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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Patient Safety: Required Learning for Physicians

Posted By Administration, Monday, April 13, 2015

Physicians should aspire to be leaders in patient safety knowledge and practice.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Some of you may know about the recent firestorm over the American Board of Internal Medicine’s Maintenance of Certification (MOC) program. For those of you who don’t, here is a bit of background.


Prior to 2014, physicians who were board certified by ABIM could maintain that certification by successfully completing an exam once every 10 years. In January 2014, recognizing the need for a more continuous learning pattern, ABIM introduced an updated MOC program that would have required physicians to be assessed every two years in areas such as medical knowledge, practice assessment, and patient safety. (In full disclosure, the American Board of Medical Specialties [ABMS], of which ABIM is a member, made the NPSF Online Patient Safety Curriculum available to diplomates of their Member Boards to bring patient safety education to physicians participating in the ABMS MOC®.)


For those of us working in the patient safety field, such changes sounded sensible and warranted. In large numbers, however, physicians disagreed, even starting petitions against the new MOC requirements.


This issue is complicated, largely because physicians already face rigorous requirements. For example, continuing medical education credits are required to maintain state licensure, and health care organizations require physicians (and all staff) to complete mandatory education modules every year. Moreover, most physicians work in stressful environments where they battle the clock and burnout every day, so any time away from their practice is a difficult trade-off.


In February of this year, bowing to critics, ABIM announced it was “suspending the Practice Assessment, Patient Voice, and Patient Safety requirements” for MOC. Since then, ABIM has embarked on a “listening” campaign, and one of the ways they are collecting the opinions of their diplomates and others is through a website, Assessment 2020. I recently submitted the following comments on behalf of NPSF:


To the ABIM Assessment 2020 Team,


I write on behalf of the National Patient Safety Foundation to support the call for ongoing patient safety education for physicians. We understand the current, vocal criticism of the ABIM Maintenance of Certification requirements. However, we remain hopeful that the re-evaluation currently under review will result in meaningful standards for incorporating safety science and practice into the core medical knowledge that physicians are expected to demonstrate in order to achieve board certification.


Physicians commit to lifelong learning, and by its very definition, lifelong learning needs to incorporate new knowledge. No one would deny vast changes in medicine, clinical practice, and in our knowledge of how to improve quality and safety that have taken place over the past 20 years or so. For example:

  • The Institute of Medicine’s report on medical error, estimating that 98,000 people die preventable deaths each year
  • Research showing that patients receive the correct care only 55% of the time
  • Systems approaches to the design of care (e.g. human factors design, checklists)
  • The growing use of electronic health records to improve care

Today, being a good physician requires a lot more than being smart and technically skilled. Those of us who work in patient safety know how much the field is changing as new research is conducted and new practices adopted. In a 2010 report, the NPSF Lucian Leape Institute called for medical schools to address patient safety as a science encompassing key areas such as error causation and mitigation, human factors concepts, systems theory and analysis, and error disclosure and apology.


The American Association of Medical Colleges and the Accreditation Council for Graduate Medical Education (ACGME) have seen substantive changes in curricula over the years. The authors of a 2010 paper looking at medical education in the US and Canada found that “medical student education has undergone and continues to undergo substantive change…and has continued to evolve during the past decade.” Among the changes were the introduction of content addressing teamwork, patient safety, and the use of simulation.


Similarly, ACGME has developed the Clinical Learning Environment Review (CLER) program, which specifically addresses patient safety as one of its areas of focus. The goal of the CLER program, according to an ACGME brochure is “to improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care.”


We strongly believe that ongoing education about patient safety is as important for established physicians as it is for physicians in training. In fact, established physicians should aspire to be leaders in patient safety knowledge and practice.


We believe that revamping board certification standards to incorporate the science of patient safety is an exercise that is long overdue. However, it is critical that patient safety is not incorporated as a rote set of requirements; instead patient safety must be incorporated in a way that is meaningful, practical, and useful to practicing physicians so they can improve the safety of practice and see the value.


We hope that ABIM and its diplomates will be able to move beyond the current acrimony and create plans for ongoing patient safety education that will ultimately benefit the patients our health system serves.


I have had the privilege of working alongside many skilled, caring, dedicated physicians who understand safety science and are helping to ensure that we deliver the safest care. We need to determine the best path forward to ensure that all physicians (trainees and established) have the skills to improve patient safety. I hope you, too, will visit the Assessment 2020 website and make your voice heard.


Do you believe that established physicians should be required to receive ongoing education in patient safety? Comment on this post below.


Tags:  board certification  education  physicians 

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