Background

Part of Washington University School of Medicine's mission is to develop and maintain excellent clinical programs that provide outstanding care. To fulfill this mission and ensure the safety of both learners and patients, we have created this clinical supervision policy to direct our clinical health care teams on the required oversight of medical students.

Liaison Committee on Medical Education Standards 9.2 and 9.3 require that a medical school ensures that the members of the school's faculty provide appropriate supervision of medical students in clinical learning situations involving patient care to ensure patient and student safety. We must also ensure that the level of responsibility delegated to the student is appropriate to their level of training and supervised by an individual within the scope of their practice.

For the purposes of this policy, the following definitions will be used:

• Direct supervision means that the supervising provider is physically present (or continually present on virtual telehealth visits) with both the student and the patient.
• Indirect supervision means that the supervising provider is not physically (or continually on virtual telehealth visits) present with both the student and the patient but is immediately available to provide direct supervision (or to join the telehealth visit) upon request, thus requiring that the supervising provider remain physically present within the hospital or other site of patient care. The supervising provider may include any member of the heath care team including residents, fellows, and attending physicians. There are also some situations in which it is appropriate that direct supervision be provided by other health care providers (e.g., registered nurses, advanced practice nurses, physician assistants, certified registered nurse anesthetists) if the specific clinical activity falls within their defined scope of practice.
• Independent practice is defined as a licensed practitioner providing medical care that is within their scope of practice.
• A medical procedure is defined as a noninvasive or minimally invasive action intended to measure, diagnose, evaluate, or treat a medical condition. It is inclusive of but not limited to breast/pelvic/bimanual/rectal exams, venipuncture, peripheral intravenous catheter placement, peripheral arterial puncture, urinary catheter placement, nasogastric tube placement, suturing, simple incision and drainage, lumbar puncture, thoracentesis, paracentesis, arthrocentesis, and central venous catheter placement.
• A surgery is a more invasive form of a medical procedure. It most often involves some form of incision, and it occurs only in specified environments such as an operating room or a procedure suite.

Policies

Medical students are not permitted to independently practice at any time. Medical students may not under any circumstances assist or perform procedures or any portion of a surgery without continuous direct supervision.

The oversight of medical student learning experiences involving patient care (e.g., immersions, clerkships, clinical electives) is provided by members of the school’s faculty serving in course, clerkship, or other leadership roles. These leaders must set expectations regarding the level of student supervision required during the patient care activities that occur during the clinical experience, and they are responsible for communicating that information to all supervising providers. Specifically, these leaders are responsible for making any required skills/procedures and patient types/clinical conditions known to medical students and the supervising provider teams, including the required levels of supervision. This information must also be specified in any required clinical experience logs and syllabi.

Phase 1 medical students may do the following:

• Participate in the review of medical records, history-taking, physical examination (excluding sensitive portions of the exam; see "Physical Examination" below), and the analysis of clinical data with indirect supervision when deemed capable of doing so by the supervising provider.
• Document in the medical student section of the electronic health record. All medical student clinical documentation requires review and co-signature by a licensed physician who will be directly responsible for the documentation. The supervising physician must independently confirm the documented findings.
• Enter patient care orders into the electronic health record in a pended state that requires review and co-signature by a licensed physician who will be directly responsible for the orders.
• Observe/assist in procedures under continuous direct supervision and only when deemed capable of doing so by the supervisor.
• Observe/assist surgeries under continuous direct supervision when deemed capable of doing so by the supervisor.

Phase 2 and 3 medical students may do the following:

• Participate in the review of medical records, history-taking, physical examination (excluding sensitive portions of the exam; see "Physical Examination" below), the analysis of clinical data, patient counseling, shared decision making, and frontline communication with consulting services with indirect supervision when deemed capable of doing so by the supervising provider.
• Document in the medical student section of the electronic health record. All medical student clinical documentation requires review and co-signature by a licensed physician who will be directly responsible for the documentation. The supervising physician must independently confirm the documented findings.
• Enter patient care orders into the electronic health record in a pended state that requires review and co-signature by a licensed physician who will be directly responsible for the orders.
• Perform patient written and verbal handoffs with direct supervision and, in the case of Phase 3 medical students, with indirect supervision when deemed capable of doing so by the supervising provider.
• Assist/perform procedures under continuous direct supervision only when deemed capable of doing so by the supervising provider.
• Observe/assist surgeries under continuous direct supervision when deemed capable of doing so by the supervising provider.

Physical Examination

At the discretion of the physician health care team and in accordance with course-specific guidelines, students are able to perform general physical examination techniques under indirect supervision, excluding portions defined as “sensitive.” Sensitive portions of the physical examination must always be performed under continuous direct supervision, even if the supervising provider determines the student capable of performing these examinations under indirect supervision. These include but are not restricted to external genitalia, rectal, breast, and pelvic examinations. Infant (<24 months of age) external genital examinations can be performed under indirect supervision at the discretion of the supervising provider.

Guidelines

For the sake of patient safety and personal growth, medical students are expected to request assistance in all circumstances beyond their level of skill and comfort, regardless of concerns regarding assessment or reprisal. If a student has concerns about the lack of clinical supervision, they are encouraged to discuss this with either the course director or the Office of Medical Student Education. If the issue is not resolved to satisfaction, students can then approach the Associate Dean for Student Affairs or Medical Education, the Senior Associate Dean for Education, or the Office of the Ombuds for Washington University School of Medicine.

If any member of the health care team has concerns about violations of the Clinical Supervision Policy, they are to contact the course director for immediate investigation of the situation. The course director is responsible for notifying the Office of Medical Student Education of any suspected violations of the Clinical Supervision Policy.

Last approved October 30, 2023

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