Important: This Protocol is NOT for emergency use.
Students concerned about impending harm to themselves or others should call 911 or seek immediate assistance from onsite security or other authorities. Students should make a subsequent disclosure/report as described in this Protocol, only after safety is ensured.
A. Preamble: Purpose and Scope
The MD Program places the utmost importance on the safety and well-being of students, including their ability to learn in an environment of professionalism, collegiality, civility and respect.
All members of the MD Program community have a joint responsibility to protect the integrity of the learning environment and a right to appropriate treatment and response when the environment is compromised.
The purpose of this Protocol is to articulate procedures for University of Toronto medical students to disclose/report mistreatment that they have experienced or witnessed. This Protocol is informed and governed by the University of Toronto, Faculty of Medicine, regulatory body and government statements, policies, protocols, codes and standards listed in Appendix A. This Protocol does not supersede powers and procedures set out in other policies of the University, the Faculty of Medicine or hospitals. Where an existing University or Faculty policy applies, the procedure described in that document will be followed. Likewise, if a University or Faculty office or a clinical institution has jurisdiction in a given situation, its authority will be respected.
B. Categorization and Definitions of Mistreatment
The Association of American Medical Colleges (AAMC) defines mistreatment within the medical education context as intentional or unintentional behaviour that shows disrespect for the dignity of others and interferes with the learning process. Mistreatment can involve a single incident or a pattern of behaviour, and can range from subtle gestures and/or comments to egregious actions. Any behaviour involving mistreatment of another person compromises the learning environment.
The Faculty of Medicine recognizes as harmful all of the behaviours and actions that are deemed unacceptable under one or more of the statements, policies, protocols, codes and standards referenced below and listed in Appendix A.
Mistreatment includes ‘micro-aggressions’, which are often unintentional, but experienced as a pattern of, snubs, slights, put-downs, and gestures that demean or humiliate individuals based on their belonging to a group, particularly those identified by gender, race/ethnicity, sexual orientation, immigration status, and/or socioeconomic class.
For the purposes of this Protocol, mistreatment is categorized as follows:
- Unprofessional behaviour
- Discrimination and discriminatory harassment
- Sexual violence and sexual harassment
Behaviours that fall under the discrimination and discriminatory harassment and sexual violence and sexual harassment categories are considered unprofessional. However, they are presented as discrete mistreatment categories since they are defined and addressed through specific policy documents, as summarized below.
The examples provided below are not exhaustive and are not intended to represent the spectrum of behaviours that may be considered mistreatment.
Any student who experiences or witnesses behaviour that they perceive or suspect as being mistreatment can and should disclose/report the concerning behaviour, as outlined below in Section D Disclosure/Reporting Procedures, in order to make an informed decision about next steps.
The MD Program encourages all members of the Faculty of Medicine Community, including students, to practice allyship by disclosing/reporting mistreatment witnessed in the learning environment, even if not experienced directly.
i. Unprofessional behavior
Key documents with respect to identifying and addressing behaviours that are considered unprofessional include but are not limited to:
- CPSO Physician Behaviour in the Professional Environment and Guidebook for Managing Disruptive Physician Behaviour
- CPSO Professional Responsibilities in Undergraduate Medical Education
- Faculty of Medicine Standards of Professional Behaviour for Clinical (MD) Faculty
- University of Toronto Standards of Professional Practice Behaviour for all Health Professional Students
- MD Program Guidelines for the Assessment of Student Professionalism
Selected examples of unprofessional behavior (I am a medical student who experienced or witnessed someone being):
- required to perform personal services
- publically humiliated, implicitly (e.g. eye rolling) or explicitly
- subjected to recurring outbursts of anger (e.g. shouting, throwing objects)
- subjected to disparaging remarks about the character or patient care of another physician/health professional/learner
- inhibited by a person in authority from providing appropriate feedback/evaluation, including disclosures or reports of mistreatment
- subjected to retaliation in response to a disclosure, report and/or investigation of mistreatment
- threatened with physical harm
- physically harmed
ii. Discrimination and discriminatory harassment
According to the University of Toronto Statement on Prohibited Discrimination and Discriminatory Harassment, “it is the responsibility of every member of the University community to respect […] the University's institutional commitment and obligation to provide a learning and working environment free from prohibited discrimination and harassment.” This commitment and obligation is grounded in the Ontario Human Rights Code.
