ethical Issues
  • Recognizes when ethical issues in patient care arise and responds appropriately, including asking for additional support as needed
  • Communicates effectively when differences in personal and professional values arise (e.g., termination of pregnancy, medical assistance in dying)
  • Applies ethical reasoning skills where appropriate

Teachers are asked to rank students from 1 to 5, with 5 being the highest score, for each of the six professionalism domains. The assessment of each domain is based on the criteria applicable to the student’s learning activity. Teachers have the option of indicating if they were not in a position to assess one or more of the professionalism domains. Teachers are required to provide comments regarding any scores of 1 or 2, including those that are based on a critical incident (details regarding critical incident reports provided below).

Professionalism Standards of Achievement

Satisfactory professionalism competency is a requirement to achieve credit in every course, and assessment of professionalism competency is included in every course. Satisfactory professionalism competency is also required to progress from one year level to the next and to graduate from the program, in accordance with the MD Program’s Standards for Grading and Promotion for Foundations and Clerkship.

A student may be identified as not satisfactorily progressing as follows:

• One or two scores of less than 3 on any combination of the six professionalism domains, including two scores of less than 3 on the same form, will trigger a student professionalism check-in process (see below for details).
• Three or more scores of less than 3 on any combination of the six professionalism domains, including 3 or more scores of less than 3 on the same form, will trigger a student in professionalism difficulty review process (see below for details).
• A critical incident report will trigger the student in professionalism difficulty review process (see below for details).

The student in professionalism difficulty review process will be re-triggered in cases where a student who has successfully completed (or is in the process of completing) a focused professionalism learning plan or program of professionalism remediation subsequently receives a score of less than 3 on one of the six professionalism domains.

Critical Incident Reports

Critical incident reports are intended to address situations where a student has put a patient or someone else at significant risk and/or caused harm (physical, psychological, emotional) because of their behaviour. Critical incidents of unprofessional behaviour include, but are not limited to, the following:

• Failure to keep proper medical records
• Falsification of medical records
• Breach of confidentiality
• Failure to acknowledge and manage appropriately a conflict of interest
• Being disrespectful to patients and others
• Failure to be available while responsible for contributing to patient care
• Failure to provide transfer of responsibility for patient care
• Providing treatment without appropriate supervision or authorization
• Referring to oneself as, or holding oneself to be, more professionally qualified than one is
• Being under the influence of alcohol or recreational drugs while participating in patient care
• Failure to respect the rights of patients and others, including contravention of the Ontario Human Rights Code
• Assaulting a patient or others, including any act that could be construed as mental or physical abuse
• Sexual abuse of a patient, as defined by the Province of Ontario Regulated Health Professions Act
• Stealing or misappropriating or misusing drugs, equipment, or other property
• Violation of the Criminal Code
• Any other conduct unbecoming of a physician in training that puts a patient or someone else at significant risk and/or casues harm (physical, psychological, emotional)

Please note that “patients and others” includes patients, families, staff, peers and others.

Critical incidents can be reported as part of a competency-based assessment, or by any teacher, medical student or other learner, University staff member, or hospital staff member using the MD Program’s Critical Incident Report Form or MD Program Event Disclosure Form. Completed critical incident report forms should be forwarded to the Foundations Director, Clerkship Director or Associate Dean, Learner Affairs. Receipt of a notification that a critical incident has occurred will initiate the student in professionalism difficulty review process, which is described below.

A substantiated critical incident report may to lead to a program of remediation, which the student would be required to report to the College of Physicians and Surgeons of Ontario (CPSO) and/or other provincial/territorial physician regulating bodies, as appropriate. A substantiated critical incident can also lead to failure to achieve credit in one or more courses, failure of a year, suspension, or dismissal from the program.

Student Professionalism Check-in Process

A primary goal of professionalism assessments is the provision of formative feedback to support medical 
students’ professional identify formation through the development of their professionalism competencies. 
These professionalism assessments also enable the program to monitor whether individual students are 
exhibiting a pattern of unprofessional behaviour, possibly across multiple courses or multiple learning contexts.

One or two scores of less than 3 on any combination of the six professionalism domains, including two scores of less than 3 on the same form, will trigger the student professionalism check-in process. The check-in process is intended to ensure that students have the opportunity to discuss their performance, including consideration of comments provided on the professionalism assessment form, in a safe and confidential environment, and that they are aware of the various supports available to them.

