Undergraduate Medical Education – Professional Responsibilities

Professional Standard Regarding Professional Responsibilities in Undergraduate Medical Education

Introduction

The delivery of undergraduate medical education in Nova Scotia has significantly evolved over time. Today education occurs in a variety of environments – teaching sites are not limited to traditional teaching hospitals but also extend to community settings such as community hospitals, interdisciplinary clinics, and physicians’ private practices. Also, education relies on a team-based approach to care, involving the provision of comprehensive health services to patients by multiple health-care professionals. There are no longer exclusive domains of physician practice; rather, care is delivered through multidisciplinary teams. This collaborative, team-based approach promotes optimal health care for patients and learning opportunities for students.

As part of the training endeavour, medical students need to be given opportunities to observe and actively participate in clinical interactions in order to acquire the knowledge, skills, behaviours, attitudes and judgment required for future practice. This occurs through a process of graduated responsibility, whereby students are expected to assume increased responsibility as they acquire greater competence. For this to occur safely, supervisors must assess the competencies of the students they are supervising on an ongoing basis.

During the educational process, students will also gain an understanding of the values of the profession, as well as their individual duties to the patient, collective duties to the public, and duties to themselves and colleagues. These are all essential components of medical professionalism. Students cultivate attitudes and behaviours about professionalism through observing their supervisors. Positive role-modeling is therefore of the utmost importance and supervisors are expected not only to demonstrate a model of compassionate and ethical care but also to interact with colleagues, patients, patients’ families or their representatives, students, and other staff in a professional manner. This is consistent with the College’s expectations of all physicians regardless of practice circumstances.

An understanding of the responsibilities and expectations placed on supervisors is essential for ensuring patient safety in this complex environment. Thus, while this professional standard focuses on professional responsibilities in the undergraduate environment, supervisors are expected to be familiar with other applicable College policies and guidelines. These include, but are not limited to: Guidelines for Delegated Medical Functions and Medical Directives, Professional Standard and Guidelines Regarding Informed Patient Consent to Treatment and Policy on the Content and Maintenance of Medical Records.

Supervisors should also encourage medical students to become familiar with the above-named documents, as well as any applicable medical school policies, guidelines and statements relevant to undergraduate medical education.

Definitions

Undergraduate medical students (“medical students”) are students enrolled in an undergraduate medical education program in any jurisdiction. They are members of the College of Physicians and Surgeons of Nova Scotia.

Most Responsible Physician is the physician who has final accountability for the medical care of a patient, whether or not a student is involved in the clinical encounter.

Supervisors are physicians who have taken on the responsibility to guide, observe, and assess the educational activities of medical students. 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.

Principles

1. Safe and effective patient care must always take priority over the educational endeavour.
2. Proper education optimizes patient care as well as the educational experience.
3. The autonomy and personal dignity of students and patients must be respected.
4. Allowing students to have insight into the decision-making process enables an optimal educational experience.
5. Professionalism, which includes demonstration of compassion, service, altruism, and trustworthiness, is essential in all interactions in the educational environment in order to provide the best quality care to patients.

Professional Standard

1. Designation of most responsible physicianAs there are multiple health-care professionals involved in patient care, one physician must always be designated the most responsible physician for every patient to ensure continuity of care and appropriate monitoring. The MRP and/or the supervisor are responsible for ensuring that patients are given the name of the MRP, along with an explanation that the MRP is responsible for directing and managing their care.
2. Identification of medical students
   Medical students will be involved in observation and interaction with patients from the start of their undergraduate medical education. The supervisor and/or MRP are responsible for ensuring that the educational status of medical students and nature of their role 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. Students must be introduced as medical students and it should be made clear to patients that they are not physicians. An explanation could be provided that the student is a member of the health/clinical care team and the experience forms an important part of their undergraduate medical education program. Where appropriate, medical students may introduce themselves to patients instead of relying on a supervisor and/or MRP to make a formal introduction.
3. Supervision and education of medical students
   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. Prescriptions, telephone or other transmitted orders may be transcribed by the medical student, but must be countersigned.In addition, appropriate supervision and education requires clear communication between the MRP and supervisor in order to ensure the best possible care for the patient.
4. Supervision of medical students for educational experiences not part of Dalhousie University’s Undergraduate Medical Education Program
   Physicians are occasionally asked to supervise medical students who are either not on an approved rotation from the Dalhousie University Faculty of Medicine or are from another jurisdiction. Medical students from another jurisdiction doing clinical training in Nova Scotia are required to be registered with Dalhousie University. In addition to fulfilling the obligations set out elsewhere in this professional standard, physicians who choose to supervise other learners for educational experiences not registered with Dalhousie University must:
   1. obtain evidence that the learner has obtained a permit for a medical student clinical observership;
   2. ensure that the learner has liability protection that provides coverage for the educational experience;
   3. ensure that the learner has personal health coverage in Nova Scotia;
   4. ensure that they have liability protection for that learner to be in the office; and
   5. ensure that the learner has up-to-date immunizations.Dalhousie University takes responsibility for ensuring liability coverage, health coverage and immunization status in the case of all students registered at Dalhousie University during approved rotations.

