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Medical schools need a new approach, says David B. Nash, MD, of Thomas Jefferson University in Pennsylvania. "This is not even on their radar -- that quality and safety should be part of the curriculum." Photo by Ted Grudzinski / AMA

Safety on the syllabus: Patient safety becoming part of medical education

Training in quality improvement is also being added. But some physician leaders say it's happening too slowly.

By Kevin B. O’Reilly — Posted April 19, 2010

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Robert O. Bonow, MD, graduated from medical school in 1973. Caitlin Schaninger will graduate in June. Despite training in different generations, they see similar gaps in quality and safety education.

Much has changed in medical education in the nearly four decades that separate their medical school experiences.

What has remained largely unchanged is the lack of education most medical school graduates receive in the science and skills of quality improvement and patient safety -- how to deliver the right care to the right patient at the right time, and how to prevent a patient from being harmed.

Dr. Bonow is chief of the cardiology division at Northwestern Memorial Hospital in Chicago. He directs the Center for Cardiovascular Quality and Outcomes at Northwestern University's Feinberg School of Medicine and has served on several guideline and measure development bodies. Yet even with all his experience and expertise, Dr. Bonow felt compelled to pursue a master's degree in health care quality and patient safety.

"There's a knowledge gap that I think I personally have," he said. "I've been involved with a lot of quality initiatives, but have never had necessarily formal training in this stuff. I've learned it by osmosis for a decade and a half."

Northwestern University's program, launched in 2006, was believed to be the first of its kind. At least four other universities now offer similar master's degree programs aimed at addressing this training gap and helping to educate the faculty who will teach medical students and residents skills such as how to analyze errors and how to measure quality performance. Many medical schools and teaching hospitals are working to integrate quality and safety into their training, but critics say the pace of change is too slow and too inconsistent.

"Unmet needs"

Schaninger is among medical students across the country looking outside the formal curriculum of medical school for quality and safety training. As a student at the University of Chicago Pritzker School of Medicine she helped found a campus chapter of the Institute for Health Improvement's Open School for Health Professions.

The Open School offers free online quality and safety training to medical, nursing and other health professions students, and boasts chapters on 204 campuses in 41 U.S. states and 26 other countries.

"The education I experienced over the last four years did not include a lot of mandatory coursework on quality improvement or patient safety," Schaninger said. "I can't think of any dedicated time so far where everybody has been exposed to these topics. That's something we need to work on as an educational community, not just at Pritzker, but in all medical schools."

Schaninger has plenty of company in her assessment.

"Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care," said a report released in March by the National Patient Safety Foundation's Lucian Leape Institute. The NPSF invited a group of 40 medical educators and experts in quality and patient safety to produce the 38-page document.

Two-thirds of the 126 medical schools surveyed by the Liaison Committee on Medical Education in 2007-08 reported that patient safety was included in one or more required courses, but advocates of more safety and quality training said the topics get short shrift.

Only 25% of medical schools have a well-designed patient safety curriculum, according to a survey of 83 U.S. and Canadian internal medicine clerkship directors reported in the December 2009 Academic Medicine.

The NPSF report recommended that medical schools and teaching hospitals emphasize patient safety, professionalism, teamwork and transparency, and offer incentives for faculty to learn how to diagnose patient safety problems, improve care processes and deliver safe care. Schools also should teach patient safety as a science, showing how systems can contribute to human error and how they can be redesigned to prevent harm.

Students should begin learning these skills in medical school and develop them during residency training, said the report, titled "Unmet Needs: Teaching Physicians to Provide Safe Patient Care." The LCME and the Accreditation Council for Graduate Medical Education should expand their standards to achieve these changes, the report said.

"Up to one in 10 people in hospitals experience preventable adverse events," said Dennis S. O'Leary, MD, who led the expert panel that prepared the report. "There are a number of reasons why this still happens, but none is more striking than the inadequate preparation of health care professionals, especially physicians, to anticipate, diagnose, analyze and resolve patient safety problems."

Dr. O'Leary, president emeritus of the Joint Commission, said the hierarchical culture of medical schools and teaching hospitals undermines the ability to collaborate and prevent mistakes. Most faculty members have little training in patient safety and do not know how to best teach the material to their students, he added.

"There is a lack of interdisciplinary skills and teaming skills fundamental to making care safe today and in the future," Dr. O'Leary said. "Schools in most cases are producing square pegs for the health care delivery system's round holes."

Neither the LCME nor ACGME responded directly to the NPSF report. In 1999, the ACGME adopted "practice-based learning and improvement" and "systems-based practice" -- which essentially equate to quality improvement and patient safety -- as two of six core competencies that medical residents should master. Experts said residency programs are farther ahead in teaching quality and safety but still have room to improve.

In June, the Assn. of American Medical Colleges will hold its second annual "Integrating Quality" meeting in Chicago to help medical educators learn how to incorporate quality and safety into their curricula.

