EM Resident Resource - CBD Residents

PD Message

Nazanin Meshkat Picture 2016.jpegWelcome to the University of Toronto’s Emergency Medicine Program! We are looking forward to getting to know all of our new residents, and play a part in their professional growth in the coming years.

To help residents transition to residency and CBD, we have prepared two orientation packages. One is called the “Orientation and Welcome Package” and includes program administrative items (e.g. policies, vacation requests etc.). The other, called the “Competence by Design Package” includes curriculum and assessment items you will need to navigate in the new world of CBD. Residents should familiarize themselves with both. 

Dr. Nazanin Meshkat, PD

Dr. Kaif Pardhan, APD

PGY1 Orientation Manual

orientation.jpgHere is a printable copy of the PGY1 CBD Orientation Manual. This manual includes the residency program policies and processes. For CBD related items see below.

Introduction to CBD


What is CBD?

  • Competence by Design (CBD) is a Royal College of Physicians and Surgeons of Canada (RCPSC) initiative to transition postgraduate medical education and professional practice in Canada into a model of competency-based medical education.

    What does that mean to you? There is a shift towards a coaching model of training in lieu of the current performance model. In the coaching model, you will be required to complete formative assessments called Entrustable Professional Activities (EPAs). EPAs are tasks of the discipline that can be delegated to a resident and observed by a supervisor. Typically, each EPA integrates multiple abilities simultaneously (milestones) when performing professional activities (e.g. we use our medical expertise, but also our communication skills). You will learn more on EPAs in the Assessment Section. Here is a link to a CBD Terminology Page for more information

FeedbackThanks for the feedback.jpg

  • Moving towards a coaching model will entail being able to receive feedback. Feedback can trigger negative reactions on the part of the receiver if it is perceived as a judgment on personal worthiness. Take a look at this Infographic and reflect on how you perceive yourself. We strongly recommend that you also read “Thanks for the Feedback” by Douglas Stone and Sheila Heen before you start residency and that you continue to refer back to it during your career.

CBD Stages

  • Residency will continue being 5 years. It will be split into 4 stages:
    • Transition to Discipline (TTD) 3 Months in PGY 1
    • Foundations of Discipline (FOD) 9 Months in PGY 1
    • Core of Discipline (COD) 3 years PGY 2-PGY4
    • Transition to Practice (TTP) 1 year PGY 5
  • The Royal College Exam will take place after the Core stage at the end of PGY 4 (instead of at the end of residency). The RCPSC will be providing more information in the coming years.

CBD champions

  • Our program has been working hard with multiple stakeholders in the past 2 years to prepare for this transition. We realize that this is a time of change for you, and are here to support you. We will be meeting with you as a cohort on a regular basis to monitor progress. You will also have at your disposal our CBD champions at the different sites (more information will be provided at your orientation session).

Assessments: General Documents

Stage Specific CBD Resident Expectations 

As part of CBD residents will be required to complete regular assessments.  Here is a link to an overall map of the assessment requirements for all stages.

Entrustable Professional Activities and Special Assessments

EPAs are one component of the assessments and a CBD requirement. Each stage has specific EPAs that are assigned to it (determined by the Royal College Emergency Medicine Specialty Committee), and successful completion at each stage (as determined by Competence Committee) will be required to move from one stage to another. Here is a link to a list of EPAs.Here is a link to the Royal College document for a detailed breakdown.  To avoid getting overwhelmed, start by reviewing the first stage (TTD) EPAs (there are only 4!)

  • Elentra user guide
  • Entrustment Scale
    • The staff physicians who supervise residents during clinical rotations assess EPAs using the  Entrustment Scale. We expect that most of the resident EPAs will be given an “Intervention”, “Direction” and “Supervision” category, and only a few will be given “Autonomous” and “Excellence” especially in the early phase of a stage, and in early years of residency.

      Special Assessments are non-EPA assessments that are requirements of the Royal College. Each tool is different, and residents will be provided detailed information on their completion under each stage.

      Other assessments are called “Notes to File” and “Professional Behavioural Monitoring Form”.

      All these assessments will be completed on the Elentra e-platform, and can be initiated by the resident or their supervisor. In general, we expect that each resident complete at least 1 EPA (or SA tool if applicable) per shift on EM rotations and that as the resident is able, they complete EPAs on off-service rotations.

  • Emergency Medicine EPAs – All Stages
    • For more details on stage-specific EPA and SA tool completion please refer to the specific sections below – TTP documents will be provided and uploaded to the website at a later date

In-Training Exams

You are required to attend mock orals and written exams as outlined in the Stage Specific CBD Resident Expectations.

Royal College

TTD Stage Assessments

The Royal College requires that residents complete the assessment requirements for 3 EPAs (TTD 1-3) and one special assessment (TTD SA 1) in Transition to Discipline (TTD). For a detailed guideline please refer to the below links




TTD residents will also be required to complete an Objective Structured Clinical Examination (OSCE) in TTD, based on the TTD EPAs (scheduled in Block 4).

ITARS - See Below

FOD Stage Assessments

The Royal College requires residents to complete the assessment requirements for 4 EPAs (FOD 1-4) and one special assessment (FOD SA 1) in Foundations (FOD). However, in our program residents are required to complete FOD SA 1 in the Core stage. You will also be required to complete Core EPA 14 requirements in FOD. For detailed guidelines on completing these assessments, please refer to the link below:


ITARS - See Below

COD Stage Assessments

The Royal College requires residents to complete the assessment requirements for 15 EPAs (COD 1-15) and five special assessments (COD SA 1-5) in Core (COD). However, in our program, residents are required to complete 14 Core EPAs (COD 1-13, and 15). You are also required to complete FOD SA 1 in the Core stage You will also be able to complete FOD EPA 4 in the Core stage. For detailed guidelines on completing these assessments, please refer to the link below:



ITARS - See Below

TTP Stage Assessments - Coming Later



ITARs, or In-Training Assessment Requirement, are evaluations that your preceptor or rotation coordinator will complete at the end of each rotation. All ITARs are reviewed by the Competence Committee and the PD, and your previous EM rotation ITARs will also be reviewed by the resident's upcoming EM rotation coordinators to help identify areas to coach them on.



