Monday, September 05, 2011

Bob is good and lucky; Others are not

Bob Wachter, one of my heroes in the patient safety arena, is on sabbatical and has written this blog post comparing the approach of US and UK hospitals with regard to improvements in this area.  As always, it is thoughtful and provocative.

I found the post a bit too self-congratulatory, though, with regard to the progress made in US academic medical centers.

While engaging practicing doctors is vital, so too is capturing the hearts and minds of the next generation.... In the US, kids go to four years of college, then to medical school for four more years. From there, they enter a residency in the specialty of their choice and, for some, additional fellowship training. Training programs are run by individual academic medical centers, such as NYU or Johns Hopkins, or smaller teaching hospitals. While in training, American residents work under the wing of a single program director and rotate through a limited set of training experiences, usually in 2-3 hospitals.... Because the training director is responsible for the residents and can track them easily, he or she has the tools to create new curricular experiences in crosscutting areas like patient safety. At UCSF, for example, all our interns now have a two-week safety/quality rotation, during which they learn core principles and begin working on a project.

While I would like to think that USCF is the norm, it is not.  I have met residents and young attendings from throughout the country who have decried the lack of such programs as part of their multi-year graduate medical education.  At my former hospital, where such training was included, we noticed a stark difference in the ability of our residents to perform systems analytic work compared to residents from other institutions who had rotations in our hospital.

Perhaps the biggest difference I’ve noticed is in the background of the leaders in safety research and policy. In the US, the vast majority of the leaders are physicians, most of them based in academia and still seeing patients part-time. In the UK, most of the prominent and highly published patient safety experts are PhDs—mainly in psychology and sociology.

How to explain this striking difference? I’m guessing it reflects several factors. The first is the US college-before-med school system, which allows kids with a social science intellectual sweet tooth to pursue their passion in college, yet still become physicians. Atul Gawande, for instance, has a Stanford degree in biology and political science, and then studied philosophy at Oxford. Johns Hopkins safety expert Peter Pronovost double majored in biology and philosophy at Fairfield University, and I majored in political science at Penn. One can’t really do this in Great Britain; kids here begin their professional education at age 17. In England, a student like me probably wouldn’t go to med school in the first place, and if he did, he wouldn’t have had much time to study politics during his university years.

Second, the US has a strong tradition of physicians receiving additional social and political training after their clinical years, through the Robert Wood Johnson Clinical Scholars and similar fellowship programs. In the UK, while many MDs pursue additional training in biomedical research, relatively few receive (or have access to) the kind of training that promotes leadership in safety or quality. Just as importantly, there isn’t an obvious pathway for physician-leaders in quality or safety research to be promoted, funded, or valued by their academic institutions, as they increasingly are in the States, and so there are few role models with this phenotype.

Yes, the leaders in the US are the type of people mentioned, but they are often "prophets in their own land," valued more by people in other hospitals than their own.  Some cannot even get their own hospital to agree to conduct studies of their safety theories.  Some cannot get their hospital to implement the protocols and approaches that have proven to be efficacious in their experiments elsewhere.

Indeed, you sometimes get the feeling that academic medical centers are very happy to have these "trophy doctors" on staff more for the prestige they bring to those centers than for the knowledge they offer.

I think Bob is lucky that UCSF values his work so much and has done the types of things he mentions in his blog post.  (The patients there are even more lucky!)  But I fear that his view is skewed by that positive experience and overstates the progress made in the attitude and work of many other academic medical centers.


lisalora said...

its such a inspiring article for me as well as the young medical in Asian countries,medical students are not allowed to choose extra subjects during their MBBS period(6 or 5 and half yr) if any student wants to apply for countries like USA,UK...passing licence exam is the only way to be there..

Anonymous said...

Dr. Wachter has an interesting point that 3 of the giants of the patient safety field in the US majored in subjects other than science, but as they say, correlation does not mean causation. Many other countries employ the same MD educational system as the UK. And, although there is physician-directed research in the field, it is institutions such as IHI and others who have really pushed this issue to the forefront, and the research followed on that.

I agree this article is a bit too soft on the US in terms of physician involvement in patient safety. Go outside these few ivory towers and you still encounter walls of silence, ignorance of method or benefit, and angry patients and families. As you have said before, Paul - what will it take?

nonlocal MD

Anonymous said...

The Canadian system is IMO the worst when it comes to patient safety.
98 percent of malpractice victims never receive a penny.
The CMPA has 2.9 billion at their disposal to use to hire the best experts and lawyers.The public pays a portion of their annual fees and don't even know it.
If a patient wants to bring a lawsuit they have to fund it and pay if they loose.This was done to discourage lawsuits.
Few doctors in Canada are ever found guilty of anything.
The College of Physician and surgeons squashes complaints then the public does not find out how bad things really are.Its all about giving people the perception we are getting quality care.In an emergency situation you can be refused care and admittance.That complaint will be squashed.In the USA this would be illegal.
A study done in Ontario showed 99 percent of complaints investigated in secret for that year.
In Canada if you file complaints or are the victim of negligent care you can easily be blacklist from any care tests or treatment.This means getting damage assessed elsewhere out of the country at your expense.This is happening to me right now.I am paying for medical care through my tax dollars and cannot get care except blood tests.