Unmet Needs: Teaching Physicians to Provide Safe Patient Care
Health care delivery continues to be unsafe despite major patient safety improvement efforts over the past decade. The Roundtable concluded that substantive improvements in patient safety will be difficult to achieve without major medical education reform at the medical school and residency training program levels. Medical schools must not only assure that future physicians have the requisite knowledge, skills, behaviors, and attitudes to practice competently, but also are prepared to play active roles in identifying and resolving patient safety problems. These competencies should become fully developed during the residency training period.
Medical schools today focus principally on providing students with the knowledge and skills they need for the technical practice of medicine, but often pay inadequate attention to the shaping of student skills, attitudes, and behaviors that will permit them to function safely and as architects of patient safety improvement in the future. Specifically, 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, to wit: systems thinking, problem analysis, application of human factors science, communication skills, patient-centered care, teaming concepts and skills, and dealing with feelings of doubt, fear, and uncertainty with respect to medical errors.
In addition, medical students all too often suffer demeaning experiences at the hands of faculty and residents, a phenomenon that appears to reflect serious shortcomings in the medical school and teaching hospital cultures. Behaviors like these that are disruptive to professional relationships have adverse effects upon students, residents, nurses, colleagues, and even patients. Students frequently tend to emulate these behaviors as they become residents and practicing clinicians, which perpetuates work environments and cultures that are antithetical to the delivery of safe, patient-centered care.
The LLI Expert Roundtable on Medical Education Reform makes the recommendations set forth below.
Setting the Right Organization Context
Health care has undergone a major sea change over the past two decades. As these
changes and the complexities of health care have escalated, patient safety problems have become increasingly evident, and medical education and training institutions have found themselves struggling to keep up with the need to assure that student physicians are properly equipped with the skills, attitudes, knowledge, and behaviors (i.e., patient safety competencies) that will make them capable of becoming part of the patient safety solution. This need constitutes a major challenge to medical schools and teaching hospitals, and particularly their leaders and faculty, to develop their own competencies to guide their charges in learning to manage a new “disease state.”
Medical school and teaching hospital leaders should place the highest priority on creating learning cultures that emphasize patient safety, model professionalism, enhance collaborative behavior, encourage transparency, and value the individual learner.
Medical school deans and teaching hospital CEOs should launch a broad effort to emphasize and promote the development and display of interpersonal skills, leadership, teamwork, and collaboration among faculty and staff.
As part of continuing education and ongoing performance improvement, medical school deans and teaching hospital CEOs should provide incentives and make available necessary resources to support the enhancement of faculty capabilities for teaching students how to diagnose patient safety problems, improve patient care processes, and deliver safe care.
Recommendation 4. The selection process for admission to medical school should place greater emphasis on selecting for attributes that reflect the concepts of professionalism and an orientation to patient safety.
Strategies for Teaching Patient Safety
Medical schools have done an excellent job of providing students with the knowledge and related skills they will need for the technical practice of medicine. However, the new and still evolving care environment requires more than this with respect to patient safety. The elemental nature of patient safety education has profound implications for future curricular design. The teaching of patient safety needs to begin on Day 1 of medical school and be extended throughout the four-year medical school experience and beyond by becoming embedded in all teaching activities. It is equally important to understand that patient safety education is much more than the absorption of concepts and knowledge and requires particular attention to the acquisition of desired skills, attitudes, and behaviors. This is because the long-term intent is that these skills, attitudes, and behaviors become an integral of the physician’s professional way of life.
Medical schools should conceptualize and treat patient safety as a science that encompasses knowledge of error causation and mitigation, human factors concepts, safety improvement science, systems theory and analysis, system design and re-design, teaming, and error disclosure and apology.
The medical school experience should emphasize the shaping of desired skills, attitudes and behaviors in medical students that include, but are not limited to, the Institute of Medicine and Accreditation Council for Graduate Medical Education (ACGME )/American Board of Medical Specialties (ABMS ) core competencies—such as professionalism, interpersonal skills and communication, provision of patient-centered care, and working in interdisciplinary teams.
Medical schools, teaching hospitals, and residency training programs should ensure a coherent, continuing, and flexible educational experience that spans the four years of undergraduate medical education, residency and fellowship training, and life-long continuing education.
There is today apparent growing interest among medical school faculty and students in understanding and teaching patient safety. Many of the current efforts involve limited courses, but some schools are pursuing much more aggressive and elaborate patient safety education and training initiatives. However, the progress is uneven at best and still non-existent in some schools, while the urgency to train physicians to become patient safety problem-solvers and leaders is great. This requires attention to formulating strategies that are likely to leverage acceleration of the desired changes set forth in this paper. Among the potential strategies, modernization of the Liaison Committee on Medical Education (LCME) and ACGME standards appears to offer the greatest opportunity to create universal substantive positive change. In addition, public monitoring of school efforts in making these changes is another potentially strong lever. Other opportunities exist as well.
The LCME should modify its accreditation standards to articulate expectations for the creation of learning cultures having the characteristics described in Recommendation 1 above; to establish patient safety education—having the characteristics described herein—as a curricular requirement; and to define specific terminal competencies for graduating medical students.
The ACGME should expand its Common Program Requirements to articulate expectations for the creation of learning cultures having the characteristics described in Recommendation 1; to emphasize the importance of patient safety-related behavioral traits in residency program faculty; and to set forth expected basic faculty patient safety competencies.
The LCME and the ACGME should direct particular attention to the adequacy of the patient safety-related preparation of graduating medical students for entry into residency training.
A survey of medical schools should be developed to evaluate school educational priorities for patient safety, the creation of school and teaching hospital cultures that support patient safety, and school effectiveness in shaping desired student skills, attitudes, and behaviors.
Financial, academic, and other incentives should be utilized to leverage desired changes in medical schools and teaching hospitals that will improve medical education and make it more relevant to the real world of patient care.