RCPSC Policy on Intimidation and Harassment

ACCREDITATION AND THE ISSUE OF INTIMIDATION AND HARASSMENT IN POSTGRADUATE MEDICAL EDUCATION

GUIDELINES FOR SURVEYORS AND PROGRAMS
Approved October 2004 - RCPSC, CFPC, CMQ
 
Download the RCPSC Policy
 
BACKGROUND:
 
At the request of the RCPSC, the CFPC and the CMQ the current working group reviewed work
done on this topic from 1996 to 2003.  This includes the document by the previous working group and also the Ethics and Equity Committee.  The goals were to develop further definitions and to clarify an approach to the problem that could advise programs, Universities and survey teams. We also have the CanMEDS competencies and Principles of Family Medicine, which govern attributes that are to be taught, evaluated and modelled.
 
“Intimidation is a form of abuse and, as with other forms of abuse, any is too much.”  (Ref.1).  It is clear that when behaviours of this nature are recognized in a program, there must be a response. This can be at the level of the program director, hospital unit, department or university.  If there needs to be a formal review, this occurs via the postgraduate office or the office that deals with complaints of this nature.   During a survey, the Chair’s team must review the office within the University that has the formal role of support and investigation.  This will include the scope, numbers, decisions and resolutions.  The survey team and surveyors will listen for comments on the educational environment. When there are allegations during a survey, they must be understood as fully as possible and even more important the university and program response must be clarified.  The survey team will document comments during a survey, but ultimately the resolution is within the program, department and university.
 
A fair question to ask is whether this is a substantive problem that requires further clarification and action.  The RCPSC carried out a major survey of all RCPSC residents graduating between 1995 and 1999 to assess aspects of intimidation and harassment experienced during their training.  The preliminary findings were presented at the RCPSC Educational Meeting in September 2001.  This work clearly outlines that there is an on-going and substantial problem across a variety of Canadian training programs.  The report indicated problems involving men and women in almost equal numbers although there were more male trainees overall.  Although the dyads involved in abusive situations can be varied, the overwhelming majority of instances involve staff people towards residents.  Given the inherent power differential between faculty and residents, this is not surprising. However, there are instances when a resident can exhibit inappropriate behaviour towards faculty. The same mechanisms can be used to investigate a complaint in either direction. Occasionally the situations involve more than one individual, but again, the vast majority are dyadic.  
 
It is imperative that we strive towards supportive respectful learning environments in all of our
training programs. At some universities there is a formal Code of Conduct governing behaviour and professionalism.  Royal College standards require: “ensuring a proper educational environment free of intimidation and harassment with mechanisms in place to deal with such issues as they arise” (Blue Book A1:3.7).   There is a detailed section in the CFPC book that defines the learning environment (Red Book).  The CanMEDS competencies of “professionalism”, “collaboration” and “communication” are particularly relevant in helping to define this learning environment.  The Four Principles of Family Medicine also emphasize these attributes.  These are concepts of major importance that need to be understood and incorporated into training.  There should be opportunities within the university for trainees and teachers in all disciplines to be involved in seminars and discussion sessions.  These aspects of behaviour also need to be both modelled and evaluated as they are integrated into daily fundamental attitudes.
 
However, in reality, there will continue to be instances where problems occur and need attention.  There must be mechanisms within each university that can both identify problems in the learning environment as they unfold and develop a response. One difficulty is that residents might suffer reprisals for complaints.  Thus, there needs to be an identified individual or office within the university for safe and confidential reporting.  This office must have the capacity to receive complaints, assess the information and start an internal process to review and resolve the problem.   
 
DEFINITIONS:
 
As one attempts to give the universities and survey teams some mechanisms for review and an
approach to identifying and resolving issues of intimidation and harassment it is useful to have some clarity about the actual definitions.
 
The terms intimidation, harassment and abuse tend to be used interchangeably.  It is useful to review the technical Oxford and Webster Dictionary definitions:
  1. Intimidate: terrify, overawe, cow, especially as to influence conduct.  Force to do or deter from some action by threats or violence. Inspire with fear.  To daunt or make afraid.
  2. Intimidation: the act of intimidating someone in order to interfere with the free exercise of political or social rights.  The fact or condition of being intimidated.  The use of authority to influence someone to do or refrain from an action or to do something they would not do or should not do otherwise.  e.g. asked to do extra work; refraining from reporting patient events; falsely positive faculty evaluations.  It can also include ‘flattering’ intimidation such as “you are different than the others so I wonder if you can..”;  “you’re great, you never complain and I wonder if you could take on this task for me…”
  3. Harassment:  trouble by repeated attacks.  Subject to constant molesting or persecution. Repeated, often public, critical remarks or ridicule.  Singling out for grilling or interrogation.  Unjustified negative remarks or inappropriately positive remarks about appearance or dress.  Unjust assignment of duties.
  4. Abuse:   exploitation of trust and exploitation of authority.  Improper use, perversion, reviling abusive language, injury, maltreatment.  Types can include verbal, mental, psychological, physical and sexual.