Discrimination refers to unequal treatment based on the following protected grounds: ancestry, citizenship, colour, disability, ethnic origin, religion/faith/belief system, family status, gender expression, gender identity, marital status, place of origin, race, sex (including pregnancy), and sexual orientation. Discrimination can be direct or indirect, subtle or overt.
Medical students also have the right to freedom from discriminatory harassment, which refers to comments or conduct based on any of the protected grounds identified in the Ontario Human Rights Code that ought reasonably be known to be unwelcome.
The University of Toronto Statement on Prohibited Discrimination and Discriminatory Harassment states that “offensive or threatening comments or behaviour which create a ‘poisoned environment’ in the workplace or in the provision of services [including education] or accommodation, whether or not amounting to harassment, may violate the right to equal treatment without discrimination.”
Selected examples of discrimination and discriminatory harassment (I am a medical student who experienced or witnessed someone being):
- subjected to offensive remarks/names related to or based on race, ethnicity, gender, sexual orientation, religion or any of the other protected grounds identified in the Ontario Human Rights Code
- denied opportunities for training or rewards based on any of the protected grounds identified in the Ontario Human Rights Code
- received lower evaluations/grades based on any of the protected grounds identified in the Ontario Human Rights Code
- denied and/or subjected to critical, dismissive or demeaning remarks about approved academic accommodations (e.g. time to perform a smudging ceremony, pray, commemorate religious observance)
- not provided with reasonable academic accommodations based on disability
iii. Sexual violence and sexual harassment
According to the University of Toronto Policy on Sexual Violence and Sexual Harassment:
Sexual violence includes any sexual act or act targeting a person’s sexuality, gender identity or gender expression, whether the act is physical or psychological in nature, that is committed, threatened or attempted against a person without the person’s consent, and includes sexual assault, sexual harassment, stalking, indecent exposure, voyeurism, and sexual exploitation.
Sexual harassment includes but is not limited to engaging in a course of vexatious comments or conduct that is known or ought to be known to be unwelcome. It also includes any sexual solicitation or advance made by a person in a position to confer, grant or deny a benefit or advancement to the person where the person making the solicitation or advance knows or ought reasonably to know that it is unwelcome. Reprisal or a threat of reprisal for the rejection of a sexual solicitation or advance, where the reprisal is made or threatened by a person in a position to confer, grant or deny a benefit or advancement to the person is also sexual harassment.
Selected examples of sexual violence and sexual harassment (I am a medical student who experienced or witnessed someone being):
- subjected to offensive sexist remarks/names
- subjected to sex-related comments about my/someone’s physical appearance or actions
- subjected to unwanted sexual advances
- asked to exchange sexual favours for grades or other rewards
- inhibited by a person in authority from reporting unwelcome sexual comments or unwanted sexual advances
C. Disclosure/Reporting Principles
Implementation of mechanisms for medical students to disclose/report mistreatment is informed by the following mutually-related principles:
- Student safety, well-being and support: The first priority is on student safety, well-being and support. The experience of any kind of mistreatment may be extremely stressful. Throughout the disclosure/reporting process, utmost care will be taken to minimize further harm or stress to the student, to limit the number of times a student has to share their story, and to protect the student from retaliation. Students who disclose/report mistreatment should have appropriate physical, emotional and psychological supports. Where appropriate, educational leadership will endeavor to modify the learning environment such that a student will not have to have direct contact with the individual responsible for the concerning behaviour and that other meaningful changes are made to support a student’s safety and wellbeing.
