Purpose

The purpose of this document is to provide a student-centred approach to consent for physical examination of students by peers and tutors that is respectful of students’ privacy and to provide a clear procedure for negotiating adverse events

Scope

This document applies to all students and faculty involved in the teaching and learning of clinical skills in the MD Program curriculum. In this document, the term “peers” refers to MD Program students

Guideline

1. Examining peers is part of the Foundations Curriculum clinical skills training in the MD Program
2. Students and tutors may examine head, neck, and limbs typically exposed with T-shirts and shorts. Abdomen and chest (anterior and posterior) exposed by removal of top layer of clothing may only be examined with students’ explicit consent and in accordance with appropriate draping procedures as found in the “Examination of the Patient” section in week 12 of ICE Clinical Skills syllabus
3. Students and tutors will not be expected to examine breasts, the genitals or rectal area
4. Students must obtain verbal consent from peers to be examined before each instance of physical examination. Any concerns regarding consenting to peer exam in general should be discussed with the Clinical Skills Director, Foundations Director or Associate Dean, Learner Affairs at the beginning of the academic year
5. Students may withdraw verbal consent to be examined at any time. Students are not required to disclose their reasons for withdrawing consent
6. Students may decline to give consent to be examined by tutors and peers. Students are not required to disclose their reasons for refusing consent
7. Students who refuse or withdraw consent for any component of the physical exam may discuss this decision with either their tutor, Clinical Skills Director, Foundations Director or Associate Dean, Learner Affairs.   All parties will handle this discussion sensitively and confidentially
8. Students may opt to pre-select partners from within the group with whom they are comfortable
9. Tutors must not coerce students into consenting to be examined. They should only invite students to volunteer for demonstration purposes who have previously given consent. Any instances of perceived coercion or discomfort should be discussed with the Foundations Director and/or Associate Dean, Learner Affairs. Tutors will have access to ongoing faculty development opportunities to ensure they have clear, ongoing understanding of these guidelines
10. Tutors shall not take a refusal into account when considering the student’s academic performance
11. In the event that peer participation for physical examination is not possible within the student’s group, other avenues to ensure that student learning is not compromised will be implemented (i.e. combining groups, use of standardized patients, etc)
12. In the event of discovery of a suspicious finding, inappropriate behaviour, or a breach in confidentiality, tutors and students will follow the adverse event procedures outlined below

Adverse Events Procedure

A. Discovery of a suspicious finding

During physical examination of students by peers and tutors it is possible that a new suspicious finding may be discovered, for example, discovery of a mass, a heart murmur, or elevated blood pressure. The goal is to enable the student to obtain timely medical attention

The following steps will be taken

1. The examining student confidentially informs the examined student of the suspicious finding
2. The examining student determines whether the student is already aware of the suspicious finding
3. Both students confidentially inform their tutor
4. The tutor asks permission to perform the same physical examination
5. If the tutor confirms the suspicious finding, the tutor recommends that the student seeks medical advice
6. The tutor reminds both students of the duty of the examining student to maintain confidentiality regarding the incident

B. Inappropriate behaviour

Inappropriate behaviour, such as inappropriate use of medical equipment, offensive language, or physical abuse may occur during physical examination of students by peers and tutors. Tutors may directly witness inappropriate behaviour or be alerted to it by a student. The consequence for inappropriate behaviour will vary and will be determined on a case-by-case basis

The following steps will be taken

1. The tutor speaks to the student(s) behaving inappropriately
2. The tutor informs the student that their behaviour is inappropriate and may be a breach of University or Faculty policy or standard
3. For serious breaches of behaviour, the tutor contacts the course director regarding the incident
4. The course director checks applicable policies and standards regarding the incident and takes required actions
5. If a student has potentially been harmed by the inappropriate behavior, the tutor ensures that he or she seeks appropriate care (i.e. counseling)

C. Breach in confidentiality

Confidential information about a student may be revealed during history taking or physical examination. For example, students may reveal a history of medical issues, or physical examination may reveal surgical scars. It is possible in these situations that a breach in confidentiality may occur despite students being taught about the importance of confidentiality

NOTE: Some students may willingly provide specific consent to have their physical findings used for the instruction of others, which would not breach confidentiality

The following steps will be taken in the case of a breach in confidentiality

1. The tutor takes the student(s) who breached confidentiality aside to speak with them
2. The tutor informs the student(s) that sharing confidential information without consent is unacceptable and a breach of standards
3. The tutor contacts the local site coordinator and course director regarding the incident
4. The course director checks applicable policies and standards regarding the incident and takes required actions
5. The tutor ensures the student whose confidentiality has been breached is informed and, if required, seeks appropriate care (i.e. counseling)