The check-in procedures are as follows:

1. The student is contacted in writing by and required to meet with the course or component director of the course or component in which the score of less than 3 was received. In order to support the early identification of potential patterns of unprofessional behaviour and/or to identify appropriate supports or resources for a student who may be experiencing professionalism difficulty, the course/component director may consult with the Faculty Lead, Ethics and Professionalism; Foundations Directors; Clerkship Directors; and/or other curriculum leaders prior to or following the check-in.
2. The check-in process normally results in one of three outcomes:

3. No voluntary professionalism activities and/or supports are suggested by the course/component director. A record of the discussion is created by the course/component Director, reviewed by the student, and retained in the student file.

4. Voluntary professionalism activities and/or supports are suggested by the course/component director. A record of the discussion is created by the course/component director, reviewed by the student, and retained in the student file.

5. The course/component director forwards the matter to the relevant curriculum (Foundations or Clerkship) director for further review. This action is taken only in exceptional circumstances, where the course/component director considers the professionalism issue serious enough to warrant further review. A record of the discussion is created by the course/component director, reviewed by the student, and forwarded to the relevant curriculum director. The student will meet with the curriculum director in accordance with the student in professionalism difficulty review process, described below.

See Appendix A for a check-in process flow chart.

Student in Professionalism Difficulty Review Process

The student in professionalism difficulty review process will be triggered if a student receives:

• Three or more scores of less than 3 on any combination of the six professionalism assessment domains, including 3 or more scores of less than 3 on the same form
• A critical incident report

A course or component director may decide to initiate the student in professionalism difficulty review process as the outcome of a check-in meeting. This action is taken only in exceptional circumstances, where the course/component director considers the professionalism issue serious enough to warrant further review.

Prior to the Student Meeting described below, the curriculum director may consult with the Faculty Lead, 
Ethics and Professionalism, to discuss whether or not there are any potential underlying complexities. If 
potential underlying complexities are identified prior to the student meeting or at any point during the student in professionalism difficulty review process described below, the Faculty Lead, Ethics and Professionalism may strike an ad hoc consultation panel to inform next steps, including the identification of appropriate resources or supports. With the goal of enabling a fair and equitable process, the reasons for striking an ad hoc consultation panel include but are not limited to student mental health, accessibility needs, or potential power asymmetries, particularly for students from equity-deserving groups. Only those who need to be involved should be invited to participate on an ad hoc consultation panel, and all panel members shall maintain confidentiality to the extent possible.

The student in professionalism review process may lead to a program of remediation, which the student would be required to report to the College of Physicians and Surgeons of Ontario (CPSO) and/or other provincial/territorial physician regulating bodies, as appropriate. The review can also lead to failure to achieve credit in one or more courses, failure of a year, or dismissal from the program, in accordance with the MD Program’s Standards for Grading and Promotion for Foundations and Clerkship.

The student in professionalism difficulty review procedures are as follows:

A. Student Meeting

1. The student is contacted in writing by and required to meet with the relevant curriculum director (i.e. Foundations Director or Clerkship Director), or delegate, to discuss the professionalism issues identified in the professionalism assessments and/or critical incident report. The student viewpoint as well as input from the course/component director and other curriculum leaders, as appropriate, will be considered during the meeting.
2. Reviews that involve a critical incident report will normally result in one of three outcomes:
   1. The critical incident is not substantiated by the curriculum director, in which case no further action is required.
   2. The critical incident is not substantiated as a critical incident but is substantiated as a low professionalism score, in which case the curriculum director will facilitate the submission of a non-course based professionalism assessment form
   3. The critical incident is substantiated by the curriculum director, in which case the review process proceeds.
3. The curriculum director, in consultation with the Faculty Lead, Ethics & Professionalism and other curriculum leaders, as appropriate, will determine next steps. The student’s record of professionalism (including their professionalism assessments, substantiated critical incidents reports, and previous programs of professionalism remediation) and severity of the incidents (critical or otherwise) will inform next steps. The student’s perspective and other background information will also be taken into account. Next steps will involve one of four outcomes:
   1. No further action required
   2. Focused Professionalism Learning Plan (See section B below)
   3. Professionalism Remediation (See section C below)
   4. Academic sanctions (See section D below)
4. The student may be required to meet with the Associate Dean, Learner Affairs or delegate for the purpose of exploring health-related or personal reasons for their unsatisfactory progress and potential supports needed.

