Healthcare delivery continues to be unsafe and will probably remain that way for some time unless medical schools make substantial improvements in how they teach patient safety, according to
Unmet Needs: Teaching Physicians to Provide Safe Patient Care, a new report issued by the National Patient Safety Foundation's Lucian Leape Institute.
The report charges that medical schools do an inadequate job of developing student understanding of concepts such as systems thinking, problem analysis and team collaboration that will help them become architects of patient-safety and quality improvement efforts.
Information technology does not get mentioned much in the report, but its importance is noted.
“They must realize the value of information technology in helping them deliver up-to-date, evidence-based care, and be able to use information technology tools to find pertinent literature, review guidelines, calculate patient risk factors, and apply clinical pathways,” the report states in a section that talks about doctors being lifelong learners.
At a news conference, the institute's namesake, Lucian Leape, the Harvard School of Public Health adjunct professor of health policy, added that “too often, the students are being educated in a toxic environment” where about 5% of physicians mistreat students and others and are allowed to “poison the well” and perpetuate a culture that hinders the collaboration that is needed for patient-safety learning to occur.
The report lists steps schools can take to mitigate these characteristics in future doctors by promoting attributes such as mindfulness, compassion, empathy and collaboration; screening and identifying school applicants with “sociopathic tendencies”; and monitoring students and intervening early if there are “displays of unprofessional or maladaptive behavior.”
John Prescott, M.D., the chief academic officer with the Association of American Medical Colleges, also spoke at the conference and said that, “Educating new doctors about patient safety is a top priority” of his organization and that many of the report's recommendations have already been implemented.
The report's authors agree somewhat and list 23 medical schools where, in fact, implementation has begun.
“One would hope that others will follow,” the report states. “But hope is far from sufficient when the stakes are this high. Some ongoing credible mechanism is needed to monitor school progress toward, and, later, maintenance of achievement of, the objectives set forth herein.”
Patient-safety advocate Rosemary Gibson, author of the books
Wall of Silence and
The Treatment Trap, calls the report “right on target,” and also has praise for the patient-safety focus for one particular school included among those listed by the report as already beginning the implementation of its recommendations: the University of Illinois at Chicago College of Medicine, which is also the nation's largest medical school.
In addition to its medical school program, Gibson notes how the residency program at UIC encourages patient-safety discussions with requirements for reporting adverse events that they observe. “That approach is very rare,” she says. “I think the purpose of the Lucian Leape report is to make those types of active steps the norm rather than the exception.”
Gibson also says patient-safety concepts need to be included in licensing exams, and she echoes the report's call for instruction that prepares doctors in training to be future patient-safety leaders saying that medical students not only need to be trained to provide safe care, but also they need to know how to design safe systems.
“We have to raise the stakes if the recommendations are going to become a reality,” Gibson says.
David Mayer, M.D., associate dean for curriculum and co-executive director of the University of Illinois at Chicago College of Medicine's Institute for Patient Safety Excellence, says the biggest need is for faculty development.
“We never had had training in this in med school,” Mayer says, and adds that the new report will help “raise the urgency” of the issue.
Mayer and his co-executive director Tim McDonald, M.D., have been sponsoring roundtable discussions in Telluride, Colo., for five years where patient-safety education issues are hashed over and a consensus is reached. The sixth roundtable is scheduled for July 12-16.
Mayer and McDonald formed an organization called Transparent Health, which helped produce an award-winning instructional film. “The Faces of Medical Error … From Tears to Transparency: The Story of Lewis Blackman” tells the story of how the 15-year-old son of patient-safety advocate Helen Haskell died in 2000 after elective surgery at the Medical University of South Carolina Medical Center in Charleston, where the staff dismissed her concerns.
Mayer says that Haskell speaks to his fourth-year students about the experience. “There really isn't a dry eye in the house after that,” he says, adding that Haskell has also helped develop the school's full-disclosure program. “Instead of her telling it to 20 students at a time, we thought about putting it in a film, and it's gotten tremendous acceptance.”
The film received a $30,000 U.S. Education Department grant to distribute copies to every medical school in the country. Mayer says scripting is about to begin on three more films and the goal is to produce 10 to 12 altogether.
At UIC, patient safety is introduced from the get-go with the goal being to raise awareness, which is then continued through all four years of the curriculum.
Patient-safety course work includes components of information technology, Mayer says, with instruction on computerized physician order entry, electronic health records, and how electronic medical literature searches can advance evidence-based medicine.
Mayer expresses concern, however, that the use of IT may “improve things one way, but then take us to a new class of errors,” and says more IT patient-safety research needs to be done.
In describing the residency error-reporting program Gibson mentioned, Mayer says residents are required to file at least one report a month on an adverse event, “near miss,” or case of harm that resulted from how care was delivered and analyze why it occurred.
Joint Commission President Emeritus Dennis O'Leary, M.D., also spoke at the conference and said no student should graduate without learning how to do a root-cause analysis of a medical error. He also noted how patient-safety “misadventures” are the eighth-leading cause of death in the U.S. and one of the country's “most solvable public health problems.”
The report states that “a strong case can be made that patient safety is a major public health issue and that patient-safety education and training should be made a high priority” for government funding.
The report concludes by noting that, while progress has been made, “the bad news is that most medical schools are lagging well behind where they should be in embracing patient-safety education and training.”
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