Pulse: Lucian Leape Institute Finds Medical Schools Fall Short in Teaching How to Provide Safe Care

March/April 2010

Pulse

Lucian Leape Institute Finds Medical Schools Fall Short in Teaching How to Provide Safe Care

The Lucian Leape Institute at the National Patient Safety Foundation has released 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.” The report comes approximately 10 years after the Institute of Medicine’s landmark 1999 report, To Err Is Human, which found that 98,000 Americans die unnecessarily from preventable medical errors. “Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, healthcare remains fundamentally unsafe,” said Lucian L. Leape, M.D., Chair of the Institute and a widely renowned leader in patient safety. “The result is that patient safety still remains one of the nation’s most solvable public health challenges.”

A major reason why progress has been so slow is that medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer. These education and training activities, the report states, need to begin on Day 1 of medical school and continue throughout the four years of medical education and subsequent residency training.

“The medical education system is producing square pegs for the delivery system’s round holes,” said Dennis S. O’Leary, M.D., President Emeritus of The Joint Commission, a member of the Institute, and leader of the initiative. “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.” The new report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, is based on a Roundtable of leading experts in medical education, patient safety, healthcare, and healthcare improvement convened by the Institute. Participants ranged from some of the most eminent figures in these fields to patients and current medical students who are experiencing medical education first-hand.

The 40-member Roundtable quickly surfaced several major themes. Most medical schools do not teach safety science nor equip new doctors with the interpersonal skills they need to practice safely. The singular focus of medical schools for the past 100 years has been on teaching basic sciences and clinical knowledge; this is no longer adequate. To practice safely, and to improve care, students need to learn safety science, human factors engineering concepts, systems thinking, and the science of improvement. And they need to develop the interpersonal skills to communicate effectively with co-workers and patients and work well in teams.

Teaching hospitals, where clinical education of students and residents takes place, are also falling short in their safety education and training roles. Like medical schools, most teaching hospitals have hierarchical cultures that are inimical both to safety education and safety improvement. The unquestioning deference to physician authority inhibits adherence to safe practices and team-building across disciplines. In addition, too many students suffer humiliating and dehumanizing experiences at the hands of the faculty, their role models, which creates a culture of fear and intimidation, impairs learning, and creates the likelihood that students and residents so treated will pass these behaviors on to the next generation of learners.

The report concludes that “substantive improvement in patient safety will be difficult to achieve without major education reform at the medical school and residency training program levels.”

The report’s 12 recommendations center on three main themes:

• Medical schools and teaching hospitals need to create learning cultures that emphasize patient safety, model professionalism, encourage transparency, and enhance collaborative behavior. They should have zero-tolerance policies for egregious disrespectful or abusive behavior.
• Medical schools should teach patient safety as a basic science and ensure that students develop interpersonal and communication skills through experiences working in teams with nursing, pharmacy, and other professional students.
• Medical schools and teaching hospitals need to launch intensive faculty development programs to enable all faculty to acquire sufficient patient safety knowledge and to develop the interpersonal skills in teamwork and collaboration that permit them to function effectively as teachers and role models for students.

“Because they are powerful role models, all clinical faculty need to be the kinds of physicians we want our students to become,” said Dr. Leape.

In addition, the report calls on the accrediting body for medical schools (the Liaison Committee on Medical Education) and the accrediting body for residency programs (the Accreditation Council for Graduate Medical Education) to modify their accreditation standards accordingly.

“Patient safety is a top priority for our nation’s medical schools and teaching hospitals,” said John E. Prescott, M.D., Chief Academic Officer of the Association of American Medical Colleges. “Improvements in instruction and training in this area are on the rise in all phases of medical education.”

This report is the first of a planned series of such reports on issues that the Lucian Leape Institute has identified as top priorities in ongoing efforts to improve patient safety. “We are very excited about this initial report of the Lucian Leape Institute,” said Diane C. Pinakiewicz, MBA, President of the Lucian Leape Institute and the National Patient Safety Foundation, “but we recognize that this is just the beginning of a major collaborative effort to see the report’s recommendations through to their full implementation.”

Subsequent Institute initiatives will address integration of care across health care organizations and delivery systems; restoration of pride, meaning and joy in professional work; active consumer engagement in patient care; and provision of fully transparent care.

Besides Drs. Leape and O’Leary and Ms. Pinakiewicz, members of the Lucian Leape Institute include Donald M. Berwick, MD, President and Chief Executive Officer, Institute for Healthcare Improvement; Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality; James B. Conway, Senior Vice President, Institute for Healthcare Improvement; Paul A. Gluck, Immediate Past Chair, NPSF Board of Directors; James A. Guest, President, Consumers Union; David M. Lawrence, MD, Chairman and Chief Executive Officer (retired), Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals; Julianne M. Morath, RN, Chief Quality and Safety Officer, Vanderbilt Medical Center; Paul O’Neill, Former Chairman and Chief Executive Officer, Alcoa, and 72nd Secretary of the US Treasury.
The full report is available online at http://www.npsf.org/LLI-Unmet-Needs-Report/