Sunday, December 21, 2014

Your unrealistic assumptions and unmet expectations

I'm so grateful that many of you answered my question of last week:

"As a patient or family member in a hospital, what are your assumptions and expectations with regard to medical students and residents when it comes to patient safety?"

I promised to respond to your comments, and I will, but first, I'd like to reprint an excerpt from Gene Lindsey's weekly email message to his friends and colleagues, for I think it sets the scene nicely.

Although I graduated with honors and was fortunate to match with an excellent internship and residency program, I graduated as a physician in name only. In retrospect medical school for me was not much more than a big vocabulary lesson. By graduation I was well versed in the “what” of medicine and my clinical rotations had been an effective introduction to the “how” of hospital practice, but I was very short on the understanding of “why” and the complexity of effective practice especially in the ambulatory environment. I could talk like a doctor or at least pass for an intern.  I looked the part. I knew how to do a few things and was rapidly gaining the swagger associated with increased confidence in my ability to tap fluid off of the water soaked lungs of a patient who was short of breath, do a lumbar puncture as part of a fever work up, or rapidly and effectively respond to a code.

What took a lot longer to gain was confidence in my ability to meet a patient, understand them, appreciate the world they came from, really know their concerns, translate those concerns into a medical assessment, and finally help them understand what I had formulated and then help them choose a path forward. I think that my mentors or something in my development taught me to search for the equivalent of the IHI’s admonition to ask “What matters to you?” But putting that combined process of inquiry, empathy, discovery, diagnosis and treatment into practice is hard work.  Incorporating that mind set of patient centrality into all of the vocabulary, clinical skills, and social awareness is a long slow learning process that consumed many more than the 10,000 hours Gladwell says is the foundation of competence.

Wow, as a non-doctor, I am impressed with how hard it is to get good at this profession/craft/art/science.  And note that Gene's remembrances don't even cover the additional topic about which I asked, patient safety. Let's see what your expectations are.

Many of you raised the issue of training:  Andrew expects "that they have a high level of training for what they are asked to do and that safety [is an] important part of that."  From across the Pond, Anne Marie hopes "that they are working within their frame of competence." An anonymous person expects that "their training is a systematic, tested, and reviewed process, as evidenced by defined skills, knowledge, and abilities."

But you also recognize that these folks are trainees and therefore might not know the answers. Therefore you hope for self-awareness of their limitations and also expect that supervisors will be available to step in when help is needed.

On the first point, from Down Under, Kim hopes that they will "know their limits and seek help whenever needed." Kashif likewise says, "If there is any gray area, doubt or question, it is incumbent on the student - and should be part and parcel of the learning process - to ask for clarification and education from an attending or other superior."

Anonymous adds that the other part of the equation must also be present: "I would expect that there's someone around who is accessible that the trainees could turn to, with immediacy and in-person, when they're in over their head. And, I'd expect that that person would be around sufficiently to recognize when a resident or med student is in trouble with regard to understanding what's happening with a patient, even if he or she does not."

And, now, turning directly to the issue of safety, Bart assumes "that they're better oriented toward safety [than older doctors] since they're newly trained." E-patient Dave wants them "to follow documented safety procedures and welcome my questions (and my family's) and our attempts to help keep things safe." Nonlocal MD expects "exactly the same from them with regard to patient safety as I would expect from their attendings or, indeed, any doctor - awareness and attention to safety best practices."

Hilary then adds an important proviso, hoping "that residents, medical students -- and anyone in the hospital -- are empowered to speak up if they see a patient safety issue. More fundamentally, that they are supported by faculty and a hospital system which make patient safety a priority."

Paul expands on this:

"[T]here clearly needs to be a place to go (likely even anonymously) to report on patient safety issues that the student observes.

"Reporting is not with a punitive goal, but with a goal of protecting patients and supporting quality improvement. The organizational system where the student is placed ought to support this ability to report without fear of retribution or negative consequences for the reporting student."

OK, now let's turn to reality, which is nicely represented by a number of participants at the Telluride Patient Safety Camp, captured in submissions on the camp blog.  On the issue of training, it is not uncommon to hear from residents that their cumulative training in safety and quality issues during four years of medical school and two to three years of residency is in the vicinity of three hours.   AWilliams noted: "My school has a Patient Safety elective (of which I am on the waitlist for), but beyond that we are given no formal training in the Patient Safety Culture."

Thinking about cognitive, communication, and team behavior determinants of safety and quality, Giana O'Hara noted:  "I am struck by the lack of education in our institutions. Today’s lessons were profoundly important and informative, yet, our schools do not have room for things in their education such as human factor engineering and negotiations. They don’t even make time for true team building!"

