Clinical Supervision Policy
This policy addresses the expectations around the clinical supervision of medical students.
All medical students must have direct supervision or indirect supervision with direct supervision immediately available
Direct supervision is where a supervising physician or designated mid-level provider (NP, PA, CNM) is physically present with the patient.
Indirect supervision with direct supervision immediately available is where the supervisor is immediately available in the clinical location and can be present with the patient and student.
Supervising clinicians are either faculty members, designated mid-level provider (NP, PA, CNM) or residents who have been designated to supervise the medical students. Faculty members or residents functioning as supervising physicians should delegate portions of care to those being supervised, based on the needs of the patient and the skills of the medical student.
Intimate Exam refers to pelvic, genitourinary, and rectal exams
Supervising Primary Clinical Faculty and Residents are responsible for providing direct oversight to students as outlined in this policy.
Course, clerkship, and site directors are responsible for adherence to this policy.
The Associate Dean of Medical Education and Assistant Dean of Medical Education for Affiliated Sites (ADME-AS) are responsible for oversight on this policy.
Initially, the primary clinical supervisor members should designate time to observe the student performing the following: history taking, focused physical exam, clinical problem solving, interaction with patients and patient education. Once the supervisor establishes the student’s level of confidence and competence, the student should be provided with the level of responsibility appropriate to their skills and the supervisor should provide increasing levels of responsibility in patient care over time, as appropriate. Although students may initiate a particular patient encounter on their own and without direct supervision, the supervisor must review the encounter with the student at some point during the patient visit and inform the patient in-person that the student’s assessment and management plan has been reviewed, and approved or modified by the supervisor. The faculty is ultimately responsible for the evaluation, treatment, management, and documentation of patient care. Faculty must complete a note that documents that they were the person responsible for seeing and examining the patient
Under no circumstances should the following occur:
- Patient leaves the office/hospital with never having had a direct face-to-face encounter with clinical faculty.
- Primary faculty gives “prior approval” for student to perform intervention (order labs, prescribe meds) without satisfactory review.
- Patient leaves the office/hospital without being informed that assessment/ management plan has been directly reviewed and approved or modified by the faculty.
- Learning in which a student is expected to perform an intervention or participate in an encounter without the prerequisite training and/or adequate supervision.
- Student note provides the only record of the visit.
Students are allowed and encouraged to write complete notes in patient electronic charts as designated by the site and the site’s documentation policy. Supervisors must review all student documentation that is used for billing.
CMS Guidelines from February 2, 2018, state: “The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
Supervision and Delegating Increasing Levels of Responsibility
It is expected that the level of student responsibility and supervision will be commensurate with student’s competence and level of confidence. It is recommended that when a student arrives in a clinical setting, a supervisor provides an opportunity for the student to observe a faculty or resident for the first session. Thereafter, they should begin to see patients on their own. In the outpatient setting, it is recommended that the student should initially perform 4-5 focused visits per day in the first week, increasing to 6-12 thereafter. In the inpatient setting, the student should initially follow 1-2 patients and increased to 3-4 thereafter. When a student feels that he or she is being asked to perform beyond his or her level of competence, it is the responsibility of the student to promptly inform the preceptor. It is then the preceptor’s responsibility to constructively address the student’s concerns and appropriately restructure the teaching encounter to address the student’s learning needs.
Students participating in an intimate exam with a patient must have a chaperone with them, irrespective of the gender of the patient or the student. The chaperone must be an MD/DO (residents included), NP, PA, or CNM. Permission to participate in an intimate exam must be obtained by the supervisor in advance of the examination itself. The patient has the right to decline student attendance at any examination. If a student is unable to perform any intimate exam due to patient preference, the student’s evaluation will not be impacted and if necessary, the clerkship director will provide an alternative experience.
Certain clerkships have home visits. The clerkship director needs to provide complete instructions regarding the home visit and expectations for the student.
Home visit safety
Student and patient safety is a priority for home visits. Students are required to go to their home visit with another student or clinician (MD, DO, NP, PA, RN, CNM, Resident, etc.). At no time should a student participate in an experience where they are in danger or feel uncomfortable. The site director or primary faculty should assist the student in identifying an appropriate patient for their home visit with respect to educational, patient care, logistical, and safety goals. Students are encouraged to talk with their primary faculty or the clerkship director if they have questions or concerns at any point. The student should notify the primary faculty or a designated staff member of the date and location of their home visit before they go to the patient’s home.
Course and Clerkship Directors monitor this policy through direct feedback from students, discussions with site directors and faculty, and as part of the annual educational quality improvement process.
The Affiliated Sites Office reviews clinical supervision during scheduled site visits.
The Curriculum & Assessment Office monitors student feedback regarding clinical supervision on the annual end of third year survey.
Non-compliance is reported to the Associate Dean of Medical Education for action.
[Approved by the Medical Education Committee on November 8, 2018.]