Supervision for Provisional Licensure Purposes (2011)

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Preamble

FMRAC has developed a National Framework for Assessment and Supervision of physicians for Provisional and Full Licensure. The framework is a continuum from first application to the Medical Regulatory Authority (MRA), to obtaining a Provisional Licence that culminates in the achievement of full licensure. Prior to issuing a Provisional License, a candidate will undergo a review of qualifications, and a pre-practice assessment including an OSCE. Successful completion of these stages enables the candidate to obtain a Provisional License in which he/she can enter practice in their expected location as the Most Responsible Physician (MRP).

During the stage of Provisional Licensure, supervision is required. This report was developed by a group of FMRAC members and included extensive consultation with the Registrars and their staff in all MRAs. It provides national expectations and best practices on supervision that are applicable in all jurisdictions during provisional licensure. When applied in a consistent and responsible manner, supervision will contribute to ensuring we have quality physicians and public trust.

The route from a provisional license to a full license without achieving the FMRAC Canadian standard requires the physician to have:

a) Satisfactorily completed a period of supervised practice in a Canadian jurisdiction; and
b) Satisfactorily completed a summative practice assessment in a Canadian jurisdiction.

As the process of assessment and supervision is a continuum; there may be additional emphasis on any competency within the supervision period as determined by the outcome of the prior assessment. Accordingly, the level of supervision may be greater at the beginning and will be reduced over time.

There currently are different classes of registration across jurisdictions. The object of FMRAC members is to move to consistent terminology and practices nationally to facilitate physician mobility. In the context of this document, a provisional license is subject to terms, conditions or restrictions whether or not this information appears on the public register.

Assumptions

• Candidates entering the supervision phase of the provisional licensure period will all have been assessed as having the necessary knowledge, clinical skills and professional characteristics to practice medicine safely in Canada.
• It is expected that candidates in supervision will eventually succeed to full licensure following the summative assessment.
• The CanMEDS and CanMEDS –FM framework and competencies form the criteria by which the MRA determines the competence of the Candidate.

Principles of the Supervision Arrangement

The principles for the supervision arrangement are as follows:

1. Consistency in both the supervision process and methods facilitates fairness to the Candidate and the Supervisor, and justifiable decision making by the MRA.
2. The prime objective of the supervision phase is to reaffirm the finding from the prepractice clinical assessment that the Candidate possesses all the necessary CanMEDS and CanMEDS –FM competencies and that all physician-patient interactions reflect the best interests of the patient. CanMEDS are considered the norm for evaluation in assessment.
3. The candidate will be assessed against a common standard of care appropriate to each discipline or specialty of practice.

Glossary of Terms
Most Responsible Physician (“MRP”) is the physician who has final responsibility and is accountable for the medical care of a patient.

Candidate refers to the physician who has a provisional license granted by the MRA in a specific jurisdiction that enables him/ her to practice under supervision until full licensure is achieved. S/he is the MRP in this role.

Supervision is the act of overseeing the practice of a candidate. The nature, frequency, level and duration of interaction between Supervisor and the Candidate will depend on the practice objectives of the supervisory arrangement defined by the MRA.

Mentor refers to a member of the MRA in the jurisdiction who is a trusted, experienced colleague. S/he is considered a “Friend of the Candidate” who serves to guide the Candidate through the health care system in that jurisdiction. Though the mentor may provide advice on how to deal with clinical and other practice matters they do not have an obligation to provide reports to the MRA, as this individual is not considered a Supervisor as defined in this document.

Supervisor is a physician, approved by the MRA who checks a Candidate’s clinical practice at regularly prescribed intervals set by the MRA in that jurisdiction, to ensure that the Candidate is meeting the expected standard of care and that patient safety is not compromised. The Supervisor is considered a “Friend of the MRA” and provides reports to the MRA.

Sponsor is generally an organisation responsible for recruiting a Candidate and providing a place of practice for the candidate who is under supervision. It is expected that the role of the sponsor is separate and distinct from that of the supervisor or mentor of the candidate.

CanMEDS framework and competencies are a guide to the essential abilities physicians need for optimal patient outcomes. The framework defines the competencies needed for medical education and practice and are organized thematically around 7 key physician Roles: Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional. Within this document “CanMEDS” refers to both CanMEDS and CanMEDS-FM.

Expectations are the requisite conditions for achieving the standard in the respective criterion for supervision.

