Approved by Council: June 2021

Companion Resource: Advice to the Profession

Definitions

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

Postgraduate trainees²: Physicians who hold a degree in medicine and are continuing in postgraduate medical education (commonly referred to as “residents” or “fellows” in most teaching sites). Postgraduate trainees often serve in the role of supervisors but do not act as the most responsible physician for patient care.  If postgraduate trainees are supervisors, then the provisions of the policy regarding supervisors apply to them.

Most responsible physicians (“MRP”): Physicians who have overall responsibility for directing and coordinating the care and management of a patient at a specific point in time, regardless of the amount of involvement that a medical student or postgraduate trainee has in that patient’s care.

Supervisors: Physicians who have taken on the responsibility to observe, teach, and evaluate medical students and/or postgraduate trainees.  The supervisor of a medical student or postgraduate trainee who is involved in the care of a patient may or may not be the most responsible physician for that patient.

Policy

Supervision of Medical Students

1. MRPs and/or supervisors³ must provide appropriate supervision to medical students which is proportionate to the medical student’s level of training and experience. This includes:
   1. assessing interactions (which may include observation) between medical students and patients to determine:
      1. whether a medical student has the ability and readiness to safely participate in a patient’s care without compromising that care;
      2. a medical student’s performance, abilities, and educational needs; and
      3. whether a medical student is capable of safely interacting with patients in circumstances where the supervisor is not present in the room;
   2. meeting at appropriate intervals with a medical student to discuss their assessments of patients and any care provided to them;
   3. ensuring that a medical student only engages in patient care based on previously agreed-upon arrangements with the MRP and/or supervisor;
   4. reviewing and providing feedback on a medical student’s documentation, including any progress notes written by a medical student;
   5. subject to any institutional policies, using their professional judgment to determine whether to countersign a medical student’s documentation;
   6. countersigning all orders written under the supervision or direction of a physician;⁴ and
   7. managing and documenting patient care, regardless of the level of involvement of medical students.

Supervision of Postgraduate Trainees

2. MRPs and/or supervisors must provide appropriate supervision to postgraduate trainees. This includes:
   1. regularly assessing a postgraduate trainee’s ability and learning needs, and assigning graduated responsibility accordingly;
   2. ensuring that relevant clinical information is made available to a postgraduate trainee;
   3. communicating regularly with a postgraduate trainee to discuss and review their patient assessments, management, and documentation of patient care in the medical record; and
   4. directly assessing the patient as appropriate.
3. Postgraduate trainees must:
   1. only take on clinical responsibility in a graduated manner, proportionate with their abilities, although never completely independent of appropriate supervision;
   2. communicate with a supervisor and/or MRP:
      1. in accordance with the guidelines of their postgraduate program and/or clinical placement setting;
      2. about their clinical findings, investigations, and treatment plans;
      3. in a timely manner, urgently if necessary, when there is a significant change in a patient’s condition;
      4. when the postgraduate trainee is considering a significant change in a patient’s treatment plan or has a question about the proper treatment plan;
      5. about a patient discharge;
      6. when a patient or family expresses concerns; or
      7. in an emergency or when there is significant risk to the patient’s well-being;
   3. document their clinical findings and treatment plans; and
   4. identify the MRP or supervisor who has reviewed their consultation reports and indicate the MRP’s or supervisor’s approval of the report.

Availability of MRP and/or Supervisor

4. MRPs and/or supervisors must ensure that 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) or if unavailable, they must ensure that an appropriate alternative supervisor is available and has agreed to provide supervision.
5. The degree of availability of an MRP and/or supervisor and the means of availability (by phone, pager or in-person) must be appropriate and reflective of the following factors:
   1. the patient’s specific circumstances (e.g., clinical status, specific health-care needs);
   2. the setting where the care will be provided and the available resources and environmental supports in place; and
   3. the education, training and experience of the medical student and/or postgraduate trainee.

