Patient Consent to Physical Examination by Undergraduate Learners Policy

The purpose of this policy is to provide guidance to tutors and undergraduate learners for obtaining patient consent to physical examinations undertaken by these learners in clinical learning contexts.

Physical examination skills are core to the practice of clinical medicine. To practice and develop their skills, undergraduate learners interact with patients in the clinical therapeutic context.

This policy is based on broadly accepted consent principles in its approach to physical examination by learners. The doctrine of informed consent is central to autonomy-based ethics, wherein a patient’s preferences are to be respected because all patients possess dignity, moral agency and inherent worth.

Informed consent has three recognized components: disclosure, capacity, and voluntariness. It can only be considered valid if 1) adequate information regarding risks, benefits and alternatives has  been explained to the patient, 2) the patient is able to is understand this information fully, and 3) the patient then makes a voluntary decision.

Learner: any student in the College of Medicine MD Program

Tutor: any faculty member, supervisor or resident responsible for teaching clinical skills to MD Program learners.

Simulated Patient: An individual who is a member of the community and who assists with health care learners’ education by portraying symptoms, histories, emotions and patient concerns in learning sessions.

Patient: An individual engaged in seeking/receiving medical and/or surgical care in outpatient or inpatient health care settings.

Informed Consent: the autonomous authorization, by patients, of any medical or surgical intervention, including physical examination

Sensitive Examinations: any physical examination involving the genitalia, the anus and rectum, the inguinal or groin areas, and/or the breasts. Depending upon the patient’s personal background, experiences and preferences, the definition of ‘sensitive’ examinations may expand to include additional components.

This policy applies to all learners and tutors involved in the learning and teaching of clinical skills in the MD Program curriculum. While physicians are already subject to informed consent policies as set by their various governing bodies, this policy is meant to provide further guidance when learners are involved in the patient-physician relationship.

This policy is not intended to apply to examination of standardized patients participating in learning sessions in clinical learning centres; simulated patients will have been oriented in advance and will expect to be examined when that is an objective of the teaching session.  However, students should still seek consent from standardized patients as they would from patients in the health care setting and respect each standardized patient’s right to decline physical examination.

1. Informed consent to be examined by learners for primarily instructive purposes is to be viewed as a distinct process lying within the usual medical/surgical requirements for consent to therapeutic or investigative interventions.
2. While consent can be implied in some clinical circumstances, this policy requires that explicit consent be obtained from patients prior to physical examination by learners when the purpose of such examination is primarily instructive rather than solely therapeutic.
3. Learners and their tutors will obtain explicit consent from patients to be examined prior to the initiation of any such examinations.
4. Explicit consent to be examined by learners can be either verbal or written.
5. Learners should introduce themselves as trainees and clearly identify their role(s) in the proposed examination and subsequent interventions. An opportunity should be provided for patients to ask for clarification or further information. Patients may withdraw their consent at any point in the physical examination.
6. Tutors must not coerce or otherwise inappropriately attempt to persuade patients to consent to be examined by learners. Rather, tutors should explicitly state to patients that it is their choice to participate in the learning process or not.
7. Anaesthetized or sedated patients lack capacity and cannot provide informed consent. Consent should be obtained by the tutor in advance of the patient being anesthetized/sedated. When this consent is being obtained, the process should ideally involve the learner; if that is not feasible, then the tutor should advise the learner that consent has been obtained.
8. Patients who lack capacity due to age, immaturity, cognitive impairment, or other factors, cannot provide informed consent and should not be examined by learners unless adequate consent is provided by the appropriate substitute decision maker.
9. Explicit consent is of particular importance in the context of sensitive physical examinations. Patients should be offered the opportunity to have a chaperone present for any sensitive examination. Strategies to support patient autonomy and comfort throughout sensitive examinations must be employed.
10. Learners must remain cognizant of how cultural diversity, past trauma, and any other emotional, physical or personal factors may affect a patient’s decision to allow or refuse physical examination and their comfort with communicating any reservations they have about being examined by a learner. This is particularly true for sensitive examinations.
11. Learners who decline to participate in physical examinations for which, in their judgement, adequate informed consent has not been obtained, will not be subject to negative performance assessments by tutors.
12. Learners who refuse to participate should fully and confidentially (i.e. not in the presence of the patient or family members) discuss the reasons for their refusal with their tutors. Tutors should attend to learner diversity and inclusivity factors when discussing learner concerns, while also recognizing that learners must be trained in examination of all body systems.
13. In the event a learner discovers a previously unrecognized and potentially suspicious finding, they are obliged to discuss said finding with their tutor(s) and to share in determining how and when the finding and its implications should be  shared with the patient.

Tutors and learners share the responsibility of ensuring that patients have been offered the opportunity to provide fully informed consent prior to physical examination by learners. A learner’s request to act in accordance with this policy shall not be viewed in a negative light by tutors. Ultimately, tutors are responsible for ensuring compliance with this policy.

In the event of tutor non-compliance with this policy, learners are encouraged to confidentially state their concerns as soon as reasonably possible with the appropriate College of Medicine course director or program leadership.  Similarly, tutors encountering learner refusals to participate should confidentially discuss such refusals with the appropriate course director or program leadership, without prejudice to the learner(s) involved.

• CPSS Informed Consent and Determining Capacity to Consent.
• CPSS Physicians and Sensitive Examinations. CPSS, 2021.
• SHA Informed Consent to Care Policy. SHA, 2024.
• ACHA guidelines: Best Practices for Sensitive Exams. ACHA, 2019.
• Trauma-Informed Physical Examinations and STBBI Testing. Canadian Public Health Association, 2021.
• JOGC: Guideline No. 246 – Pelvic Examinations by Medical Students. Liu, K et al. JOGC, 2017-09-01, 39 (9): p. e322-e324.

Dr. Keith Ogle, retired faculty member with the USask Department of Academic Family Medicine, contributed substantially to the authorship of this policy.  Various faculty and students reviewed and provided input.  Grateful acknowledgment to these individuals for their contributions.

Associate Dean, UGME

Ph: (306) 966-6150

Email: medicine.ugme@usask.ca