Best Practices refers to the preferred conditions to enhance the supervisory experience.

Expectations and Best Practices for Supervision
Eight criteria have been identified as the essential components of supervision. These are:

1. Roles and responsibilities of the Supervisor
2. Length of the period of Supervision
3. Qualifications / Characteristics of the Supervisor
4. Training and support of the Supervisor
5. Tools for Supervisors
6.  Number of Supervisors who are involved in submitting official reports of the Candidate.
7.  Reporting Mechanisms
8.  Arrangements with the Supervisor

Expectations and Best Practices for each criterion are identified in this section.

1. Roles and responsibilities of the Supervisor

Expectations

• The Supervisor is responsible for reviewing a Candidate’s practice at regular intervals, as prescribed by the Medical Regulatory Authority (MRA), to ascertain whether the physician is practising safely and meets the expected clinical standard of care.
• The Supervisor maintains appropriate boundaries with the Candidate, respecting his/her role as an agent of the MRA.
• The Supervisor must be an unbiased reporter of the observations of the Candidate‘s practice.
• The Supervisor will provide written reports to the MRA at the prescribed frequency.
• The Supervisor will make recommendations to the MRA regarding the frequency of the supervision based upon the performance of the Candidate.
• The Supervisor will provide feedback to the Candidate in an unbiased and constructive manner. The Supervisor may identify physician enhancement opportunities to the Candidate as well as assist learning about community resources to help meet patient needs.
• A Supervisor will utilize the input of others, including other health professionals, in completing a report.
• The Candidate is linked to a separate Mentor to assist with orientation, integration into the health care system and identification of professional development based upon need.
• In the occasional situation where a separate mentor, cannot be obtained, the supervisor may also assume the role of coach / mentor, as long as this does not interfere with the supervisor’s role as an agent for the MRA.

2. Length of the period of supervision

Expectations

• Supervision during provisional licensure offers a progressive path to full licensure.
• Some component(s) of supervision of the Candidate remain(s) in place until the candidate receives full licensure.
• The components and frequency of reports of supervision for the duration of the Provisional Licence are determined by the MRA.
• Supervision is of a graduated nature; the level will be more intense at the onset and will be gradually reduced through the supervisory period. (Refer to Section 5 Tools For Supervisors for information on tools and resources)
• Supervision will be removed immediately if the Candidate achieves the minimum eligibility requirements for a full license (e.g. a successful summative assessment; success on all required Canadian examinations).

Best Practices

• While in supervision, the length of time remaining and the intensity of supervision may be decreased (or increased) by the MRA based on, but not limited to:
  • Supervisor’s reports that provide explicit indications that the Candidate is or is not meeting the standards in prescribed areas.
  • Recommendations by the Supervisor
  • Other forms of feedback e.g. 360 surveys; portfolio of competency in Can Meds; self reports re: personal development etc.
  • Record of complaints to the MRA or Fitness to Practice (health) issues

3. Qualifications / Characteristics of the Supervisor

Expectations

• The Supervisor must be approved and trained by the MRA.
• The Supervisor must be a fully licensed physician who is free of any disciplinary or capacity issues; i.e. has a satisfactory Certificate of Professional Conduct or equivalent.
• The Supervisor should have a similar scope of practice and be in a similar current practice situation and environment as that in which the Candidate will be practising, including the possibility of geographic isolation
• The Supervisor should be experienced in the system, with a minimum of 3 years of practise.
• The Supervisor recognizes the importance of his or her need to demonstrate:
  • effective communication and interpersonal skills;
  • knowledge and understanding of cultural differences and values and beliefs that affect performance in a Canadian environment.

Best practices

• Affiliation with a Faculty of Medicine.
• Affiliation with relevant health institutions in the community
• Committed to training and evaluation of the work they do as Supervisors.Has valid and adequate liability protection (This is relevant to jurisdictions in which having liability protection is not a requirement for registration with the MRA.)

4. Training and support of the Supervisor

Expectations

The Supervisor has formal orientation and training by the MRA.

• Training should be in the form of a one-time activity and ongoing follow-up sessions. Training should include, but not be limited to:
  • Application of CanMEDS Framework to assess competence
  • How to use the tools
  • Elements of report writing
  • How to provide constructive critical feedback.
• Training shall include cultural sensitivity and diversity awareness.
• The Supervisor has a direct link to a member of the MRA staff or an experienced Supervisor in the field to discuss supervision practices and concerns.

