Medical Liability Insurance

It is common practice in medical education to allow third-and fourth-year students to write orders on patients they have worked with. This practice must be viewed as an educational activity and not as a service activity. As a learning experience, the teaching occurs when a supervising physician (either resident or attending), reviews the orders, discusses them with the student, provides constructive feedback, and countersigns the orders.

Under these circumstances students are covered by the university's medical liability insurance. The key conditions are that 1) the student is functioning under the direct supervision of a licensed physician, and 2) that the orders are countersigned before they are executed.

The university's medical liability insurance also covers Brown medical students when they are doing clinical electives at institutions other than Brown's affiliated hospitals, so long as the above conditions are fulfilled. Therefore, if a medical student is permitted to write orders on patients that are not countersigned or countersigned after they have been executed, the student may be personally liable for any damages that result from that action.

The medical liability insurance also covers students for any injury that results to a patient as a consequence of a student's actions in carrying out the usual and customary functions of a medical student in the course of caring for a patient. This includes taking a history, conducting a physical examination, and performing procedures of an investigatory or therapeutic nature. However, the same conditions apply, namely, that the student must be functioning under the direct supervision of a licensed physician.

Particular prudence should be exercised in the performance of procedures. It is customary for students to become proficient in certain basic procedural skills such as phlebotomy, starting IVs, inserting catheters and nasogastric tubes, doing lumbar punctures and obtaining other bodily fluids and tissues of a relatively simple nature, and minor surgical procedures. Other activities that are customarily conducted by students may include administering skin tests, relatively nontoxic medications by injection, and applying dressings, splints, and casts. Even when conducting these procedures the student should be closely and personally supervised by a licensed physician while gaining proficiency. After proficiency has been obtained, the student must perform these procedures only when they have been ordered by a supervising licensed physician. It is important for students to inform their supervising physician when they have not attained proficiency in a given procedure in order to receive close, personal supervision, even though it is the supervising physician's responsibility to ascertain the student's competence and provide appropriate supervision.

In situations that go beyond the usual and customary functions of medical students, it is imperative that the procedure is conducted under the direct, close, and personal supervision of a licensed physician. This would include such activities as major surgery, reduction of fractures, invasive procedures (e.g., bone marrow biopsies, organ biopsies, central line placement, thoracentesis, endotrachael tube insertion, etc.), and administration of relatively toxic substances (e.g., intravenous narcotics, chemotherapeutic agents, provocative tests, general anesthetics, etc.). Students should refuse to do these procedures without the direct, close, and personal supervision of a licensed physician.

Students should also refuse to obtain informed consent from patients for any procedure. This is the responsibility of the attending physician. Students are encouraged, however, to be present when the attending physician discusses the procedure with the patient as part of the informed consent process, in order to become acquainted with how this extremely important process occurs.

Students must always wear their identification name tags when dealing with patients and staff in the hospital. Students must identify themselves as medical students and sign all notations they make with the identification that they are medical students (e.g., John Smith, BMS III).

The best way to avoid being involved in a malpractice suit is to always act professionally, respect the rights of patients and treat them respectfully and kindly, act prudently, know the limits of your competence, and don't be afraid to say "I don't know," or "I'm not comfortable doing such-and-so." Listen to what staff nurses say and don't do something they don't want you to.

If a student is involved in a medical malpractice action, legal representation is provided by the Office of the University Counsel, provided the student has acted within the guidelines specified above.

Health Insurance

All medical students must pay the annual health service fee that entitles them to use of Health Services during the regular academic year. Coverage during the summer months is optional. Payment of the Health Service fee entitles students to unlimited professional visits to practitioners and consultants in Health Services and seven days bed care with a charge only for food. Also included is a wide range of counseling services through the Counseling and Psychological Consultation Service. Their major emphasis is on the evaluation of problem situations, short-term psychotherapy and immediate crisis intervention.

Waivers of the Health Services fee are available only to students who meet one of the following requirements: students who will not be in geographic residence during an entire semester (e.g., taking away electives, studying abroad, doing research at another institution, etc.), nondegree candidates other than guest students from other institutions, university employees, special students, and faculty/staff spouses with tuition benefits. Requests for Health Service fee waiver should be processed through the Office of Student Affairs no later than June 1st of each year.

Health insurance is not included in the Health Services fee. The University’s Insurance office is responsible for the student health insurance program and works with key areas of the University to maintain a plan design that is appropriate for our students. Students who are not covered under either a parental, spouse, or other private plan are required to participate in the university's group health and accident insurance program. Those students covered under a parent's, spouse's, or other private plan may request a waiver. The waiver process is now web based. Information is sent to students each May with instructions on how to waive out of the plan.

All information regarding student medical treatment and itemization of charges incurred is strictly confidential. Information will only be released by Health Services upon the written consent of the student. This includes itemization of charges for insurance purposes.

Accidents and Injuries While in the Hospital

Students who are involved in an accident or who are injured while in one of the affiliated hospitals as part of their educational program should go to the hospital's Employee Health Service for attention and treatment. This is particularly important in accidents and injuries involving needle sticks or other possible contamination incidents. The Employee Health Service staff is familiar with the testing and/or treatment protocols utilized under these circumstances. Students should also notify the student affairs office as soon after the incident as conveniently possible.

If the accident occurs outside of an affiliated hospital, such as in a doctor's office or community health center, students should obtain the needed health care in the most expeditious manner possible, and then contact the student affairs office. Students may also call University Health Services for advice at (401) 863-3953.

Routine Immunizations

Rhode Island state law requires that all college students, including graduate and medical students be immunized or have documented natural immunity against measles and rubella.