- Distinction between disclosure and reporting: The University, in various contexts, distinguishes between disclosures and reporting. Disclosure is when a complainant conveys information about the conduct of an individual to the University, or seeks information about options. Reporting is when a complainant conveys information about the conduct of an individual to the University with the intention that the University formally reviews and potentially acts upon the information, which could result in remedial or disciplinary action taken against the individual responsible for concerning behaviour. The decision to disclose and the decision to report are separate decisions made by the student, except in cases where the Faculty of Medicine and/or affiliated health care institution is required to take steps, including out of health or safety concerns, as required by law or university regulation.
- Designated points of trusted contact: Students will have designated points of trusted contact to disclose/report mistreatment they experienced or witnessed. These designated points of contact will include individuals who are not in an evaluative role, who can provide students with advice and guidance regarding possible next steps, and who are in a position to, as appropriate, facilitate and support steps to investigate and address the concerning behaviour.
- Confidentiality and anonymous disclosures/reports: All parties must maintain confidentiality to the extent possible. Only those who need to be involved to review the matter, to respond or are requested to provide personal support, should be informed about the disclosure or report. If a student identifies themselves to the University, but does not wish to be named to the individual who is the subject of the disclosure or report, the student should be made aware:
- that there are circumstances where the University may need to disclose their identity in extenuating circumstances (i.e. including health or safety concerns, regulatory or legal obligations;
- that it may be possible for the individual to identify them based on their description of the underlying incident(s);
- that the individual may have a limited ability to respond to an unidentified or anonymous disclosure or report;
- that the University may be limited in the scope of its review, if the individual has not had a meaningful chance to respond to the disclosure or report;
- that the University may be limited in the sanctions that it can impose against the individual.
Students will also have the option to disclose/report mistreatment anonymously (i.e. without the requirement that they provide their identity), with the understanding that the ability to respond to such disclosures/reports is limited. When deciding whether to proceed with a review of an anonymous disclosure or report, the University may consider whether the issues underlying the disclosure or report are egregious and if there is sufficient information to enable the review. If the University decides to proceed with an anonymous disclosure or report, the student(s) who submitted the disclosure/report will not be known and so will be unable to participate in the review process or receive information about its outcome.
- Good faith disclosure/reporting: The University may choose not to review a disclosure or report if it determines that the disclosure or report is frivolous, has been made in bad faith, or there is insufficient information to proceed. Disclosures/reports that are frivolous or made in bad faith may be subject to disciplinary action, in accordance with the appropriate statements, policies, protocols, codes and standards.
D. Disclosure/Reporting Procedures
If a student feels comfortable, willing, and judges that it is safe to do so, they may choose to approach the individual responsible for the concerning behaviour and communicate their concerns with the goal of ending the behaviour. This approach recognizes the important role of collegial conversation in the MD Program community, and emphasizes the principle of addressing problems locally wherever possible. However, if such a conversation is inappropriate in the circumstances (e.g., it has previously been ineffective, or if more support is required due to a significant power imbalance) then a student may disclose their concerns to trusted MD Program leader, teacher, or staff member with whom they feel comfortable. It will be the choice of the student to make a disclosure or formal report, ideally following discussion with a designated MD Program leader as outlined below.
i. Who to Contact: Designated MD Program Leaders
For the purposes of this Protocol, the term “designated MD Program leader” refers to the following individuals, who are officially designated to receive and discuss disclosures/reports from medical students regarding any behaviour experienced or witnessed that a student perceives or suspects as being mistreatment. These designated MD Program leaders include the:
- Director, Learner Experience
- Associate Dean, Health Professions Student Affairs (HPSA)
- Academy Directors
As detailed below under “How to Disclose/Report”, students have the option to provide information anonymously (i.e. without the requirement that they provide their identity) to a designated MD Program leader regarding mistreatment they have experienced or witnessed, with the understanding that doing so is subject to the limitations outlined above under Confidentiality. Contact information for the designated MD Program leaders is provided on the MD Program Student mistreatment webpage.
Individuals who are not a designated MD Program leader who nevertheless receive a mistreatment disclosure are advised not to attempt or agree to intercede in such an incident by making contact with anyone, without the assistance of a designated MD Program leader. If a student chooses to disclose an incident of mistreatment to an individual other than a Designated MD Program Leader, the individual receiving the submission should:
- make the student aware of this Protocol.