      In addition, physicians who do not have experience supervising medical students or  are unable to fulfill the expectations outlined above should limit the activities of the medical student to the observation of clinical care only. While it is laudable for physicians to assist students or other learners in acquiring the experience they need for future practice, patient safety must prevail in all situations.

5. Professional relationships
   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. Displaying appropriate behaviour and providing an ethical and compassionate model of patient care is particularly important for the MRP and supervisor, as 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.The MRP and supervisor must be mindful of the power differential in their relationship with the student. Also, they should not allow any personal relationships to interfere with the student’s education, supervision, or evaluation. 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.), must be disclosed to the appropriate responsible member of faculty (such as the department or division head or undergraduate program director). The appropriate faculty member would need to decide whether alternate arrangements for supervision and evaluation of the student are warranted and, if necessary, make these arrangements.

   Moreover, the undergraduate medical education environment should be safe, and free of harassment, discrimination and intimidation. Any form of behaviour that interferes with, or is likely to interfere with, quality health care delivery or quality medical education is considered “disruptive behaviour.” This includes the use of inappropriate words, actions, or inactions that interfere with a physician’s ability to function well with others. Failure to display professional behaviour may also interfere with students’ education. Physicians, in any setting, are expected to display professional behaviour at all times.

6. Reporting responsibilities
   Physicians involved in the education of medical students are expected to report to the Dalhousie University Faculty of Medicine and, if applicable, to the health-care institution when a medical student exhibits behaviours that would suggest incompetence, incapacity, or abuse of a patient; or when the student fails to behave professionally and ethically in interactions with patients, supervisors or colleagues; or otherwise engages in inappropriate behaviour.Similarly, educational institutions should provide a safe, supportive environment that allows medical students to make a report if they believe their supervisor and/or the MRP exhibits any behaviours that would suggest incompetence, incapacity, or abuse of a patient; or when the supervisor and/or MRP fails to behave professionally and ethically in interactions with patients, supervisors or colleagues; or otherwise engages in inappropriate behaviour. The College expects that students will not face intimidation or academic penalties for reporting such behaviours.
7. Consent and the educational nature of the undergraduate environment
   The MRP and/or supervisor are responsible for communicating to patients 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.Student involvement in patient care will vary according to the student’s stage in the undergraduate medical education program as well as their individual level of competency.

   Student-patient interaction may be limited to observation alone, while students who develop and demonstrate competencies may be actively involved in patient care, including performance of procedures. While patient consent is necessary for treatment in any setting, there are circumstances unique to the undergraduate environment, which require additional consideration:

   1. Significant component of procedure performed independently by studentIn 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 patient must be made aware of this fact and, where possible, express consent must be obtained. Express consent is directly given, either orally or in writing.
   2. Investigation and procedures performed solely for educational purposes
      An investigation or procedure is defined as solely “educational” when it is unrelated to or unnecessary for patient care or treatment. An explanation of the educational purpose behind the proposed investigation or procedure must be provided to the patient and his or her express consent must be obtained. This must occur whether or not the patient will be conscious during the examination. If express consent cannot be obtained, e.g., the patient is unconscious, then the examination cannot be performed. The most responsible physician and/or supervisor should be confident that the proposed examination or clinical demonstration will not be detrimental to the patient, either physically or psychologically.