Advice to the Profession: Professional Responsibilities in Medical Education

The Professional Responsibilities in Medical Education policy sets out expectations for physicians involved in medical education and training, including most responsible physicians (MRPs), supervisors, and postgraduate trainees. This Advice to the Profession (Advice) document is intended to help physicians interpret their obligations as set out in this policy and to provide guidance around how these obligations may be effectively discharged. In addition, this document provides links to relevant resources.

Does an MRP and/or Supervisor need to provide direct supervision at all times?

An MRP and/or supervisor do not need to provide direct supervision at all times; however, as the policy states, MRPs and/or supervisors must ensure that they are identified and available to assist medical students and/or postgraduate trainees when they are not directly supervising them (i.e. in the same room). If unavailable, they must ensure that an appropriate alternative supervisor is available and has agreed to provide supervision.

If an MRP and/or supervisor is not available in person and they are called or paged, the MRP and/or supervisor’s responsiveness needs to be appropriate to the circumstances.  What is appropriate will depend on a number of factors including: the level of training and experience of the medical student and/or postgraduate trainee, the clinical status of the patient, other available support, etc.

It may also be beneficial to ensure that on-call schedules be structured to provide continuous supervision to medical students. For postgraduate trainees, it may be beneficial to provide guidance with respect to on-call interactions as sometimes postgraduate trainees are off-service and may not know what is expected of them. For example, it may be helpful to have a phone call/in-person meeting at the start of a shift to determine the postgraduate trainee’s PGY level, home program, how long they have been on the particular service, what procedures they have done, when staff would like to be called overnight, etc.

It is also important for medical students and postgraduate trainees to develop awareness of their limitations and inform the Most Responsible Physician and/or supervisor and, seek appropriate assistance when necessary if they are unable to carry out their duties. Good communication is vital to facilitating appropriate supervision and optimal patient care.

How can physicians demonstrate a model of compassionate and ethical care to medical students and trainees?

Medical students and postgraduate trainees often gain knowledge and develop attitudes about professionalism through role modeling. MRPs and supervisors have a duty to lead by example and to translate into action the principles of professionalism taught to medical students and postgraduate trainees.

Characteristics of effective role models are well established. They include availability, clinical excellence, empathy, good communication skills, interest in teaching, self-reflection, transparency and respect for others.¹ Being an effective role model is not only beneficial to medical students and postgraduate trainees, but it is also an important part of ensuring the best possible care for patients.

Engaging in favouritism of medical students and/or postgraduate trainees is detrimental to the learning environment. In addition, predatory behaviour is unacceptable anywhere, but it is particularly problematic in a learning environment where medical students and postgraduate trainees model the behaviour of their teachers. For these reasons, it is imperative that clinical teachers consistently uphold and display the highest values of the medical profession.

The policy requires physicians to not engage in disruptive behaviour including, violence, harassment, and discrimination against medical students and postgraduate trainees. These behaviours are the antithesis to being a positive role model and physicians must not engage in them.

What does the policy say about intimidation?

Expectations around harassment are an important addition to this policy. Both the Ontario Human Rights Code and the Occupational Health and Safety Act (OHSA) set out definitions of harassment. Harassment means engaging in a course of vexatious comment or conduct that is known or ought to be reasonably known to be unwelcome. Harassment can include behaviour that intimidates.

Unfortunately, intimidation of medical students and postgraduate trainees is still an issue that arises in medical school education. Increasingly, the culture of medical education, and prevalence of bullying and harassment are contributing to the rise of depression, anxiety, burnout and suicidality amongst medical students and postgraduate trainees. The policy is clear that physicians must not engage in this type of behaviour.

How can I provide support and direction to medical students and/or postgraduate trainees in addressing disruptive behaviour (including violence, harassment and discrimination)?

MRPs and supervisors may see, or become aware, that a learner has experienced violence, harassment and/or discrimination in the learning environment. When physicians see this occurring, the policy requires that they take reasonable steps to stop violence, harassment or discrimination against medical students and/or postgraduate trainees and take any steps as may be required under applicable legislation², policies, institutional codes of conduct or by-laws.

MRPs and supervisors can also acknowledge the disruptive behaviour that has taken place and ask the learner how you can support them. The support and direction you provide could include, but is not limited to:

• Naming the disruptive behaviour as violent, harassing and/or discriminatory;
• Addressing the disruptive behaviour directly with the patient, health-care professional, or staff who engaged in the behaviour, or supporting the learner in doing so;
• Explicitly stating that the disruptive behaviour is not appropriate and will not be tolerated;
• Acknowledging the learner’s feelings and giving them the time and space they need to deal with the disruptive behaviour;
• Offering to remove the learner and/or patient, health-care professional or staff from the physical environment in which the disruptive behaviour occurred, where appropriate (e.g., by not assigning the learner to that patient, not having the learner work on the same shift as that health-care professional or staff, etc.);
• Reporting the act(s) to the appropriate authority, or supporting the learner in doing so; and
• Providing the learner with the opportunity to debrief with a person who has the necessary skills required to do the debriefing.

In what situations will patients need to be asked for consent to have medical students participate in their care?

The policy requires consent to be obtained when the participation of medical students (or postgraduate trainees) is solely for their own education (e.g. observation, examinations unnecessary for patient care, etc.).

