Patient Safety: Conversation to Curriculum
By DANIEL BLUMENTHAL and ISHANI GANGULI
Published: January 25, 2010
Gretchen Ertl for The New York Times
LEARNING As Harvard medical students, Daniel Blumenthal and Ishani Ganguli are trying to develop good habits for safety.
Two summers ago, as bright-eyed third-year medical students, we rushed into clinics and operating rooms, eager to apply our textbook knowledge at last to the daily practice of working with patients.
To our untrained eyes, the system in which we were expected to deploy this knowledge was often baffling, with its unfamiliar rituals of scribbled notes and morning rounds. And it was at its most baffling when things did not go according to plan: if a patient took an unexpected turn for the worse, was that because of natural causes or medical error?
Since the publication of the well-known Institute of Medicine report in 1999 estimating that medical errors kill as many as 98,000 people a year, the topic has become part of the national conversation. More recently, a study in The New England Journal of Medicine and a new book, “The Checklist Manifesto,” by Dr. Atul Gawande (Metropolitan Books, 2009), have testified to the efficacy of surgical checklists and the value of encouraging all members of a surgical team to speak up about potential sources of error.
But so far, the conversation has been slow to trickle down to medical schools.
A 2008 survey by the Liaison Committee on Medical Education, which accredits United States medical schools, reported that two-thirds of medical schools mentioned patient safety in a required course, with an average of two sessions on the topic.
But another survey of 391 medical students by the nonprofit Institute for Healthcare Improvement found that four out of five felt their exposure to the topics of patient safety and quality improvement had been fair at best. And Dr. David Davis, senior director for continuing education and performance improvement at the Association of American Medical Colleges, told us there was “still some debate” about how and when to teach this material.
Why haven’t medical schools moved faster? For one, medical education is a zero-sum game, with vast amounts of material to cover. Dr. Donald M. Berwick, president of the health care institute, said the idea that schools “should give up the Krebs cycle or membrane transport” ― basic biochemistry concepts ― for patient safety was hard to swallow. Further, doctors tend to put a much higher value on their own clinical skills than on communication and cross-checking. While “medicine has historically valued disciplinary excellence ― doing your doctoring or surgery right,” Dr. Berwick said, most errors probably “lie at interfaces and handoffs” from one doctor to another.
In 2003, deans at 10 medical schools, including Dartmouth, the University of Minnesota and the University of Illinois, formed a collaborative group to foster communication across disciplines. Each school experiments with teaching strategies, then shares the results with the collaborative.
At Dartmouth, for instance, students participate in debriefing sessions with teams of medical professionals trained to respond quickly to in-hospital emergencies. Courses at other schools have invited parents of children injured or killed as a result of errors to talk with students about their experiences, putting a human face on the problem.
In a new three-week course on patient safety, fourth-year students at the University of Pennsylvania spend time at the Wharton School of Business. Among other things, they learn how Toyota’s model of product reliability can be applied to health care.
“The final piece is the economic analysis,” said Dr. Richard Shannon, chairman of the Penn health system’s department of medicine. “What does this mean? What do hospital infections cost in real dollars?”
Through such sessions, students can learn how medical errors are defined and how to tell an error from a negative outcome, said Dr. Melissa A. Fischer, an assistant professor of medicine at the University of Massachusetts Medical School. As she emphasizes to her students, “bad things can happen even when everything is done right.”
Because curriculum change at a national level has been slow, organizations like Dr. Berwick’s institute are taking another approach: reaching out to students who are eager to tackle these issues.
The institute’s new Open School for Health Professions is a hub of free online courses, case studies and discussion forums addressing errors and other quality improvement topics. The school went live in fall 2008 and has already registered more than 20,000 students, with more than 173 school- and hospital-based chapters in 41 states and 24 countries, according to its director, Jill Duncan.
The challenge is translating open discussion among medical, nursing and pharmacy students in online forums into open discussion on the hospital floor, and in turn, into day-to-day change in health care quality. Studies have implicated poor communication in medical errors ― especially between doctors of different ranks ― and demonstrated the role of open communication in improving patient outcomes.
As fresh observers of hospital dynamics across specialties, medical students are in an ideal position to effect change by speaking up. But patient safety experts question whether doctors, particularly those in hierarchical fields like surgery, are really ready to hear it ― especially, Dr. Berwick said, from medical students, who run the risk of being labeled “troublemakers” and “nai"ve.”
These factors suggest a pressing need for a cultural shift, one that dissolves the secrecy surrounding medical errors and allows trainees and seasoned doctors to speak openly about their mistakes and those their colleagues have made.
The psychological safety of this blame-free setting can feel scarce indeed in some high-powered institutions. A classwide poll of third-year students revealed that most of us had witnessed errors by superiors or peers or had committed them ourselves ― and demonstrated our striking ignorance of what to do about them.
Harvard’s limited coursework on this topic is by no means unique among medical schools. But as we came to realize, the tenets of avoiding medical error must be learned and enforced in real time.
So on the wards we did our best to develop good habits: rechecking medication flow sheets to ensure that a patient was getting the treatments we ordered, or making the trek from the on-call room to the nurses’ station at 4 a.m. to confirm that he was scheduled for his early morning CT scan.
It took a degree of humility to ask what seemed the obvious question and confidence to approach senior doctors with our own literature search on the best way to manage a patient’s unruly hypertension.
The hope is that thinking through these issues, and understanding the advantages and flaws of current practices, will help us become better doctors.
“What’s the purpose of medical school? And what is the product we have in mind? And who ought to answer that?” asked Dr. Lucian Leape, a patient safety researcher at the Harvard School of Public Health. “When I go to a doctor, I should have somebody who I know is competent, who I know I can trust and who will put my interests first. Two of those three have nothing to do with science.”
Daniel Blumenthal and Ishani Ganguli are fourth-year students at Harvard Medical School.
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