Involvement in Patient Care

Informing Patients about the Health-Care Team

6. MRPs or supervisors must ensure that patients⁵ are informed of their name and roles, the fact that the MRP is ultimately responsible for their care, and that patient care often relies on a collaborative, team-based approach involving both medical students and postgraduate trainees.
   1. As medical students or postgraduate trainees are often the first point of contact with a patient, the information above can be provided by them where appropriate.

Obtaining Consent

Medical student and postgraduate trainee involvement in patient care are necessary elements of medical education and training, as well as essential components of how care is delivered in teaching hospitals and other affiliated sites. Respect for patient autonomy may warrant obtaining consent to the involvement of medical students and postgraduate trainees. Whether the consent is implied or express⁶ will depend on the circumstances.

7. In situations where medical students or postgraduate trainees are involved in patient care solely for their own education (e.g., observation, examinations unrelated to the provision of patient care⁷, etc.), physicians responsible for providing that care must ensure consent to medical student or postgraduate trainee participation is obtained, either by obtaining consent themselves or, where appropriate, by another member of the health care team (including the medical student or postgraduate trainee involved).
8. Where medical students provide care to patients, physicians responsible for that care must ensure that consent for the participation of the medical student is obtained in appropriate circumstances, and must determine who from the health-care team (including the medical student) will obtain it, taking into account the:
   1. type of examination, procedure or care that is being provided (e.g. complexity, intrusiveness, sensitivity);
   2. patient’s characteristics/attributes, including their vulnerability;
   3. increasing responsibilities medical students have in participating in patient care;
   4. level of involvement of the MRP/supervisor in the care being provided; and
   5. best interests of the patient.

Professional Behaviour

9. MRPs and supervisors must demonstrate a model of compassionate and ethical care while educating and training medical students and postgraduate trainees.
10. MRPs, supervisors, and postgraduate trainees must demonstrate professional behaviour in their interactions with:
    1. each other
    2. medical students,
    3. patients and their families,
    4. colleagues, and
    5. support staff.
11. MRPs, supervisors, and postgraduate trainees must not engage in disruptive behaviour that interferes with or is likely to interfere with quality health-care delivery or quality medical education (e.g., the use of inappropriate words, actions, or inactions that interfere with a physician’s ability to function well with others.⁸)

Violence, Harassment, and Discrimination

12. Physicians (including MRPs, supervisors, and postgraduate trainees) involved in medical education and/or training must not engage in violence, harassment (including intimidation) or discrimination (e.g., racism, transphobia, sexism) against medical students and/or postgraduate trainees.
13. Physicians must take reasonable steps to stop violence, harassment or discrimination (e.g., racism, transphobia, sexism) against medical students and/or postgraduate trainees if they see it occurring in the learning environment and must take any other steps as may be required under applicable legislation⁹, policies, institutional codes of conduct or by-laws.
14. MRPs and/or supervisors must provide medical students and/or postgraduate trainees with support and direction in addressing disruptive behaviour (including violence, harassment and discrimination) in the learning environment, including but not limited to taking any steps as may be required under applicable legislation¹⁰, policies, institutional codes of conduct or by-laws.

Professional Relationships/Boundaries

15. MRPs and supervisors must not:
    1. enter into a sexual relationship with a medical student and/or postgraduate trainee while responsible for mentoring, teaching, supervising or evaluating the medical student and/or postgraduate trainee; or
    2. enter into a relationship¹¹ with a medical student and/or postgraduate trainee that could present a risk of bias, coercion, or actual or perceived conflict of interest, while responsible for mentoring, teaching, supervising or evaluating the medical student and/or postgraduate trainee.
16. MRPs and/or supervisors (including postgraduate trainees who are supervisors) must, subject to applicable privacy legislation¹², disclose any sexual or other relationship¹³ between themselves and a medical student and/or postgraduate trainee which pre-dates the mentoring, teaching, supervising or evaluating role of the MRP and/or supervisor to the appropriate member of faculty (e.g., the department or division head or undergraduate/postgraduate program director) in order for the faculty member to decide whether alternate arrangements are warranted.