It should be recognized that intimidation and harassment does not always have to be repetitive to be significant.  A single incident can have an impact.  
 
These terms are on a continuum with some overlap representing increasing severity to full abuse.  One factor in confronting these issues is that as these problems have been identified and discussed over several years, there has been a shift away from using these words.  They are too laden with ominous meaning.  Instead there is a tendency to shy away to euphemisms such as “unfortunate moment”, “he/she was a bit off…” “that tendency popped up again”.  We need to help the learners and teachers address these issues with courage to clarify and hopefully to resolve.  This remains a challenge, as the identification and exploration of these types of situations can often provoke defensive reactions.
 
It is important to emphasize that there are people whose personality style can be perceived as
intimidating but they are not actually practising intimidation.  They may be “austere, remote,
demanding and have high standards.”  This is not intimidation, harassment or abuse providing that their requests for high performance are not injected with sarcasm or ridicule. Also, the process of training demands that feedback and constructive criticism be made regularly.  This is not intimidation, again provided it is not done with ridicule.  The inherent power differential between trainees and supervisors may invoke a degree of feeling intimidated or anxiety to perform well.   This is not unique to medical training but is common in many situations of training and job performance.  The distinction between being intimidated and feeling pressure to function well needs to be clarified for residents, programs, universities and survey teams.
  
 
PRINCIPLES 
  1. Timely identification of a concern about intimidation and harassment should be the goal of all programs.
  2. Trainees should be encouraged to inform their program director or university administration of problems.  
  3. The initial discussion must occur in a confidential setting.
  4. There should be a process to clarify the facts concerning the allegation.
  5. The process of clarification must occur in an atmosphere free of retribution.
  6. There should be a process to address and resolve allegations in a timely manner.
 
INVESTIGATING A COMPLAINT
 
UNIVERSITY
 
Concerns of this nature will continue to occur across our broad and complex teaching systems. Many instances of problems occur and are solved at a local level.  Individuals that face a problem will choose a confidant with whom they are comfortable.  This could be a Chief Resident, another staff or mentor, a site director or even another peer.  Often resolution can occur without the problem being referred to the more formal university mechanisms.  There is no way of knowing the frequency of such events and resolution nor is there any real need to know.  If an immediate and local approach can solve matters, this is to everyone’s advantage.  
 
However, for the more difficult or persistent situations, it is essential to have an approach within the university that is thorough and can produce significant results and resolution.  
 
Internal Reviews
 
All universities conduct their own Internal Reviews through the Postgraduate Medical Education
office.  These occur in at least the last two years in the six-year cycle between external full College accreditation visits.  Some universities may find it advantageous to use Internal Reviews as an on-going mechanism for continuous improvement throughout the six years.  This provides an organized opportunity to train the internal review surveyors to understand these questions and to help programs improve continually.  This helps mitigate against surprise allegations at an external review.
 
Investigating Office
 
Each university must have a mechanism for investigation of their internal problems. There must to be a person or office that is identified to receive this information, for example, an Associate Dean of Equity, the Associate Dean Postgraduate, or an Ombudsman.  Each university must have a Code of Conduct or Standards of Professionalism that is foundational in defining the behaviour that is required throughout the institution and training programs.  
 
This formal mechanism for support and investigation should be widely known.  The authority for investigation should not be broad, but should reside primarily within this one office.  This minimizes the opportunities for lack of confidentiality.  This is of critical importance to everyone involved.  Concerns are often not brought forward in an environment where confidentiality is uncertain.   When concerns are discussed in a safe environment, this action alone often allows some strategies and resolution.  
 
The reality of the sensitivity of many of these issues is such that most details never need be known even within the University, outside of the investigating office.  However, a well-functioning office will be well known and accessible within the university.  In some instances, this office must come to some conclusions and recommendations that need to be acted on.   At this point of action, a Program Director, Associate Dean Postgraduate, Department Head or the Dean may need to be involved to carry out the recommendations.  The courage and clarity with which a university has acted when necessary becomes part of the evaluation at an external full accreditation.  In some rare instances, the problem may need intervention from outside the university.  This can always be done as a review from the appropriate College at the request of the University.
 
CLARIFICATION DURING A SURVEY
 
Ideally, allegations should not surface de novo at external surveys.  However, there will remain
times when this is the mechanism of discovery or the opportunity for the raising of the issues.
 
