3.4: Definition of Medical Student Practice Role
Pre-clerkship students have structured interactions with patients, with an emphasis on understanding patient perspective of illness and practicing specific aspects of history-taking, general communication skills, and physical exam skills. These interactions occur at various points during the pre-clerkship experience, including Hospitalized Patient Encounter sessions and Clinical Practicum sessions. Students are also introduced to the frameworks of reporting patient data during the Medical H & P session in the first year and in Clinical Practicum sessions in the second year. The Clinical Reasoning thread, which runs through both years of the pre-clerkship curriculum, introduces students to the interpretation skills of clinical data in the context of patient case discussions.
All pre-clerkship patient encounters are done under the overall supervision of faculty preceptors who have received formal orientation training and are offered periodic faculty development sessions. For the pre-clerkship encounters, faculty, students, and patients are all explicitly operating under the understanding that the students are not part of the clinical care team (and accordingly are neither allowed nor expected to assume the roles of care providers).
In the clerkship years, the role of the medical student evolves to where they are an integral part of the patient care team. The guidelines below provide an overview of expectations, supervision, milestones, and laws regarding their participation in clinical activities.
- Medical students are not to be involved in any portion of the medical care of other medical students.
- Determination of appropriate level of supervision should be determined by the course/clerkship director and communicated to both the medical student and supervising faculty, resident, and/or fellow and should be based on the level of training of the medical student.
- Students are not permitted to perform procedures without direct supervision.
- Medical students are not permitted to provide care without supervision of a faculty member.
The School of Medicine has adopted the RIME framework (Pangaro, 1999) to describe expectations for performance in Patient Care. The RIME framework is based on the understanding that students progress through a sequence of developmental stages:
Reporter > Interpreter > Manager > Educator
- Focus at this stage: Reliable, accurate, complete data-gathering and presentation of clinical information.
- Emphasis on the S/O (Subjective/Objective) part of SOAP.
- Students are expected to move through the Reporter stage during preclinical training, i.e. Practice of Medicine.
- Focus at this stage: Diagnostic reasoning. Begins to see how details fit together.
- Emphasis on the A (Assessment) part of SOAP.
- Data-gathering and reporting become more purposeful, more focused on pertinent positive and negative information and exploring diagnostic possibilities.
- Students are expected to perform at the Interpreter stage during their core clerkship training.
- Focus of this stage: treatment planning - including diagnostic testing and therapy.
- Emphasis on the P (Plan) in SOAP.
- Data-gathering and decision-making become more flexible, individualized, and patient centered. Student thinks critically about recommendations, takes a more sophisticated approach to using medical literature to support patient care.
- Students typically perform at the Manager level by their sub-internships.
Medical Board of California
The Medical Board of California requests that medical students be carefully instructed about what they may and may not do in terms of writing orders or prescriptions for patients. Thus, Educational Programs and Services, in collaboration with the clinical department chairs, Stanford-affiliated hospitals, and nursing offices, has prepared the following description of the appropriate role of the Stanford medical student on a patient care team.
California state law allows specific exceptions for medical students to the general code, which requires that all medical acts must be performed by licensed physicians. The exception specifies that a student may do all things that a physician may do with the following provisos:
- That any medically related activity performed by students be part of the course of study of an approved medical school; and
- That any medically related activity performed by students be under the proper direction and supervision of the faculty of an approved medical school.
- Where clinically and educationally appropriate, physicians who are supervising medical students may delegate responsibility for some elements of teaching and supervision to non-physician care providers, e.g. allied health professionals, nurses, respiratory therapists, etc., within the institution. It will be the responsibility of each supervising physician to determine which learning experiences are appropriately delegated in this manner and to ensure that non-physicians providing such supervision are working within their scope of practice.
Medical students may therefore write orders for drugs, treatments, etc., provided that:
- the provisions of number 2 above are observed;
- the students are assigned to or are consultants to the service on which the order pertains; and
- a licensed physician countersigns all orders before the orders are executed. Telephone orders of counter-signatures will be accepted from licensed physicians (including licensed housestaff). Medical students may locate and solicit the licensed physician’s verification by telephone, but the licensed physician must speak directly to the registered nurse and must actually sign the order before going off duty. The counter-signature is recorded as a telephone order. Routine admission orders are not exempted from the above provisions.
Medical students acting as subinterns, are still subject to the above provisions. Medical students will identify their signatures with CC (Clinical Clerk) or MS (Medical Student), just as licensed physicians identify their signatures with MD. Medical students will also wear badges identifying them as medical students.
updated August 2021