Hepatitis B Immunization

All medical students are required to obtain active immunization against hepatitis B. This is provided at no cost through the University Health Services. This should be obtained before entering year 1 (Doctoring). Students who work as phlebotomists or as research assistants in which they might work with hepatitis B infected blood or blood products should be immunized against hepatitis B. They may obtain this immunization at no cost from their employer.

Students who may have been inoculated with blood or blood products infected with hepatitis B virus while on a clinical clerkship should immediately consult the hospital employee health service so that the blood source can be tested and appropriate passive and active immunization procedures undertaken, as appropriate in the situation.

Acquired Immune Deficiency Syndrome (AIDS)

Throughout history physicians have placed the welfare of the patient above other considerations in the noblest tradition of the Hippocratic Oath. Despite risks to their own health and safety, physicians attended to the afflicted throughout the great scourges of history.

We reaffirm this noble tradition of medicine today, expecting the same devotion to all those who are sick, regardless of cause, by the medical faculty and medical students of Brown University.

Compounding the devastating effects of their disease, those who are afflicted with AIDS have also had to suffer the isolation, rejection, and even loathing, of those in society whose unfounded fears of this disease blind them to the compassion and understanding that is required.

The Warren Alpert Medical School of Brown University fully ascribes to the position of the Council of Deans of the Association of American Medical Colleges that expects that all medical faculty and medical students will provide care to those patients with AIDS with compassion, sensitivity, and understanding, as they would to any and all other patients. Failure to do so would constitute a violation of the professional standards expected of a physician in the Brown medical community.

Likewise, Brown will encourage, support, and assist any student afflicted with AIDS just as sensitively and compassionately as it currently and historically has treated students with other life-threatening illnesses and diseases.

Since AIDS is not transmitted through casual contact, there is no justification for excluding HIV-infected students from participation in university activities or use of university facilities including cafeterias, gymnasiums, and swimming pools. No effort will be made to identify persons with AIDS or those carrying the AIDS virus as part of the university's admissions process or during the students' stay at Brown, except as requested by the individual student.

The Human Immunodeficiency Virus (HIV) is transmitted by blood-to-blood contact. Cases of transmission from an infected health care worker to a patient are very rare.

According to the Rhode Island Department of Health, scrupulous adherence of health care workers to appropriate infection control precautions (called "standard precautions") offers the greatest possible protection to health care workers and to patients alike. All students, then, are expected to follow routine recommendations for standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments.

The Rhode Island Department of Health recommends that all health care workers who are at risk for HIV infection because of occupational exposure or personal behaviors be tested voluntarily in order to know their status. This is not a requirement, but the Warren Alpert Medical School of Brown University also urges voluntary testing by medical students.

Students who are infected by HIV or have HIV-related illness may remain actively enrolled in the university and medical school and participate in all medical courses and clerkships so long as they are capable of doing so. Students who are HIV-positive may participate in invasive procedures in the same fashion as all other medical students and with the same scrupulous adherence to standard precautions as noted above. All students, regardless of their HIV status, who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment and devices used in performing procedures with an identifiable risk until the condition resolves.

Students who are HIV positive should voluntarily report their HIV status to their primary care physician who would then report the infected student to the state epidemiologist at the Rhode Island Department of Health; or the student could contact the state epidemiologist directly. This would be reported to an expert panel constituted by the Rhode Island Department of Health for review of any health care worker or health care worker-in-training who is HIV positive and is involved in direct patient contact. The review procedure is voluntary, confidential, and available to any health care worker who is HIV or hepatitis B (HBV) infected. The review of any infected health care worker will be based on the premise that infection with HIV or HBV alone does not justify limiting the worker's professional duties, according to a draft set of policies developed by the Rhode Island Department of Health.

The panel will focus on the practitioner's compliance with standard precautions, infection control practices, the nature of the work performed and the techniques used by the individual. The panel may recommend adjustments of practice, restrictions, or other appropriate measures. Whether an infected health care worker will be required to notify patients in order to perform certain procedures will be judged on a case-by-case basis. The panel may recommend that the health care worker return for periodic review if his or her medical condition warrants such action. If the panel finds that the worker is not complying with recommendations, it may refer the case to the appropriate regulatory body, such as the Dean's office of the medical school and the Board of Medical Licensure and Discipline, for further action. In cases of noncompliance, the Associate Dean for Medical Education will review the case and take appropriate actions which may include dismissal of the student from the medical school. The student may appeal the decision as outlined in Section X—Appeal and Grievance Procedures. HIV-related information shall not be shared except as allowed by Rhode Island General Statutes (23-6-17).

Students who know or believe they are carrying the AIDS virus, or who believe they are developing symptoms of the disease, should seek the university's support and assistance through the Director of Student Health Services, Dr. Edward Wheeler (863-3953), the Director of Psychological Services, Dr. Belinda Johnson, (863-3476), or the Associate Dean for Medical Education, Dr. Philip Gruppuso, (863-1618). Students should be assured that their contacts with university officers listed above will be governed rigorously by the traditional policies and practices of privacy and confidentiality associated with the sharing of personal information in the framework of the university's health and counseling functions and services.

Additional Resources At Brown

Dean of Chemical Dependency, Kathleen McSharry (401) 863-2536
The Dean of Chemical Dependency provides comprehensive academic and social support in non-clinical settings for Brown students, faculty and staff affected by alcohol or drug abuse. You can contact her by email at Kathleen_McSharry@brown.edu.

Health Education (401) 863-2794
Confidential appointments for drug or alcohol concerns for Brown students. Located on the third floor of Health Services at 13 Brown Street; Providence, RI 02912.

Psychological Services (401) 863-3476
Confidential appointments for alcohol or drug concerns and for adult children of alcoholics. Located on the fifth floor of J. Walter Wilson.