Reporting Responsibilities

17. Physicians (including MRPs, supervisors and postgraduate trainees) involved in the education and/or training of medical students and/or postgraduate trainees must report to the medical school and/or to the health-care institution, if applicable, when a medical student and/or postgraduate trainee:
    1. exhibits behaviours that would suggest incompetence, incapacity, or abuse of a patient;
    2. fails to behave professionally and ethically in interactions with patients and their families, supervisors, and/or colleagues; or
    3. otherwise engages in inappropriate behaviour.¹⁴
18. Physicians involved in administration at medical schools, or health-care institutions that train physicians must contribute to providing:
    1. a safe and supportive environment that allows medical students and/or postgraduate trainees to make a report if they believe the MRP and/or their supervisor:
       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 and their families, supervisors or colleagues; or
       3. otherwise engages in inappropriate behaviour, including violence, harassment, and discrimination against medical students and/or postgraduate trainees; and
    2. an environment where medical students and/or postgraduate trainees will not face intimidation or academic penalties for reporting such behaviours.

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

19. In addition to fulfilling the expectations set out above, physicians who choose to supervise medical students for educational experiences that are not part of an Ontario undergraduate medical education program must:
    1. comply with the Delegation of Controlled Acts policy,¹⁵
    2. ensure that they have liability protection for that student to be in the office,
    3. ensure that the student:
       1. is enrolled in and in good standing at an undergraduate medical education program at an acceptable medical school,¹⁶
       2. has liability protection that provides coverage for the educational experience,
       3. has personal health coverage in Ontario, and
       4. has up-to-date immunizations.¹⁷
20. 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 patient care only.

Endnotes

^1. The Regulated Health Professions Act, 1991, S.O. 1991, c.18 (RHPA) permits students to participate in the delivery of health care by allowing them to carry out controlled acts “while fulfilling the requirements to become a member of a health profession and the act is within the scope of practice of the profession and is done under the supervision or direction of a member of the profession”.

^2. The majority of postgraduate trainees in Ontario hold a certificate of registration authorizing postgraduate education, but regardless of the class of certificate of registration held, postgraduate trainees cannot practise independently in the discipline in which they are currently training.

^3. A postgraduate trainee may also be a supervisor.

^4. Prescriptions, telephone or other transmitted orders may be transcribed by the medical student but must be countersigned.

^5. Throughout this policy, where “patient” is referred to, it should be interpreted as “patient or substitute decision-maker” where applicable.

^6. Express consent is direct, explicit, and unequivocal, and can be given orally or in writing. Implied consent can be inferred from the words or behaviour of the patient, or the surrounding circumstances, such that a reasonable person would believe that consent has been given, although no direct, explicit, and unequivocal words of agreement have been given. Obtaining consent for involvement of medical students and postgraduate trainees is different than that of obtaining consent in the context of the Health Care Consent Act regarding treatment decisions. More information is provided in the Advice.

^7. See Advice for examples.

^8. 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.

^9. For example, the obligations set out in the Occupational Health and Safety Act, R.S.O. 1990, c.0.1 (“OHSA”) and the Human Rights Code, R.S.O. 1990, c. H.19 (the “Code”).

^10. 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.

^11. Including but not limited to, family, dating, business, treating/clinical, and close personal relationships.

^12. If the relevant information to be disclosed contains personal health information or is otherwise protected by privacy legislation, the MRP and/or supervisor may either obtain consent from the medical student and/or postgraduate trainee to disclose this information or state that alternate arrangements are warranted.

^13. Including but not limited to family, dating, business, treating/clinical and close personal relationships.

^14. The College’s Disclosure of Harm policy also contains expectations which may be relevant to these circumstances.

^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 the World Directory of Medical School’s online registry.

^17. Please refer to the Council of Ontario Faculties of Medicine’s Immunization policy .