JHollorman learned lessons at Telluride that had never been presented during formal training.  Among them: "Our own human fallibility causes us to deviate from safety protocols in the face of stress, make conclusions based on cognitive bias rather than real information, and underestimate our likelihood to cause an error."

Compare our small sample with the self-congratulatory comments of the Association of American Medical Colleges: "Most medical schools currently include patient safety and/or quality in their curricula."  That embedded link purports to indicate the number of medical schools with "patient safety" and/or "quality improvement" in their curriculum.  In truth, the vast majority of medical schools have no longitudinal curriculum through the undergraduate years that touches on this topic.  Here's a quote from a few years back that is still accurate:

The Lucian Leape Institute at the National Patient Safety Foundation released today a report that finds that U.S. “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.

I remember a conversation with the dean of a well known Boston medical school three years ago when I suggested that these items be added to the curriculum."Our faculty aren't interested in that," he said dismissively.  His students are now the ones taking care of you, the ones you expect will be trained in quality and safety matters.

And, finally, let's turn to Hilary's and Paul's hope, that students and residents will find an open and welcoming environment within which to report areas of concern, or specific instances of patient harm.  Again, as we all know from experience, this is observed more in the breach than in the reality.  The ACGME's CLER Program mandates that these features be included at hospitals that sponsor residency programs.

"How's it going?" you might ask.

Well, we can't find out because the ACGME will not release the results of its assessments.  If the medium is the message, the lack of transparency evidenced by the residency supervisory body is a clear indication of its poor understanding of the importance of meeting these educational criteria.

I offer all of these comments not to get you overly discouraged but to suggest that the patient safety movement and its advocates are missing a big topic.  In their focus on process improvement, patient engagement, and the like, they are missing the fact that much hope lies with the coming generation of doctors.  In our zeal, for example, to require reporting of hospital acquired infections and never events, or to pursue changes in the payment system to supposedly prompt better management of care, we neglect the coming generation's need for education and support.


Isabel said...

Paul, I'm wondering if you could also comment on the effect of the increasing "corporatization" of medicine on patient safety. I fear it could be quite destructive. When the bottom line becomes the supreme priority, patient safety often takes a back seat; patients' lives get treated as variables in a calculus that doesn't put them first. I can't help but feel some frustration and resentment over recent trends I've seen in this direction.

Paul Levy said...

Thanks, Isabel, here's the most recent post on that topic:

Gene Lindsey said...

From g+:

Well done! I think my own story underlines how poorly medical schools have performed for decades. The profession has also been extremely slow to respond after 25 years of data showing the breath taking extent of our problem.

Safety was not a focused concern for any one until the late 80s. I remember Don Berwick grabbing me at the elevator at our BPW office in Brookline Village back in the late 80s. He was very excited. He said, "Gene, I have this incredible data that shows that it is not safe to get care at Kenmore!

I never knew exactly what happened. He was the VP of Quality and Safety for HCHP at the time. Not long after our encounter he left HCHP and we had IHI. I always felt that he left because his ideas and concerns got no support from senior management but I have no data or facts to support that idea. I have never asked him for the details.

Keep doing what you are doing. You are shining light on some pretty ugly realities.

Joe Hess said...

The med student may present a question, statement, or concern about a patient safety or quality issue, in an unrefined, under developed manner, which the attending physician may dismiss, not hear, or focus on as important. The attending physician or senior residents who are working with the med students play a vital role in establishing the context from which a med student participates and contributes to patient safety and quality. While the med student may have experience, education and a responsibility to this question at hand, the attending physician and senior residents have vial and necessary role as well.

nonlocal MD said...

The irony of this whole thing is, whom are we expecting to train these doctors in training? Their attendings, who have received less training than their subordinates and, worse, care less too. This also applies to faculty members in med schools, as evidenced by the response to Paul's conversation with the Dean of the well known Boston medical school. It is an intimidating obstacle.

e-Patient Dave said...

This could get traction in Health Affairs, you know ... importantly, it's one of the few (if not ONLY) things I've seen that so starkly draw the contrast between what clearly should be and what actually is.

e-Patient Dave said...

nonlocal, I might humbly suggest that we engage (and pay!) the people who've spent decades developing materials on patient safety! National Patient Safety Foundation and many others ... perhaps some previous victims of errors and hospital-acquired conditions. I betcha with some modest compensation they'd be REALLY motivated inspectors.

I even wouldn't be surprised to see some willing to relocate to be near a medical school - I know some who might make it their (new) life's work to guide the awareness of young docs-to-be.