B. Focused Professionalism Learning Plan

1. The student will meet with the Faculty Lead, Ethics & Professionalism to develop a Focused Professionalism Learning Plan, including specific performance criteria that reflect the specific professionalism concern(s) at issue and time period for completion. The Faculty Lead has ultimate responsibility for approval of the learning plan details and timelines, in consultation with the student.
2. Following the time period specified for completion of the learning plan, the Faculty Lead will review the student’s progress. The review may include consultation with relevant curriculum leaders. The outcome of this review will be a report provided by the Faculty Lead to the Foundations or Clerkship student progress committee.
3. The Foundations or Clerkship student progress committee will review the student’s professionalism progress and decide whether the student is satisfactorily progressing in professionalism:
   1. If the student progress committee decides that the student is satisfactorily progressing in professionalism, the student will be informed by the Faculty Lead that their learning plan has been successfully completed. A record of the learning plan, including its successful completion, will be retained in the student file.
   2. If the student progress committee decides that the student is not satisfactorily progressing, a recommendation for professionalism remediation will normally be recommended, as described in section C below. 
4. In cases where professionalism remediation is recommended to the Board of Examiners, the student should be provided with timely notice of the recommendation, disclosure of the evidence on which the recommendation is based (i.e. the reasons for the recommendation), and an opportunity to provide a response to the Board of Examiners.

C. Professionalism Remediation

1. Professionalism remediation may be recommended following unsuccessful completion of a Focused Professionalism Learning Plan or as an immediate outcome of the student meeting.
2. The student will be informed in writing by the relevant curriculum director or delegate that they are not satisfactorily progressing in professionalism, and that a recommendation for professionalism remediation will be made to the Board of Examiners. The student must be fully informed of their rights, including their right to provide a written submission to the Board of Examiners.
3. If the recommendation for formal professionalism remediation is approved by the Board of Examiners, a provisional MedSIS course grade of “Unsatisfactory Progress” (for Foundations) or “Conditional” (for Clerkship) will be assigned.
4. The Faculty Lead, Ethics & Professionalism will meet with the student and determine the appropriate program of remediation, including specific performance criteria that reflect the specific professionalism concern(s) at issue and time period for completion. Remediation may include repetition of a course(s), a year, and/or suspension from the program. Students will also be informed of the consequences of not successfully completing the required remediation, including in relation to the MD Program’s Standards for grading and promotion.
5. Following the time period specified for completion of the professionalism remediation, the Faculty Lead will review the student’s progress. The review may include consultation with relevant curriculum leaders. The outcome of this review will be a report provided by the Faculty Lead to the Foundations or Clerkship student progress committee.
6. The Foundations or Clerkship student progress committee will review the student’s professionalism progress and decide whether the student is satisfactorily progressing in professionalism:
   1. If the student progress committee decides that the student is satisfactorily progressing in professionalism, the student will be informed by the Faculty Lead that their professionalism remediation has been successfully completed. A record of the program of remediation, including its successful completion, will be retained in the student file.
   2. If the student progress committee decides that the student is not satisfactorily progressing, a recommendation will be forwarded to the Board of Examiners. This recommendation will normally include academic sanctions, in accordance with the MD Program’s Standards for Grading and Promotion for Foundations and Clerkship. In such cases, the student should be provided with timely notice of the recommendation, disclosure of the evidence on which the recommendation is based (i.e. the reasons for the recommendation), and an opportunity to provide a response to the Board of Examiners.

D. Academic Sanctions

1. Academic sanctions are normally recommended following unsuccessful completion of a program of professionalism remediation, in accordance with the MD Program’s Standards for Grading and Promotion for Foundations and Clerkship. In exceptional circumstances, the outcome of a student meeting involving a substantiated critical incident report may be the immediate recommendation for academic sanctions. Academic sanctions may include failure to achieve credit in one or more courses, being placed on probation (with specified performance requirements and consequences for not successfully completing those requirements), failure of a year, suspension, or dismissal from the program.
2. The student will be informed in writing by the relevant curriculum director or delegate that they are not satisfactorily progressing in professionalism, and that a recommendation for academic sanctions will be made to the Board of Examiners. The student must be fully informed of their rights, including their right to provide a written submission to the Board of Examiners.

See Appendix A for a student in professionalism difficulty process flow chart.

Appendix A: MD Program Student Professionalism Check-in Process PDF

Date of original adoption: 7 December 2010

Date of last amendment: 10 July 2024