- clearly inform the student of any limitations on their authority or ability to respond.
- inform the student that the preferred approach to dealing with incidents of mistreatment is to contact a designated MD Program leader. This approach helps ensure that the student has access to suitable support, that the applicable University, Faculty, and hospital policies are followed, that investigations or other actions can be undertaken, and that the MD Program is able to monitor the learning environment effectively.
- obtain the student’s permission regarding the sharing of any potentially identifying information, including completion of an Disclosure From and/or contacting a designated MD Program leader on behalf of the student.
Special note regarding disclosures made in the context of an educational experience
There are certain occasions in the MD Program curriculum, such as Portfolio group sessions, during which students share personal experiences related to their training with the expectation that those experiences will be kept confidential. Teachers who learn of mistreatment in the course of a curricular session are encouraged to privately and discreetly approach the student who described the behaviour to make sure they are aware of options available to them to disclosure and/or report the behaviour. Students should be informed that no action can be taken based on what was said in class. If the student wishes to discuss the matter, including the option to pursue it further, then the procedure described below should be followed.
ii. How to Disclose/Report
The MD Program Disclosure Form (DF) is an online tool that medical students can use to provide information to a designated MD Program leader regarding any behaviour experienced or witnessed that the student perceives or suspects as being mistreatment. The MD Program, via a designated MD Program leader, will strive to contact the student within three business days of receipt of a DF to initiate a discussion regarding the behaviour, possible next steps and supports. Students have the option submit a DF anonymously (i.e. without the requirement that they provide their identity), with the understanding that doing so is subject to the limitations outlined above under Confidentiality.
Designated MD Program leaders can also be contacted through more traditional communication, such as email, telephone, and in-person communication. Written submissions (including by e-mail) should be clearly dated and labelled “Confidential disclosure for the attention of Dr. ” to ensure priority review. Contact information for the designated MD Program leaders, as well as other supports, is provided on the MD Program Student mistreatment webpage.
Since the DF facilitates tracking of harmful incidents, students should be aware that even if they use another option, they may be asked to complete a DF. Alternatively, the designated MD Program leader may complete a DF in consultation with the student, preserving confidentiality as applicable, to ensure there is a record of the student’s recollection of the experience
Medical students also have the option of providing information regarding experienced or witnessed mistreatment on course and teacher evaluation forms. While every effort is made to review evaluation forms in a timely manner, students should not assume that course or teacher evaluations will be actioned in the same manner as a report of learner mistreatment.
The MD Program Guidelines for the assessment of student professionalism enables teachers, University staff members and hospital staff members to report unprofessional behaviour by medical students, including towards fellow medical students.
E. Next Steps Following a Disclosure/Report
- All Disclosure Forms or written submissions to a designated MD Program leader will be personally reviewed as soon as possible by the designated MD Program leader, who will strive to contact the student within three business days receipt of the submission to initiate a discussion (if the student provided their identity on submission).
- At the outset of the initial discussion, the designated MD Program leader should inform the student:
- about the supports that are available to them, ensuring that best efforts are made to prioritize the complainant’s psychological, social, and physical safety;
- about the distinction between disclosure and reporting (and gauge the complainant’s intent);
- that there could be rare egregious circumstances triggering the University’s obligation to act on a complaint, independent of the complainant’s intent to disclose vs. report (e.g., CPSO mandatory reporting, health/safety risk, other requirements at law);
- about the restrictions associated with confidentiality and anonymity (outlined above);
- that the University will not tolerate retribution or reprisal towards complainants.
- At the initial and/or subsequent discussion(s), the designated MD Program leader should:
- seek to clarify the details of the behaviour, including the need for discussion with other individuals.
- discuss the severity of the behaviour. In some instances, the student who disclosed the behaviour and designated MD Program leader may conclude that the behaviour does not in fact require any further follow-up.
