Background

Part of Washington University School of Medicine’s mission is to develop and maintain excellent clinical programs to provide outstanding care. To fulfill this mission as an academic teaching hospital, we have created this clinical supervision policy to direct our clinical health care teams with the oversight of our medical students.

LCME Standards 9.2 and 9.3 require that a medical school ensure members of the school’s faculty provide supervision of medical student learning experiences throughout required clerkships. Furthermore, we must ensure that medical students in clinical learning situations involving patient care are appropriately supervised at all times 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 that the activities supervised are within the scope of practice of the supervising health professional.

For the purposes of this policy, the following definitions will be used. Direct supervision will mean that the supervising physician is physically present (or continually on virtual telehealth visits) with the student and the patient. Indirect supervision will mean that the supervising physician is not physically (or continually on virtual telehealth visits) present with 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 physician remain physically present within the hospital or other site of patient care. The supervising physician may include any member of the physician healthcare team, including residents, fellows, and attending physicians. There are also some situations in which it is appropriate that direct supervision be provided by a nurse or other healthcare provider, so long as the specific clinical activity falls within their scope of practice as specified below.

Policies

Supervision of medical student learning experiences involving patient care is provided on clerkships and other clinical courses by members of the school’s faculty. Faculty oversee the clinical curriculum by setting expectations for appropriate physician healthcare team members about the level of student supervision required with patient care activities and the level of responsibility delegated to the student. Course directors are responsible for communicating supervision requirements according to a student’s level of training to members of the physician healthcare team. These teams are made aware of student clinical expectations, the level of student supervision, and the level of responsibility given to a student according to the student’s level of training.

Supervision will need to be defined by the clinical environment and patient care activity. Below are several examples of types of patient care activities.

Physical Exam

Students will be equipped with the basic skills necessary to perform general physical exam techniques commensurate with their level of training as they enter the clinical training environment. At the discretion of the physician healthcare team and in accordance with course-specific guidelines, students are able to perform general physical exam techniques under indirect supervision, excluding techniques defined as “sensitive.”

Some physical exam skills are considered sensitive and will always need to be performed under the direct observation of a chaperone who is the same gender as the patient, even if the physician healthcare team determines that the student is capable of performing these exams under indirect supervision. These include — but are not restricted to — external genitalia exam on any patient, rectal exam on any patient, and breast exam on any person identifying as female. Infant external genital exams can be performed under indirect supervision without a chaperone at the discretion of the supervising physician. Pelvic examinations must always be performed under the direct supervision of a member of the physician healthcare team. Please refer to the "Patient’s Rights" policy for additional information regarding pelvic bimanual exams performed when the patient is under anesthesia.

Procedures

Students may not perform procedures without direct supervision by a member of the physician healthcare team or another health professional so long as the procedure is within that professional's scope of practice (e.g., a nurse supervising a venipuncture).

If any member of the physician healthcare 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. Students will not be down-graded or in any other way penalized for reporting concerns about suspected violations of the Clinical Supervision Policy.

Guidelines

If a student has concerns about a 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, the student can then approach the Associate Dean for Student Affairs, the Senior Associate Dean for Education, or the Office of the Ombuds for WUSM.

The Washington University School of Medicine Clinical Supervision Policy for Medical Students on Clinical Rotations was last approved by the Academic Affairs Committee on June 11, 2020. All substantive edits to this policy require approval by the Academic Affairs Committee.