Today’s new physicians are unable to improve patient safety

It has been 10 years since the landmark Institute of Medicine report “To Err is Human” uncovered disturbing deficiencies in the quality of our nation’s medical care.

Progress in correcting these deficiencies remains frustratingly slow, and it has become clear that achieving the quality and safety improvements we seek will require us to examine our approach to medical education.

Although today’s newly minted physicians are well prepared in the science of medicine and practiced in the necessary patient care skills, too few are equipped with the knowledge and training necessary to improve the quality and safety of patient care.

If we’ve learned anything from our counterparts in the aviation industry about what it takes to reduce human error and improve safety, we can no longer consider quality and safety as “electives” in the medical school curriculum.

To fill the gap, modern medical education must integrate into the curricula processes and programs that foster the development of skills such as:

* Working effectively in teams
* Understanding work as a process
* Understanding how to collect, analyze, and display data on the outcomes of care
* Working collaboratively with other health professional managers, patients, and their families
* Acquiring the ability and willingness to acknowledge and learn from mistakes

Late this spring, the Lucian Leape Institute at the National Patient Safety Foundation published an interesting report entitled “Unmet Needs: Teaching Physicians to Provide Safe Care.”

The authors’ recommendations and proposed strategies for leveraging necessary changes include:

* Patient safety training that is treated as a basic science spanning all of medical education
* Commitments from medical school deans and teaching hospital CEOs to create learning cultures that emphasize patient safety, teamwork, leadership skills, communication, and performance improvement — and, importantly, providing the resources and incentives necessary to support these goals
* A shift in philosophy that recognizes the importance of training in the development of desired behaviors and skills — e.g., problem solving — as well as transmitting facts and information
* Adopting zero-tolerance policies for disrespectful, abusive, intimidating, and unethical behaviors by physicians
* Support from the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties (ABMS) for making patient safety training an educational priority and for developing/expanding related requirements
* Developing a system to monitor and publicly report compliance with new requirements
* Implementing financial (including state and federal funds), academic, and other incentives to leverage desired changes in medical education

Although I applaud the thoroughness of the report, I can’t help but think about the inevitable barriers to implementing these very basic changes in the culture of our medical schools and teaching hospitals.

How will buy-in and coordination be achieved among all of the important stakeholders, particularly the LCME, ACGME, and ABMS? Can such basic changes to medical curricula be mandated from “outside”? If so, does this imply that accrediting organizations and governments would generate and enforce reforms?

Money also becomes a problem. Many medical schools have experienced financial setbacks along with the rest of the country. Creating an unfunded mandate at this time would place a huge burden on them and would likely generate political opposition to reforms.

Nor do we have sufficient people equipped to teach quality and safety improvement. Many of the physicians working in these fields have learned on the job — and, in too many cases, on their own time.

Further, in order for physicians to achieve success on multidisciplinary teams in the workplace, they must be trained — together with those teams — in the context of a culture that supports quality and safety improvement (e.g., measurement, teamwork, patient-centered care) and that fosters structured problem-solving and respectful questioning.

Perhaps the most challenging aspect of implementing these reforms is that, once trained, new physicians need workplaces with cultures that support these values. Training in quality and safety improvement must transcend the medical school setting. So, practicing physicians, nurses, and other healthcare professionals must also receive training in the necessary skills in order to transform the culture in all healthcare settings.

Although there is no shortage of barriers to implementation, there are a number of things that medical schools and training hospitals can do to facilitate the integration of quality and safety into medical education.

First, universities and medical schools can recognize and appropriately value the work of their professionals in quality and safety improvement. This might take the form of time allocation, remuneration, and/or consideration for seniority/tenure for professionals who specialize in these areas.

Next, all stakeholders should consider what types of incentives, economic and otherwise, will encourage physicians and other healthcare professionals to work together in teams to improve healthcare quality and safety.

Finally, academic medical centers and teaching hospitals can develop strong curricula and educational programs for physicians and other health professionals. In addition to didactic sessions, these might include the use of simulation, case studies, and hands-on experience in quality/safety improvement.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit MedPageToday.com for more medical education news.

