Professional Responsibilities in Undergraduate Medical Education

Approved by Council: September 2003
Reviewed and Updated: May 2012

Other Reference: "College broadens supervision of medical students policy," Dialogue, Issue 2, 2012

Definitions

Undergraduate medical students (“medical students”): Students enrolled in an undergraduate medical education program in any jurisdiction. They are not members of the College of Physicians and Surgeons of Ontario.¹

Most responsible physician (“MRP”): The physician who has final accountability for the medical care of the patient, regardless of whether  a student is involved in the clinical encounter.

Supervisors: Physicians who have taken on the responsibility to guide, observe, and assess the educational activities of medical students.² The supervisor of a medical student involved in the care of a patient may or may not be the most responsible physician for that patient. Residents or fellows often serve in the role of supervisors but do not act as the most responsible physician for patient care.

Policy

1. While this policy focuses on professional responsibilities in the undergraduate environment, supervisors must be familiar with other applicable College policies including, but not limited to Delegation of Controlled Acts, Mandatory Reporting, Consent to Treatment, Disclosure of Harm, and Medical Records.³
   1. Supervisors are advised to encourage medical students to become familiar with the above-named policies, this policy, as well as any applicable medical school policies, guidelines and statements relevant to undergraduate medical education.

Designation of Most Responsible Physician

2. Patient care is often provided by multiple health-care professionals, with one individual designated as the most responsible physician; therefore, the MRP and/or the supervisor must ensure that patients are given the name of the MRP, along with an explanation that the MRP is responsible for directing and managing their care.

Identification of Medical Students and their Role in the Health-care Team

3. The MRP and/or supervisor must ensure that patients are made aware that patient care in teaching hospitals and other affiliated sites where education occurs relies on a team-based approach, i.e., care is provided by multiple health-care professionals, including students.⁴
4. The MRP and/or supervisor must ensure that the educational status of medical students and nature of their role on the team are made clear to the patient, the patient’s family, and members of the health-care team as early as possible during the educational process. In particular, the MRP and/or supervisor must ensure that it is made clear to patients that medical students are not physicians.⁵
   1. Unless appropriate for the medical student to do so themselves, the MRP and/or supervisor must ensure that students are introduced as medical students.

Supervision and Education of Medical Students

5. The MRP and/or supervisor must provide appropriate supervision. This includes:
   1. determining the medical student’s willingness and competency or capacity to participate in the clinical care of patients, as a learning experience;
   2. closely observing interactions between the medical student and the patient to assess:
      1. the medical student’s performance, capabilities and educational needs;
      2. whether the medical student has the requisite competence (knowledge, skill and judgment) to safely participate in a patient’s care without compromising that care; and
      3. whether the medical student demonstrates the necessary competencies and expertise to interact with patients without the supervisor being present in the room;
   3. meeting at appropriate intervals with the medical student to discuss their assessments;
   4. ensuring that the medical student only engages in acts based on previously agreed-upon arrangements with the MRP;
   5. reviewing, providing feedback and countersigning documentation by a medical student of a patient’s history, physical examination, diagnosis, and progress notes as soon as possible;
   6. managing and documenting patient care, regardless of the level of involvement of medical students; and
   7. counter-signing all orders concerning investigation or treatment of a patient, written under the supervision or direction of a physician.⁶
6. The MRP and the supervisor, if different, must ensure that there is clear communication between them in order to ensure the best possible care for the patient.

Professional Relationships

7. Physicians must demonstrate professional behaviour in their interactions with each other, as well as with students, patients, other trainees, colleagues from other health professions, and support staff. This includes refraining from “disruptive behaviour” which is any form of behaviour that interferes with, or is likely to interfere with quality health-care delivery or quality medical education.  For example, the use of inappropriate words, actions, or inactions that interfere with a physician’s ability to function well with others.⁷
   1. Positive role-modeling⁸ is of the utmost importance and MRPs and/or supervisors must demonstrate a model of compassionate and ethical care.
8. The MRP and supervisor must be mindful of the power differential in their relationship with the student and must not allow any personal relationships to interfere with the student’s education, supervision, or evaluation.
9. In order for the appropriate faculty member to decide whether alternate arrangements for supervision and evaluation of the student are warranted, the MRP or supervisor must disclose any relationship which pre-dates or develops during the educational phase between the MRP or supervisor and the medical student (e.g., family, clinical care, dating, business, friendship, etc.), to the appropriate responsible member of faculty (such as the department or division head or undergraduate program director).
10. Physicians are advised to be aware of university policies and procedures on these issues.

Reporting Responsibilities

11. Physicians involved in the education of medical students must report to the medical school and, if applicable, to the health-care institution when:
    1. a medical student exhibits behaviours that would suggest incompetence, incapacity, or abuse of a patient;
    2. a medical student fails to behave professionally and ethically in interactions with patients, supervisors or colleagues; or
    3. otherwise engages in inappropriate behaviour.⁹
12. Physicians who are involved in medical school administration must ensure:
    1. A safe, supportive environment is provided that allows medical students to make a report if they believe their supervisor and/or the MRP:
       1. exhibits any behaviours that would suggest incompetence, incapacity, or abuse of a patient;
       2. fails to behave professionally and ethically in interactions with patients, supervisors or colleagues; or
       3. otherwise engages in inappropriate behaviour; and
    2. Students will not face intimidation or academic penalties for reporting such behaviours.