Best Practices

• A physician with previous experience as a supervisor may be a mentor to a Supervisor in the field.
• There should be regular and ongoing Supervisor training based on identified concerns of Supervisors and the need to re-examine the assessment program and/or tools for improvement.
• MRA will strive to maintain high standards in the selection, training and periodic review of Supervisors.

5. Tools for Supervisors

Expectations

• Supervisor applies best available strategies and assessment tools that are used by the MRA.
• The tools used must be based on defined objectives and must be reliable and fair.
• Supervisor is oriented to the strategies/tools used. This includes, but is not limited to:
  • Guidelines to chart audit and medical record keeping practices
  • Effective techniques for conducting chart simulated recall Interviews
  • Performing direct observation of clinical practice
  • Conducting interviews with other physicians and health professionals in the community; 360o evaluations.
  • Writing the supervision report that reflects all the CanMEDS competencies.

Best Practices

• Supervisors understand the need for consistency in the application of supervision tools used by the MRA to justify their reports.
• If the situation permits, supervision may also include direct observation of the Candidate in their respective practice setting and may include a MiniCEX or other forms of assessment.

6. Number of Supervisors who are involved in submitting official reports of the Candidate.

Expectations

• A single physician selected according to above criteria who has been trained and has an appropriate follow-up and support system assumes the role of lead Supervisor.
• Other health professionals (medical and non-medical) who are fulfilling special duties for the MRA in that environment provide reports relevant to their respective roles and responsibility.
• A Supervisor should only supervise the number of candidates that s/he can adequately provide the mandated level of supervision defined by the MRA.

Best Practices

• Multiple Supervisors may be contracted to participate in order to match the practice scope or location; frequency or context; or jurisdictional circumstances.
• Other physicians, health care professionals, non-medical co-workers and possibly nsulted for input into the reports.

7. Reporting Mechanisms

a. Nature/content of report

Expectations

• A formal documented report is provided by the Supervisor to the MRA.
• The report provides evidence identifying the competence and quality of practise of the Candidate during the identified period of supervision.
• The Candidate is appraised on a regular basis of their performance and provided with opportunities for response.
• The Supervisor reports immediately to the MRA any concerns regarding patient safety.
• The MRA makes the final decision with respect to the continuance of practice or the achievement of full licensure.

Best Practices

• A report template is in use nationally that provides evidence identifying the competence and quality of practise of the Candidate during the identified period of supervision and is based on a consistent rating scale built on CanMEDS objectives.
• The report includes, but is not limited to the tools used by the Supervisor for: chart review; chart stimulated recall; interviews with other health professionals and staff; direct observation, if possible; communication skills assessment etc.
• If needed, areas where some professional development /upgrading are needed to meet expected standards are highlighted.

b. Frequency of reports and management of the report information

Expectations

• Report frequency should be indicative that the MRA is exercising due diligence in monitoring the practice of a physician with provisional licensure.
• Schedule of reports, including tapered frequency over time, should be reflective of the demonstration of practice competence through the period of supervised practice.
• Reports are shared with the Candidate to enable them to identify personal areas for continuing professional development.

Best Practices

• Reporting mechanisms will be clearly defined with respect to content and scheduling.
• The report will form a part of the registration file held by the MRA.

8. Agreements with the Supervisor

a. Contractual arrangements

Expectations

• The MRA and the Candidate (or Sponsor) will have a written agreement regarding the responsibilities, mechanism and frequency surrounding payment (if applicable).
• There is a written and signed contractual arrangement between the MRA and the Supervisor, whether or not there is remuneration; undertaking to commit to the described roles and responsibilities.
• The agreement includes details with respect to:
  • reporting requirements and frequency;
  • declaration of freedom of any real or perceived bias or conflict of interest
  • fulfilling supervisory responsibilities notwithstanding any financial and remuneration arrangements between the Supervisor and the Candidate.
  • confidentiality between the Candidate and Supervisor
  • principles governing the relationship between the Supervisor and the Candidate and the Supervisor and the MRA including issues relating to power imbalance and resolving disputes.

b. Remuneration for the Supervisor (This section is relevant in jurisdictions where supervisors are reimbursed.)

Expectations

• There should be no direct exchange of funds relating to supervision from the Candidate to the Supervisor.
• The following will be outlined in the contract between the MRA and the Supervisor.
  • Remuneration rates and mechanisms of payment
  • Terms of payment and any limitations thereof.