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  • http://www.abimfoundation.org Amy Cunningham

    Great post! Readers may be interested to know that last week’s 2010 ABIM Foundation Forum, “Medical Education and Training: Meeting the Needs of Patients and Society,” featured a number of innovations related to improving quality and patient safety, including patient safety work by David Mayer at the University of Illinois-Chicago and Noelle Sinex of Indiana University. You can read more about the great work of these and other innovators here: http://www.abimfoundation.org/Events/2010%20Annual%20Forum/Innovators.aspx

  • Marc Gorayeb, MD

    Honestly, the only thing I got out of this post are the bullet points:
    * Working effectively in teams
    * Understanding work as a process
    * Understanding how to collect, analyze, and display data on the outcomes of care
    * Working collaboratively with other health professional managers, patients, and their families
    * Acquiring the ability and willingness to acknowledge and learn from mistakes

    I don’t know about anyone else, but when I trained in medical school and then residency thirty years ago, all of these were intrinsic to the educational process. Every one of them. Unless you have something different or more specific to say, I see no need to add another layer of bureaucracy to the medical education process.

    And regarding the idea of owning up to mistakes: it was an essential part of my education, but the discussions were among colleagues and superiors only. It should stay that way unless and until there is solid liability reform.

  • bev M.D.

    The paucity of comments on this post is discouraging but not surprising; I have seen a similar lack of reaction every time this subject is raised. One free (to medical students) and very useful, pre-packaged learning tool on the issues of quality improvement and patient safety, are the Open Learning courses given by the Institute for Healthcare Improvement, formerly headed by the current CMS administrator Don Berwick. These are available online at ihi.org. I took them all before they started charging non-students for them, and found them a down-to-earth, practical guide for implementing these principles. They could easily be made required courses for 1st and 2nd year medical students, without the medical school lifting a finger or spending a dollar.

    Dr. Gorayeb, before you dismiss the bullet points cited, I suggest you have a superficial understanding of them. Go take the courses and then tell me you didn’t learn anything.

    • Marc Gorayeb, MD

      It’s not up to me to “go take the courses.” It’s up to you to convince me that they are worth taking. You haven’t done that.

  • http://www.meyersmedmal.com Jivanmeyers

    “but the discussions were among colleagues and superiors only. It should stay that way unless and until there is solid liability reform.”
    The discussions have certainly not been candid or searching. If they were, we would not be still confronting the serious patient safety problem the author of this article makes reference to.

    Decades before lawsuits became an effective means of discovering the cause needless injury and assessing responsibility for such injuries, physicians and other health-care personnel turned away from their patients. Catastrophes that occurred at night were explained to surprised and grieving family’s by interns who were trained to say, “we did everything we could.”

    The mere occurrence of a medical catastrophe did not result in a soul searching investigation to learn the truth. The passage of decades has not changed this reality. Liability concerns are simply the current excuse for healthcare providers to fail to carry out their oath and duty to see that harm is not done to patients.

    • Marc Gorayeb, MD

      This author has it exactly backwards. For example, a long time ago, we had pathology grand rounds, and no one was immune to the pathologist’s cold analysis. Lawyers have taken care of that sunlit disinfectant.

      • http://www.meyersmedmal.com Jivanmeyers

        Marc,Trial lawyers did not prevent such rounds from continuing. There are morbidity and mortality meetings today and in Pa such proceedings are immune from discovery. The failure lies within the medical culture and prevents shining a light on the cause of preventable injuries and deaths with a view to improving future care.

  • Dr. Wes

    This post sounds surprisingly like an ihi whitepaper to me. The safety industry has rewarded Dhttp://www.slashgear.com/handy-sana-mobile-phone-offers-heart-patients-ecg-capability-1697788/r. Berwicke’s IHI a cool 1.7M in his retirement fund in only six years. So somehow this need for safety appears more aimed at filling the corporate trough than helping patients. As do the preceding corporate comments. Same game folks, follow the money.

    • Chris

      Seriously, offer constructive words or take the negativity elsewhere, it’s stuff like this that makes it harder to look forward to joining your profession in a couple years.

      I think the most important thing is for the schools to buy in and make it a part of the learning environment. Along with two other med students I started an IHI chapter at our medical school, but asking medical students to take safety and quality courses as an “extra” on top of our other requirements is asking for more of the same: new doctors who don’t do any of the things in the bullet points. If safety and quality were core competencies for the USMLE step 1 I promise you we’ll learn a lot about those bullet points.

  • bev M.D.

    Yeah, seriously; it’s time to get off Berwick’s back. The IHI courses were completely free until last May, and they still do not charge medical students for them. Berwick left his oh-so-lucrative job to take a thankless job at lousy pay, so you jealous, sour grapes, demoralized docs are just discouraging the med students like Chris. One of the points in Leape’s report is that the faculty are deficient in this knowledge so the students/residents have to learn the stuff themselves. Physician, heal thyself – and stop bitching while you’re at it.