Consent and the Educational Nature of the Undergraduate Environment

13. While physicians must obtain patient consent¹⁰ for treatment in any setting, there are circumstances unique to the undergraduate environment, which require additional consideration:
    1. In the rare situation where a significant component, or all, of a medical procedure is to be performed by a student and the MRP and/or supervisor is not physically present in the room, the MRP and/or supervisor must ensure the patient is made aware of this fact and, where possible, express consent¹¹ must be obtained.
    2. Where an investigation and/or procedure is performed solely for educational purposes¹², the MRP and/or supervisor must:
       1. Provide an explanation of the educational purpose behind the proposed investigation or procedure to the patient and obtain their express consent¹³. This must occur whether or not the patient will be conscious during the examination.
       2. Ensure the examination is not performed if express consent cannot be obtained, e.g., the patient is unconscious.
       3. Be confident that the proposed examination or clinical demonstration will not be detrimental to the patient, either physically or psychologically.¹⁴

Supervision of Medical Students for Educational Experiences not Part of an Ontario Undergraduate Medical Education Program

14. In addition to fulfilling the obligations set out elsewhere in this policy, physicians who choose to supervise medical students for educational experiences not part of an Ontario undergraduate medical education program must also:
    1. be familiar with the Delegation of Controlled Acts policy,¹⁵
    2. obtain evidence that the student is enrolled in and in good standing at an undergraduate medical education program at an acceptable medical school,¹⁶
    3. ensure that the student has liability protection that provides coverage for the educational experience,
    4. ensure that the student has personal health coverage in Ontario,
    5. ensure that they have liability protection for that student to be in the office, and
    6. ensure that the student has up-to-date immunizations.¹⁷
15. Where physicians do not have experience supervising medical students or are unable to fulfill the expectations outlined above they must limit the activities of the medical student to the observation of clinical care only.

Endnotes

^1. Students are able to participate in the delivery of health care through a provision in the Regulated Health Professions Act, 1991, which permits them to carry out controlled acts “under the supervision or direction of a member of the profession,” i.e., a clinical teacher or supervisor. Medical students are not independent practitioners or specialists. They are pursuing both program and individual objectives in a graded fashion under the supervision of the undergraduate medical education program. While some students hold “Affiliate Status” with the College, they are not licensed to practise medicine in Ontario, and are not members of the College.

^2. Supervision may include, but is not limited to the guidance, teaching, observation, and assessment of undergraduate medical students.

^3. There are MD program requirements set out in the “Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree” prepared by the Liaison Committee on Medical Education, as well as university and hospital policies and procedures relating to professionalism, e.g. Codes of Conduct.

^4. Typically, a hospital would have signage notifying patients that it is a teaching institution. However, physicians in private offices and clinics need to explicitly communicate this information.

^5. An explanation could be provided that team-based approach forms an important part of their undergraduate medical education program.

^6. Prescriptions, telephone or other transmitted orders may be transcribed by the medical student, but must be countersigned.

^7. For more information, please refer to the College policy on Physician Behaviour in the Professional Environment, as well as the Guidebook for Managing Disruptive Physician Behaviour.

^8. Students 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 those principles of professionalism taught to students during the undergraduate didactic curriculum.

^9. This obligation equally extends to physicians who supervise medical students from other jurisdictions. 

^10. Obtaining informed consent includes the provision of information and the ability to answer questions about the material risks and benefits of the procedure, treatment or intervention proposed. For more information, please refer to the College’s Consent to Treatment policy and also, the Health Care Consent Act, 1996, c. 2, Sched. A.

^11. Express consent is directly given, either orally or in writing.

^12. An investigation or procedure is defined as solely “educational” when it is unrelated to or unnecessary for patient care or treatment.

^13. See footnote 11.

^14. For more information, please refer to the joint policy statement “Pelvic Examinations by Medical Students” dated September 2010 prepared by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Ethics Committee and the Association of Professors of Obstetrics and Gynaecology of Canada (APOG).

^15. The College’s Delegation of Controlled Acts policy applies to any physician who supervises:

1. an Ontario medical student completing an extra rotation that is not part of their MD program, and
2. a student from outside Ontario completing an Ontario educational experience where the student will be performing controlled acts.

^16. For the purposes of this policy, an “acceptable medical school” is a medical school that is accredited by the Committee on Accreditation of Canadian Medical Schools or by the Liaison Committee on Medical Education of the United States of America, or is listed in either the World Health Organization’s Directory of Medical Schools: http://www.who.int/hrh/wdms/en/, or the Foundation of Advancement of International Medical Education and Research’s (FAIMER’s) International Medical Education Directory (IMED): https://www.faimer.org/resources/world-directory.html

^17. Please refer to the Council of Ontario Faculties of Medicine’s Immunization policy which is available on the websites of the Ontario medical schools, for more information.