- provide the student with information and guidance about University and Faculty policies, and what procedures arising from those policies will guide the response.
- determine the student’s willingness for other specific individuals to be made aware of the behaviour in order to address the situation. (These individuals must be identified to the student.)
- determine the student’s interest in proceeding with an investigation into the behaviour. Taking direction from the student, this may include a delay in action being taken to preserve anonymity and minimize risk of retaliatory behavior by the respondent, unless immediate action is required by law or university regulation.
- consult with individuals in relevant positions on a need-to-know basis and act as the student’s support and liaison with the other offices or individuals who become involved in the case. The relevant offices, individuals and policies/procedures are contingent upon the type(s) of behaviour experienced/witnessed and the role(s) (e.g. faculty, medical student, resident, patient) of the individual(s) responsible for the concerning behaviour.
- with the student’s consent, facilitate conversations among relevant parties and provide support in relation to reporting requirements and investigative procedures, as appropriate.
- keep a summary of discussions and how the behaviour was addressed on file;
- refer concerns that must be addressed through an alternative process (e.g., sexual harassment, criminal behaviour, research misconduct, referral to CPSO) to the appropriate body and/or advise the learner accordingly.
- While a reporting student has the right at any time to withdraw from further participation in any investigation or other action, the University may elect to proceed with a review without participation of the complainant (e.g., where the issue is egregious, or demonstrates a pattern of behaviour, if the conduct raises health and safety risks, or if there are potential CPSO reporting requirement, e.g., competence issue). In such a case, the student may not be advised of subsequent developments in the matter. The student retains to the right to appropriate supportive follow-up independent of his or her participation in an investigation or action, but similarly has the right to request that the designated MD Program leader cease monitoring or facilitating supportive follow-up (e.g., counselling or medical care).
F. Institutional Responsibility: Tracking, Analyzing, and Addressing Trends
The Associate Dean, Health Professions Student Affairs is responsible for oversight of this Protocol, and holds primary responsibility for the tracking of mistreatment disclosures/reports by medical students. The Associate Dean, MD Program and the Associate Dean, HPSA are jointly responsible for actively addressing concerning rates or trends mistreatment in collaboration with partners such as curriculum leaders, University departments, clinical affiliates, the decanal team, and others.
The Associate Dean, HPSA will coordinate the production of an annual report that summarizes concerning rates or trends regarding mistreatment disclosed and/or reported by medical students, including steps taken to address concerning behaviours. Any data included in the report will be conveyed in aggregate only and in such a way that endeavours to ensure that none of the individuals involved are identifiable. The Associate Dean, MD Program is responsible for determining the appropriate breadth of dissemination of the Associate Dean’s reports.
Relevant Statements, Policies, Protocols, Codes and Standards
- Ontario Human Rights Code
- Canadian Charter of Rights and Freedoms
- University of Toronto:
- Statement on Human Rights
- Statement on Prohibited Discrimination and Discriminatory Harassment
- Policy on Sexual Violence and Sexual Harassment
- Protocol with Health Care Institutions: Sexual Violence and Sexual Harassment Complaints involving Faculty Members and Students of the University of Toronto arising in Independent Research Institutions, Health Care Institutions and Teaching Agencies
- Code of Student Conduct
- Standards of Professional Practice Behaviour for all Health Professional Students
- Policy with Respect to Workplace Harassment
- Policy with Respect to Workplace Violence
- Policy on Conflict of Interest and Close Personal Relations
- Faculty of Medicine:
- Standards of Professional Behaviour for Clinical (MD) Faculty
- Relationships with Industry and the Educational Environment in Undergraduate and Postgraduate Medical Education
- MD Program:
- Guidelines for the Assessment of Student Professionalism
- College of Physicians and Surgeons of Ontario (CPSO):
- Canadian Medical Association (CMA)
- CMA Code of Ethics and Professionalism
- Hospitals and research institutes affiliated with the University of Toronto:
Consult the policies on conduct of the appropriate affiliated hospital or research institute
Date of original adoption: 21 September 2011
Date of last amendment: 17 March 2020