Socially Accountable Postgraduate Canadian Residency Programs:

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1 Socially Accountable Postgraduate Canadian Residency Programs: Within our professional responsibilities and publicly-funded health system in Canada, doctors must be accountable to the society they serve. This includes the entire spectrum of patients and communities from across our diverse geography and most particularly from Canadians experiencing health inequities. FMEC PG reaffirmed social accountability as one of the fundamental principles for postgraduate medical education in Canada. Socially accountable medical education engages, partners with and responds to the needs of communities and health-care stakeholders all across Canada and beyond. This applies to medical schools and their education partners, and the faculty, staff, students and residents who individually and collectively impact the health and health care of Canadians. This driving concept is woven through the FMEC PG recommendations. Recommendation #1 Ensure the right mix, distribution, and number of physicians to meet societal needs is directed at overall social accountability. Recommendation #2 Cultivate social accountability through experience in diverse learning and work environments is directed specifically at residency training. Socially accountable residency programs in Canada provide residents with the opportunity to acquire the requisite competencies to address the priority health concerns with their patients and wider society. It is understood that social accountability exists on a continuum from the institutional to the individual, and that residency programs must identify and provide opportunity for the development of the individual practitioner competencies specific to the specialty in question so that as physicians they participate effectively in service to society as part of the profession s collective response to societal needs. It also includes more general understanding and skills expected of our roles as professionals and citizens. Towards this goal, residency programs must clearly define and address the communities they serve, especially specific underserved, low health status populations with high needs that are a part of those communities. Residency training programs will need to develop assessment feedback mechanisms by which residents' competency acquisition with respect to social accountability and professionalism can be measured. Social accountability is being integrated into accreditation standards for all Canadian residency training programs. By building in social accountability principles throughout residency education, new in-practice physicians will be better prepared to understand and address society s evolving health care priorities including caring for those most in need. It cannot be merely an add-on or one time module in their training, but rather must actively transcend every aspect of the training, research and care

2 FMEC PG Social Accountability March 2016 environment of residency education. Medical schools and their residency programs must view implementing social accountability principles from both a top-down and bottom-up approach. There must be support at the institutional level, from the leaders and deans that set the strategic goals and mission of the school to ensure that residency training is a key component of the school s social accountability framework. At the same time, programs, clinical teachers and residents need to be acutely aware of the benefits and actively involved in teaching and learning within a socially accountable framework, both for themselves as health care providers in fulfilling their Hippocratic Oath and for the patients they ultimately serve. Clinical teachers play a key role demonstrating, role modeling and including residents in their social accountability activities in their practices, communities and medical schools. Residency programs should thus pay particular and enduring attention to the informal and hidden curriculum to ensure they are demonstrating and encouraging positive models or, at minimum reflecting on negative examples. Increasing social accountability in Canadian medical education is a progressive process that will enable postgraduate medical education to better train the physicians of tomorrow who individually and collectively will need to respond to the evolving health and health care needs of Canadians. The attached FMEC PG Guide to Improved Social Accountability in Medical Schools provides us with a snapshot of some great initiatives and ideas happening across the country, but is not an exhaustive list by any means. We encourage you to think about how some of these ideas and actions could be implemented in your own environment, and hope that you will share with your colleagues any future initiatives that you may come to be aware of over time. Thank you.

3 FMEC PG Guide to Improved Social Accountability in Medical Schools WHO definition of Social Accountability of Medical Schools: The obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public (WHO, 1995). Recommendations for Canadian medical schools and their residency programs: A statement about social accountability should be included in the institutional mission. Ensure each program has specific learning objectives regarding social accountability embedded in their training program, for example the competencies under the Health Advocate Role, to help residents develop an understanding and appreciation for improving the health and health care of underserved and disadvantaged populations. Ensure each program has required rotations in diverse learning and work environments that include varied practice settings and a range of service delivery models, within the confines of the discipline. Ensure each program has research activities addressing social accountability included in their training program, to allow residents the opportunity to focus on improving the health and health care of underserved and disadvantaged populations and develop an understanding of and respect for the variations in health, well-being and needs of different patients and communities Ensure that learning assessment includes social accountability components. Ensure that program evaluation includes social accountability components. Ensure that, to the greatest extent possible, residency programs reflect Canadian demographics, both in terms of faculty/teachers and the residents. FMECPG@AFMC.CA (613)