We have made a number of changes to our rotation schedule to align with CBD and also to address some identified gaps. For example, residents will be doing more EM rotations in your PGY 1 year under CBD then our previous rotation schedules.

CBD Sample Rotation Schedule

Here is a link to the Master Rotation Schedule for all 5 years. There are 13 rotation blocks in each academic year. A number of rotations are “on service” (i.e. emergency medicine or related rotations such as EMS and Ultrasound), and some are “off service”.  Residents will rotate through our core teaching sites, as well as affiliated sites.

  • Core sites:
    • Sunnybrook Health Sciences Centre (SHSC)
    • St. Michael’s Hospital (SMH)
    • University Health Network (UHN): includes Toronto General Hospital (TGH) and Toronto Western Hospital (TWH)
  • Affiliated Sites:
    • North York General Hospital (NYGH)
    • Hospital for Sick Children (HSC)

Transition to Discipline/ Foundations

TTD entails the first 3 blocks of the CBD PGY 1 year, and FOD the remaining 9 blocks. Here is a link to a Sample Learner Schedule for TTD and FOD. Residents will each be provided their own specific TTD and FOD learner schedule by email.

In TTD residents do 3 blocks of Emergency Medicine (EM) at one of our core sites (SHSC, SMH, or UHN). In FOD you do 4 months of adult EM (3 at our core sites and 1 at NYGH), 1 Pediatric EM at the Hospital for Sick Children, Ultrasound (includes EM shifts), Sports Medicine, GIM-Clinical Teaching Unit (CTU), Pediatric-CTU and Anesthesia.

Each Rotation has a specific Rotation Plan. Residents should review the Rotation Plans prior to the start of each rotation.

  • TTD EM Rotation Plan
  • FOD Ultrasound Rotation Plan
  • FOD Sports Medicine/MSK Rotation Plan
  • FOD Peds CTU Rotation Plan
  • FOD PEM Rotation Plan
  • FOD Anesthesia

For all EM rotations, we have asked that our site coordinators schedule 30% of a resident's shifts with a preceptor. We ask that the resident contact their preceptor and meet them at the start of their rotation, mid-way and at the end of their rotation to discuss objectives and progress. Please be advised that this is a mandatory program requirement. (Clinical Duty Scheduling and Absenteeism Policy)

Core and Transition to Practice

COD entails the full 39 blocks during the PGY2 to PGY4 years. Here is a link to a Sample Learner Schedule for COD. Residents will each be provided their own specific COD learner schedule by email.

In COD, residents do 3 - 5 blocks of Emergency Medicine (EM) at our core sites, 1 in ICU, 2 in Trauma/General Surgery, 1 in Anesthesia, 1 in Psychiatry, 1 in OB/GYN, 1 in Orthopedics, and 1 in Pediatric Emergency Medicine at SickKids. The number of EM blocks completed is dependent on their Goal Directed Experiences (GDE). The GDE replaces the traditional “electives”. You can see that it is included in the Master Rotation Schedule More details will be provided about the GDE at a later date.

Each Rotation has a specific Rotation Plan. Residents should review the Rotation Plans prior to the start of each rotation.

  • COD Anesthesia
  • COD EM - Junior
  • COD-EM- Senior
  • COD Orthopedics
  • COD Psychiatry
  • COD Trauma/General Surgery
  • COD Advanced Ultrasound
  • COD Toxicology
  • COD Peds and Community Anesthesia

The details of the TTP rotations will be finalized in the next couple of years. We will provide residents with Rotation Plans TTP closer to the date.

Area of Advanced Learning

In the past, residents in our program were provided with 1-year (PGY 4) to pursue an Area of Advanced Learning (AAL). Due to CBD requirements, this has changed to 6-7 months, and the nature of the AAL will depend on progression through the CBD stages. We will provide residents with more details as we monitor progress.

Competence Committee


The Competence Committee (CC) is responsible for making overall assessments for each resident, and recommendations regarding promotion, coaching and remediation, at multiple time points throughout residency (CC Terms of Reference). The committee is made up of faculty members from each of the core sites. The PD also sits on this committee.clinical-competency-committee.jpeg
  • Jennifer Chu (Chair)
  • Nazanin Meshkat (Program Director)
  • Kaif Pardhan (Assistant Program Director)
  • Martin Horak (St. Michaels Hospital Staff)
  • Emily Austin ( St. Michaels Hospital Staff)
  • Dana Phillips (Sunnybrook Health Science Centre Staff)
  • Dennis Cho (University Health Network Staff)
  • Tim Dalseg (University Health Network Staff)
  • Walter Tavares (Scientist at the Wilson Center) - observer

They use all the assessments described above (e.g. EPAs, ITARs, exams, Notes to File, etc.), as well as other relevant criteria (e.g. attendance records, emails to the PD), to make decisions.  Every resident will be reviewed by the CC at least two times per year. The CC provides their overall assessment and recommendations to the EMRTC and PD. The PD will meet with the resident (after the CC meeting) to review these recommendations (link to CC and PD Meeting Schedule). Residents will be required to prepare a Personal Learning Plan before meeting the PD, and send to the PD 2 days before your scheduled meeting.