Thursday, April 09, 2009

Future leaders

I joined a group of Harvard undergraduates today at their class, "The Quality of Health Care in America," co-taught by several medical luminaries -- David Blumenthal, Don Berwick, and Warner Slack and Howard Hiatt (shown here). A great conversation ensued about transparency and process improvement. There were several pre-med students in the class. Perhaps this course will give them the impetus to focus on the quality of the health care delivery system when they become doctors.


Anonymous said...

So, is there an analogous class in the Harvard medical school and if not, why on earth not? It would seem blindingly obvious that medical students should be mandated to learn this information about their own career field.

nonlocal MD

Paul Levy said...

Indeed, an excellent point. That was one of the topics we discussed. I had to report today that when I raised this issue at HMS, I was unable to get any traction from people at the school.

Read the comments here -- -- to see how excited and interested residents were when we offered this kind of topic at our hospital recently. This generation of students and doctors is hungry to learn this stuff!

Anonymous said...

Aha; I had not read that post. Being one of the late converts myself, I recognized my own "lightbulb moment" in the comments. Perhaps our younger colleagues have something to teach their elders about willingness to learn new things, and they could advocate through their Residents' Association or med school alumni associations for its inclusion in medical school curricula.

nonlocal MD

Julio said...

Excellent article by Jerome Groopman and Pamela Hartzband in The Wall Street Journal: Why "Quality" Care Is Dangerous.

It would be interesting to know your opinion.

Julio Mayol
Madrid, Spain

Maureen Bisognano said...

Thanks for inspiring these young students and I'd connect them with IHI's Open School ( so they can learn more about improvement and safety...all free.
Maureen Bisognano

Paul Levy said...

... and they can also follow it on Twitter @IHIOpenSchool.

Eva said...

First year students at HMS all take a course called Intro to Social Medicine. I know for a fact there is at least one lecture (led by Dr. Don Berwick) about patient safety and quality improvement.

As an alum of the undergrad course "Quality of Health Care in America," I can confidently say that one lecture is certainly not enough. To meet the demands of students wanting to learn more about patient safety and quality improvement, the Institute for Healthcare Improvement has launched a new initiative called the IHI Open School. Click here to learn more. As Maureen Bisognano said, there are FREE short courses available. There is also a community network of health professions students around the world interested in patient safety and quality improvement. Follow us on Twitter and read our blog!

Special Assistant to the CEO

Anonymous said...

Kudos to IHI, but they really shouldn't have to do this. Zowie, one whole lecture at HMS. Any medical school worth its salt, in today's day and age after the IOM report, should offer an entire semester course to 2nd year students on patient safety and quality improvement, followed up by formal and regular reinforcement in the clinical years. There is a large enough body of literature out there now to easily support such a course and more. Thumbs down to Harvard Medical School - if they want to be the leader in medical education, then act like it.

nonlocal MD

Anonymous said...

I got so worked up about this that I decided to research medical school curricula and what body is responsible for them. See the following links for information:

This is a chart of which medical schools teach about certain "unusual" topics. Note that health care quality (about half way down) is required by 100 medical schools, but the number of sessions (e.g. # classes) is 3+ in the preclinical years and 5+ during clerkships. This is hardly comparable to, say, physical diagnosis or biochemistry.

Also, see:

This is an "initiative to transform
medical education" but only gives passing reference to quality improvement training as far as I can tell.

If one should wish to advocate for addition of this training to medical education, it appears the contact person at the AMA's Council on Medical Education is:

I myself will be writing Mr. Winship a letter shortly. Patients deserve no less.


76 Degrees in San Diego said...

The discussion about curriculum for first and second year medical students is very complicated. A successful medical school dean must balance opinions from throughout a medical center about the relative importance of their contribution to the curriculum. I think that first and second year curriculum is too early for this. Better as part of core inpatient rotations in third and fourth year. Maybe medical students should be included in departmental peer review activities.

Anonymous said...

76 degrees;

First year, yes; but I don't think the second year is too early to formally introduce the subject and study the tools of quality improvement such as statistical run charts, common cause vs. special cause variation, root cause analysis procedures, analysis of types of errors, etc. Case studies with problem-solving would be appropriate here, such as hypothetical calculations of central venous line infection rates or other real-world situations. Then, with the background knowledge in place, your thoughts about including them in peer review activities as well as other departmental quality activities, such as those in pharmacy and lab, would make more sense to them. Certainly the average practicing physician today has little knowledge of such things; we need to start much earlier in their careers.

nonlocal MD

Anonymous said...

Dr. Mayol;

The article by Groopman et al in the WSJ speaks to one aspect of "quality" medicine that Paul complains about - that doctors always complain about the metrics that are being used, and use that as an excuse to have NO metrics. The other weakness, of course, is that these are process metrics rather than outcome metrics.
Having said that, I think there are SOME metrics, such as handwashing, which all can agree are valid. Specialty societies can also generate their own metrics which are the most solidly evidence-based. But the real danger remains that, as the article points out, whatever metrics are selected become written in stone and applied bureaucratically - such as the story I heard about an OB GYN being downgraded because he hadn't done a pap smear on one of his patients - who had had a hysterectomy, unknown to the bureaucrats.
I don't know what the answer is presently. But clearly we need to do something, not nothing.

nonlocal MD