Moral distress in the healthcare field includes feelings of frustration, anger, guilt, anxiety, depression, despair, and powerlessness to carry out ethically appropriate actions to patients in line with personal values in the setting of external constraints. Psychiatry residents are particularly vulnerable to experiencing moral distress due to the coercive aspects of psychiatric treatment, constraints in the medical system, and the internal conflicts caused by a resident’s identity as a trainee physician and competing duties to an individual patient, healthcare organizations, health care professionals, and society. Psychiatrists make complex assessments that often cannot be made with absolute certainty, but regardless, they are tasked with the duty to identify and ultimately act on their risk assessments. These unrealistic societal expectations are especially difficult for psychiatry residents who have not yet had the experience to grow their knowledge and confidence in their decision-making skills yet still must make difficult decisions in their new role as physicians. Ethical decision-making can be used to alleviate moral distress, and a consistent utilization of an ethical decision-making framework can help guide decisions that are both objective and thoughtful. The ethical framework proposed includes considerations of the patient's capacity to consent or refuse medical treatment, the urgency of the medical condition, the feasibility of the actions needed to address the medical condition, and the countertransference of the treatment team. This framework helps guide clinicians by ensuring they understand and address the ethical considerations involved in treating patients and the moral distress that arises from these difficult choices. / Urban Bioethics

Introduction: Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing postgraduate medical education quality. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in CBD than with previous curricula. This thesis aims to identify and understand the emotional effects of CBME on residents, faculty, and administrative staff. Methods: This study used a qualitative approach, specifically hermeneutic phenomenology. Seven residents, six faculty members (several with education leadership roles), and one administrative staff member from a postgraduate Psychiatry program were recruited. Participants underwent semi-structured, one-on-one interviews where they were probed on their emotions with CBME. Interviews were transcribed and analyzed using a line-by-line approach that generated individual meaning units and, subsequently, themes. Results: Five themes were identified: 1) Education is an emotional experience; 2) The emotional toll of CBD; 3) CBD is a failed educational promise—Expectations vs. realities; 4) Structural and administrative burdens of CBD; and 5) Survival of educational demands—The quest for coping. Participants initially struggled to articulate their emotions, but expressed surprise at realizing they did have strong, often negative, emotions related to CBD. There was also a dissonance identified between the anticipated benefits and the execution of CBD. Furthermore, participants highlighted administrative and structural challenges of CBD, specifically regarding Entrustable Professional Activities, which were a burden and lacked much educational value. Participants discussed using various coping strategies to manage CBD’s demands. Conclusion: The findings of this work suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges. / Thesis / Master of Science (MSc) / Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing the quality of postgraduate medical education. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in a CBD model than with previous curricula. This thesis aims to understand the emotional effects of CBME on residents, faculty, and administrative staff in a postgraduate Psychiatry program. In this qualitative study, participants underwent semi-structured, one-on-one interviews where they were probed on their emotions and experiences with CBME. The findings suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges associated with the assessment methods.