Where medical students provide care to patients, the policy requires consent to be obtained in appropriate circumstances, taking into account: the type of examination, the patient’s characteristics, the increasing responsibilities medical students have in patient care, the level of involvement of the MRP/supervisor, and the best interests of the patient.

While the factors listed are general in nature and are meant to capture a variety of scenarios, some specific examples of when it would be appropriate to obtain consent include, but are not limited to the following: 

• Medical student will be performing a sensitive examination e.g. pelvic or genital examinations.³
• Patient is a member of a vulnerable population who may have had negative experiences in health care system.
• Patient has experienced trauma.
• Patient is fearful of the examination, investigation or procedure.
• Medical student is early on in their medical school education.
• Examination, investigation or procedure is invasive or painful.
• Supervisor or Most Responsible Physician will not be present.

If the medical student’s involvement is minimal or the task is very low risk, such as taking a patient history, consent may not be required.

Is posting a sign informing patients that medical students and/or postgraduate trainees may be involved in their care sufficient?

Having a sign posted in a teaching hospital or other clinical placement setting is helpful and promotes patient education and understanding, but it is not sufficient in terms of meeting the policy expectations.

How can consent be obtained for medical student and/or postgraduate trainee participation in patient care?

Obtaining patient consent is not meant to be burdensome or time-consuming. Depending on the circumstances, simply explaining what you will be doing and why in a concise, easily understood, and non-coercive manner, and then asking, “is this okay?” may be sufficient.

If asking to participate in their care, it may be helpful to let the patient know that they can ask the Most Responsible Physician/supervisor or the physician responsible for providing their care questions after you participate in their care – this may be very helpful for patients and may contribute to their willingness to have you to participate in their care.

It is good practice to document in the patient’s medical record whether the patient consented to the participation of the medical student and/or postgraduate trainee in their care.⁴

What if patients are reluctant to have medical students and/or postgraduate trainees participate in their care?

Research shows that it’s unlikely that this will happen, but when it does it is important to respect a patient’s preferences. A patient’s care should not be jeopardized as a result of their refusal. In addition, if a patient does consent, they may at some point change their mind.

If a patient does not want to be involved in any activity that would be solely for the medical student’s or postgraduate trainee’s education, for example, observation of care, the medical student or postgraduate trainee can leave the room. It is more likely than not that another patient would be willing to have them observe the same procedure, examination, investigation at another time. Medical students and/or postgraduate trainees can also discuss the fact that they were not able to observe a procedure, examination or investigation with the MRP/supervisor for guidance about other ways to learn about the procedure, examination or investigation.

There may be additional considerations when postgraduate trainees participate in care. The Professional Responsibilities in Medical Education policy does not require that consent be obtained for their participation, but it requires MRPs or supervisors to ensure patients are informed that their care relies on a team-based approach involving both medical students and postgraduate trainees. In rare circumstances, when patients initially decline or appear ambivalent about having postgraduate trainees involved in their care, formalizing the consent process may be prudent.

What are some examples of procedures/exams/investigations unrelated to the provision of patient care?

This happens often with learners, especially medical students - a physician performs a procedure/exam/investigation and then the medical student and/or postgraduate trainee repeats it. For example, learners can be asked to examine a skin rash, check peripheral circulation, or do an eye or ear exam for educational purposes. If a patient has an unusual history, learners may be asked to question and/or examine the patient for educational purposes. Intimate examinations are also sometimes done by medical students and postgraduate trainees and can be unnecessary for the provision of patient care.

Resources

The information below provides additional information related to professional responsibilities in medical education as well as information that may be helpful to medical students and/or postgraduate trainees. It is important for MRPs and/or supervisors to encourage medical students, who are not yet members of the CPSO, to become familiar with this information.

Medical schools and institutions where learning takes place also have relevant policies, guidelines, statements and procedures which are relevant to medical students and/or postgraduate trainees.  MRPs and/or supervisors are advised to be familiar with this information and direct their medical students and/or postgraduate trainees to it. 

Dialogue Articles

Dialogue, the College’s quarterly publication for members, regularly addresses themes or issues relating medical education.

Competency-Based Medical Education

Competency-based medical education (CBME) is the current approach being used within Canadian medical education with the objective of having physicians graduate with the competencies required to meet local health needs. It aims to enhance patient care by improving learning and assessment in residency. For more information about CBME in Canada please see the following resources:

• Royal College of Physicians and Surgeons of Canada – Competence by Design
• College of Family Physicians of Canada – Triple C Competency-Based Curriculum

Canadian Medical Protective Association (CMPA)

The CMPA is a national organization and provides broad advice about a number of medico-legal issues. For Ontario specific information physicians are advised to look at the CPSO policy and advice document regarding professional responsibilities in medical education. However, the CMPA has a number of resources on the issues generally that physicians may find helpful.

For example:

• Delegation and Supervision of Medical Trainees
• Responsibilities of Physicians as Teachers

Endnotes

^1. Canadian Family Physician, Vol.66. February 2020, e55-61.

^2. Physicians may have other obligations under OHSA and the Code in regard to their own behaviour in the workplace, as well as specific obligations if they are employers as defined by OHSA or the Code.

^3. For further information about medical students performing pelvic examinations, please see the Society of Obstetricians and Gynaecologists of Canada’s Guideline #246.

^4. For more information about medical record keeping, please see CPSO’s Medical Records Documentation policy.