Representatives from 43 schools attended last year, and more are expected this year. The AAMC meeting presents a big step forward and is direly needed, said David B. Nash, MD, who served on the NPSF panel and is founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Pennsylvania.

"Quality and safety is not baked right into the curriculum," Dr. Nash said. "That's the stark reality. On average, the typical medical student gets one day in four years of true didactic training from an expert in quality and safety."

It is no longer enough to teach students and residents the technical skills of medicine, said David Mayer, MD, associate dean for curriculum at the University of Illinois College of Medicine at Chicago and curriculum director for UIC's master's program in patient safety leadership.

"Health care used to be simple, safe and ineffective," said Dr. Mayer, who served on the NPSF panel. "Today, it is complex, effective and potentially dangerous. We have to change the way we teach the next generation of providers. Other high-reliability organizations start from day one with safety training. We need to do that."

Teaching medical students about patient safety is a kind of prevention strategy, said Donna Woods, PhD, co-director of Northwestern's master's program in quality and safety.

"The health care system is like a bunch of marbles strewn across a set of stairs," Woods said. "Medical education has been excellent at teaching people to navigate the stairs, but there are still a lot of slips. A much better strategy is to teach people where those marbles are and how to remove them in order to enable a safe trajectory across medical care."

Training the trainers

The biggest challenge, experts agreed, is helping medical educators catch up with the fast-developing fields of quality and safety.

"We need to train a new generation of trainers," said Dr. Nash, whose Jefferson School of Population Health also offers a quality and safety master's degree. "We need a new cadre of leaders with content experience in this field. ... There is a dearth of faculty qualified to teach these skills, and this leads to inferior role models."

There are other impediments to teaching quality and safety. One is finding the time to squeeze these topics into an already packed four-year medical school schedule.

"It's the medical barge theory of medical education," Dr. Nash said. "There's so much stuff on there that it's going to sink. But we have, you know, 10 lectures on the myocardial cell. We could replace that with six lectures that will do the job just fine and add a few more lectures on quality and safety."

Another puzzle is how to start teaching quality and safety before medical students have clinical experience.

"The basic science of patient safety can be tough, and it can be a little hard to apply in the medical school realm," said Wendy Madigosky, MD, MPH, director of the Foundations of Doctoring Curriculum at the University of Colorado Denver School of Medicine. "It can feel a little abstract, but when you bring in examples of errors and harm to patients that's happened because of that, and talk about the importance of communication and system design, it can become applicable, and students can recognize that."

To the nearly-graduated Schaninger, training in quality and safety should not be optional.

"Every doctor needs to develop these skills," she said. "In order for us to be effective physicians, we need to have some knowledge about the systems in which we work."

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ADDITIONAL INFORMATION

Boosting quality instruction

Several medical schools and teaching hospitals have improved quality and safety training for students and residents, says a report from the National Patient Safety Foundation's Lucian Leape Institute.

Meanwhile, five universities and two other bodies offer master's degrees or certificates in health care quality and safety.

Sources: "Environmental Analysis: Current Graduate Training in Healthcare Quality and Safety," Jefferson School of Population Health, December 2009; "Unmet Needs: Teaching Physicians to Provide Safe Patient Care," Lucian Leape Institute Roundtable on Reforming Medical Education, National Patient Safety Foundation, March 10 (link)

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Learning how errors happen

Medical educators often use a case-based approach on patient safety. Here is a sample lesson plan in which trainees are asked to do a root cause analysis of a real-life, fatal medication overdose given an infant. The chain of errors began when the resident writing the order was distracted by a phone call. Students are asked to answer these questions:

What happened? What were the gaps in quality of care? Did near misses, errors without harm and/or adverse events occur in the case? Hint: Make a chronological listing or flow diagram of events.

Why did it happen? What are the contributing factors? What are the active and latent factors?

What would prevent it from happening again? What are prevention strategies?

Trainees are then asked to describe how the following systemic factors may have contributed to the error:

Equipment: Design, availability and maintenance.

Environment: Staffing levels and skills, workload and shift patterns, administrative and managerial support, physical plant.

Teamwork: Verbal and written communication, supervision and assistance.

Staff: Knowledge and skills/training, competence, physical and mental health.

Institutional context: Economic and regulatory situation, availability and use of protocols, availability and accuracy of tests.

Organization/management: Financial resources and constraints, organizational structure, policy standards and goals, safety culture and priorities.

Patient: Complexity and seriousness of condition, language and communication, personality and social factors. Each group then presents its top three contributing factors, top three prevention strategies and its explanation of how the root cause analysis could improve safety in practice.

Source: "Modified Root Cause Analysis (RCA): Improving Patient Safety/Quality of Care," University of Missouri-Columbia School of Medicine, 2004

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External links

"Patient Safety Education at U.S. and Canadian Medical Schools: Results From the 2006 Clerkship Directors in Internal Medicine Survey," abstract, Academic Medicine, December 2009 (link)

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