4 Best Practices The following are some best practices noted from across the country. The authors appreciate and acknowledge that not all will be relevant, implementable and feasible for every residency program, as there are discipline-specific restrictions that may limit what can be achieved by a particular program. Nonetheless, we would encourage every residency program to consider these best practice statements and think about how they may be able to implement some of them at their site. Program Directors need to proactively embed the underlying principles of social accountability into their programs. Residency programs with both an urban site and a rural/distributed site can ensure their residents experience both types of practice settings by requiring a minimum of 2 months of training in the alternate site. A requirement for at least 1 Underserved Population/Global Health (i.e. populations experiencing health inequities) experience, preferably within Canada, or abroad, helps residents appreciate and focus on improving the health and health care of underserved and disadvantaged populations. Within the confines of the discipline, residents should be provided with as many different practice settings and service delivery models as possible, such as inpatient hospital, community clinics, emergency rooms, rehab units, home care, long-term care, ambulatory care clinics, and outpatient hospital in a variety of community settings. Residents should be encouraged to work with allied health, nurses and other health care professionals in interprofessional team-based care models. These relationships can help residents learn about social accountability through a different lens and solidify their understanding of the nuances involved in caring for underserved and disadvantaged populations. Complementing the core curriculum with experiences in non-clinical settings, such as teaching, government advocacy, public health, shelters, and community and social service organizations, will enhance residents social accountability learning. Many disciplines will have other specific settings to consider, such as prisons for Forensic Psychiatry and schools for Pediatrics. Research opportunities investigating social accountability, or involving underserved or disadvantaged populations, should be promoted to residents and their participation encouraged and supported. Tailored learning on patients with specific needs, educational sessions on health advocacy, pandemic planning and resource utilizations will help new physicians serve a societal accountability mandate. Academic half days can be used to teach about specific populations, such as Aboriginal Health, HIV, LGBTQ, Global Health, Cultural Medicine, Refugee Health, etc. Patients giving talks to groups of residents about their experience as a member of a marginalized population or living with a particular disease could be considered. One rotation in public health, or in some disciplines a year-long project for senior residents to explore the Health Advocate role, should be considered. Residency program directors and other staff physicians who are already heavily involved in social accountability (e.g. Global Health, service in underserviced communities etc.) should be engaged to serve as mentors and role models for resident physicians. Senior residents should serve as role models for more junior residents as well. The use of alternate methods of seeing patients, such as video-conferencing and tele-conferencing (telemedicine), to increase access to care for remote patient populations should be encouraged. FMECPG@AFMC.CA (613)

5 2: CULTIVATE SOCIAL ACCOUNTABILITY THROUGH EXPERIENCE IN DIVERSE LEARNING AND WORK ENVIRONMENTS RECOMMENDATION Responding to the diverse and developing healthcare needs of Canadians requires both individual and collective commitment to social accountability. PGME programs should provide learning and work experience in diverse environments to cultivate social accountability in residents and guide their choice of future practice. ACTIONS: 1. Provide all residents with diverse learning environments that include varied practice settings, and expose them to a range of service delivery models. Leadership: ACAHO, AFMC (Committee on PGME), CFPC, CMQ, MCC, RCPSC. 2. Provide and support experiences for all residents that focus on improving the health and health care of underserved and disadvantaged populations. Develop residents understanding of and respect for variations in the health, well-being, and needs of different patients and communities. Leadership: AFMC (Committee on PGME), CFPC, CMQ, RSPSC. 3. Develop career-planning resources and supports, including mentors and positive role models. Leadership: CFPC, CMQ, medical schools (PGME programs), RCPSC. RATIONALE: Twenty-first century health care is becoming increasingly ambulatory and community-based in nature and can only be delivered effectively by well-functioning, multi-professional teams. As such, residents need to experience diverse learning environments that reflect changing realities, including the need for more generalists. Disadvantaged populations require special attention from the healthcare system and provide a focus for training residents to better understand the determinants of health and the differing needs of patients, communities, and health service delivery models. The involvement of residents in projects to improve the health and health care of underserviced and disadvantaged populations can have an immediate impact on health care and inspire residents future service. There are also changing healthcare delivery models: Family Health Teams in Ontario, the CFPC s Primary Medical Care Home, the utilization of physician assistants in both primary and specialty settings, and alternate funding plans for academic centres, to name a few. Learners need experience in these models and to understand their potential impact on access and quality. Given the complexities and uncertainties of predicting Canada s future needs for particular types of physicians, career planning is daunting not only for residents but also for medical educators and health system planners. More collective planning and analysis is needed to ensure the provision of appropriate resources and supports, including mentoring to residents as they make career decisions. 16