Medical Student Perspectives: Patient Safety & Medical School Curricula
Some time ago, a departmental morbidity and mortality conference reminded me that thinking about medical errors is akin to understanding a raging river. The attendings and residents were discussing a case in which physician error had caused the patient harm and hotly debated how it could have been avoided. The ideas came from all perspectives - some said that it was "just how things were," while others put blame on nurses, physicians from other specialties, and even colleagues within their field - but the focus was invariably placed on personal responsibility. At one point in the thirty-minute discussion, a voice from the front row suggesting that at its root, the unfortunate turn of events was a systems, not individual, problem. The idea was not received well: some ignored the comment and tapped at their phones while others glanced around, distracted, and others still shook their heads and whispered into each others' ears. Two attendings quickly reiterated that while that was a "nice idea," the mistakes could have been avoided if residents and other healthcare workers had just paid more attention. Several heads nodded in swift affirmation, and three minutes later we were dismissed.
The experience, along with many similar ones my classmates and I have experienced on clinical rotations, brought the image of a raging river to mind because it reminded me of the distinct difference between the water and the riverbed around it. When we see a river with violent eddies and currents, the most intuitive and natural response is to conclude the river itself is intrinsically violent. But if we could drain the water and inspect the riverbed - to see the rocks, the uneven shelves of soil, the protruding branches - we might instead more rightly conclude that the violent currents resulted from these external forces, and not intrinsic qualities of the water. So it often is with medical error and quality. Because without downplaying the human element in healthcare and physician responsibility in thinking clearly and acting correctly, the medical community has found time and time again since the Institute of Medicine published its seminal work To Err Is Human in 1999 that quality of the system (the riverbed) within which we work often contributes far more than individual factors in instances of comprised patient safety (violent currents). And the "quality movement" that has emerged over the last twelve years to study these riverbeds around healthcare continues to gain momentum behind a growing body of literature that supports the strong relationship between the structures of the delivery systems and the level of safe, effective care we provide.
Even as students, it has become increasingly hard to ignore the implications of these findings. Because while the majority of existing work in the last decade has focused on physicians, the medical community is realizing the need to engage future physicians on these issues, early in their education. The Accreditation Council for Graduate Medical Education (ACGME) has required that all US residencies integrate "systems-based practice" as a core competency for trainees, and a number of medical schools are following with similar changes. Additionally, groups like the World Health Organization (WHO) and the Association of American Medical Colleges (AAMC) have stressed the importance of incorporating these components into undergraduate medical curricula, and the Liaison Committee on Medical Education (LCME) has surveyed patient safety content in accredited schools as a component of the standards for their programming. Moreover, in the current political, regulatory and economic climates, it is becoming crucial for students who want to eventually serve as leaders in medicine to understand and navigate the areas of quality and safety to best promote cost-effective medicine.
To date, however, only a handful of institutions have evaluated and developed patient safety components in their core curriculum, despite work showing that medical students can be integral in preventing patient harm in the clinical setting and that the level of patient safety knowledge is limited among medical trainees across a broad range of training levels and specialties. But the progress is promising. Through a number of different methods - workshops, independent study, web-based curricula, one-or two-day seminars - a number of institutions are trying to identify crucial areas of safety knowledge and integrate these components into their course hours. At my institution, we are currently looking thoughtfully at how to both incorporate safety and quality into the core curriculum and provide interested students with additional resources through a four-year track/concentration. And as more and more schools adopt these changes and research clarifies which methods most effectively educate while allowing students to retain and apply what they learn, the quality of undergraduate medical education in patient safety issues will only improve.
Our involvement as students in patient safety is important, if for no other reason than because these issues are directly linked to how well we treat, and learn from, our patients. Processes like root cause analyses and PDSA (plan, do, study, act) cycles matter the most when we realize how many patients are saved from the financial burden of prolonged hospital stays and morbidity from catheter-based infections. The concepts of proximal cause and latent error are far less tedious when they translate into grateful patients and families. And we can more fully learn from our patients through things like morbidity and mortality conferences when we can see that the systems and processes within which we work have large impacts on whether problems are solved or remain perpetually unresolved.
In summary, patient safety is an inescapably important, emerging issue in our profession with far-reaching implications. There are growing initiatives to integrate it into undergraduate medical education. But because many of these are currently either nonexistent or in their infancy at the local level, there is a great opportunity and need for student involvement. I would echo what many have already rightly stated by encouraging all interested students to take a few simple steps and get involved in this area (see below for some good starting points). For all of us who want to practice clinically, it is part of becoming competent, conscientious physicians in 21st century medicine who do not "confuse the riverbed for the river." For those of us who find themselves passionate about these issues, it provides the opportunity to carefully study these systems early in our careers and improve them behind the vision of promoting health among individual patients and their communities.
Resources for Students Interested in Learning and
Getting Involved in Patient Safety:
- Institute of Healthcare Improvement - a well-respected, non-profit group with information for students from a variety of healthcare professions; also provides the opportunity for students to start their own local IHI chapters and utilize the "IHI Open School" curriculum, a comprehensive, introductory web-based curriculum that is free to students who want to learn more about leadership, patient safety and quality improvement.
- Improve Healthcare - a student-led initiative through which medical students can learn about issues in patient safety through lectures and case studies, as well as contribute case studies from local experience to share with others
- WHO Patient Safety Curriculum Guide for Medical Schools - published in 2009 to encourage and facilitate patient safety topics in medical school curricula
- Association of American Medical Colleges - provides helpful information to students and schools interested in assessing the current state of patient safety and quality improvement in undergraduate medical education curricula as well as helpful suggestions for future directions; also contains many helpful articles in its publication, Academic Medicine.
Joshua Liao, MS III
Baylor College of Medicine
E-mail: jmliao@bcm.edu