First, a survey team must understand the university mechanism that exists for the clarification of complaints.  This should be done as part of the review by the chairs team of the Standards. This review includes the function of the Postgraduate Office and should encompass a review of the office dedicated to this purpose, if one exists.   If there is an Office of Equity or Officer that fulfills this role, that office should present to the team the process they use and the scope and number of instances that they deal with on a yearly basis.  The scope and the types of recommendations and actions that resulted should also be reviewed.  This will give the survey team clarity about the function of the university in monitoring and dealing with these issues.  A university should be given recognition for a well functioning and tenacious process.
 
There are particular challenges when identification of intimidation is made at a survey during
program reviews. Surveyors need a repertoire of questions to guide their approach.  It is not enough to just document an allegation of intimidation.  There must be follow-up questions.  It is important to differentiate as much as possible between significant problems and allegations that are unfounded.  It is possible to have complaints made by a disenfranchised individual.  The mechanism of clarification must stay balanced and alert in the collection and assessment of the information.
 
Information that should be obtained by the surveyor when confronted during the visit with an
allegation of intimidation or harassment include: clarification that the person making the allegation knows of a process to be followed in such cases; Was that process followed.  If not, why not?  Was the incident reported to the program director?  Another person?  Was the outcome satisfactory? 
 
It is important that the surveyor ask how the concepts of professionalism, collaboration and
communication are taught and supported in the learning environment.  
 
Another challenge is that there may be ambivalence and outright disagreement within a resident cohort as to whether issues of intimidation and harassment should be discussed.  We have seen surveyors receive information that initially seems reliable but on wider discussion the residents recant and deny the concerns.  This leads to confusion and frustration on all sides.  
 
In the process of clarification by a survey team that is internal or external, it is important that the resident or person making the allegation not be left with the impression that the accreditation team will resolve the specific incident or pattern of behaviour. Rather, the team must ensure that the university is informed that an allegation has been made and has in place the means to identify and deal with such situations effectively.  The goal is to determine an accurate understanding of how the system works to address the concerns and if it is an effective approach. 
 
Allegations of these types of problems must be discussed during the survey teams meetings.  Further clarification can occur between the Chair and the Postgraduate Dean.  
 
The attempt to clarify the response to problems is critical.  The individual survey reports should
document the response that occurred within the program and university. Universities need to be given recognition for substantial processes that are in place and are carried out in a rigorous manner to address these problems.  This should be reflected in the Chairs’ report to the University and Accreditation Committees.
 
 
RESPONSE AT ACCREDITATION
 
First, if there is mention of intimidation or harassment in a program, the survey report should contain the answers to the types of questions previously outlined.  This allows the program reviewer to understand the depth and severity of the problem and also the steps that have been taken to improve and provide solutions.
 
There is no standard response for all reports of intimidation and harassment in a program.  
However, it is important to underline that there must be some response.  The issue cannot be
ignored.
 
At times an incident may be isolated and it may be clear that the program and university have
completely dealt with the problem.  There can be instances of substantial problems that have been dealt with thoroughly.  If there is sufficient awareness, a recognized office and mechanism and progress to address the problem, the accreditation status can stay at full approval.
 
If there is substantial doubt about the effectiveness of the process, the accreditation team may
recommend a Provisional Accreditation status to be followed by an internal review or a special
survey.  This is a mechanism for the university and program to have the clout and awareness to deal with the problem.  Rarely, problems may be so widespread and entrenched that consideration is given to using the category of Intent to Withdraw. Usually, if there are problems of this magnitude in a program, they will occur in many other areas.  Thus the accreditation status does not rest on the issue of intimidation or harassment alone.
 
Overall, there is clear recognition and endorsement in all our universities and programs of standards of professional behaviour that are conducive to learning.  The vast majority of teacher and learner interactions are positive and fruitful.  These are some of the mechanisms to recognize and remediate those instances that remain problematic. 
 
LITERATURE
 
  1. Report of the working Group on Intimidation in Postgraduate Medical Education March 1996 and addendum 1998
  2. 2000 RCPSC Survey on Harassment and Intimidation.  Preliminary findings presented at RCPSC Annual Conference September 2001
  3. UWO Code of Conduct
  4. CanMEDS Competencies
  5. CAIR pre-survey questionnaire
  6. RCPSC Workshop Education Meeting September 2002
  7. RCPSC General Information Concerning Accreditation of Residency Programs (Grey Book)
  8. CFPC Standards for Accreditation of Residency Training Programs (Red Book)
  9. UBC Professionalism Standards 

PARTICIPANTS of the WORKING GROUP - 2004
 
Pierre Blanchard
Paul Rainsberry
Margaret Kennedy
Karen Fung Kee Fung
Kristin Sivertz  (Chair)
Ellen Toth 
Ryan Zarychanski
 
Additional in-put from:
Jason Frank
David McKnight
Laura Musselman
Postgraduate Associate Deans
Associate Dean Equity UBC
 
 
Approved October 2004
RCPSC, CFPC, CMQ