Safety and Medical Education
Efforts to enhance safety in medical education have focused on integrating patient safety into curriculum and augmenting safety culture in teaching hospitals. Sumant Ranji, MD, explores key elements of teaching patient safety in medical schools (including the ACGME's Clinical Learning Environment Review program), assessing safety skills among trainees, and ongoing efforts to study the impact of duty hour restrictions.
Annual Perspective 2014
by Sumant Ranji, MD
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical education. Efforts to do so have generally focused on two main areas: incorporating formal training in patient safety into medical education, and examining and improving the safety of care at teaching hospitals.
The 2010 report Unmet Needs: Teaching Physicians to Provide Safe Patient Care by the Lucian Leape Institute at the National Patient Safety Foundation emphasized the importance of both of these areas. In the area of curricular change, it highlighted the need for medical schools to modernize their curricula to better prepare physicians. The report called on these schools to shift from the traditional curricular focus on medical knowledge and technical skills to a curriculum integrating systems analysis, quality improvement, and patient-centered care. In the area of changing the clinical setting in which so much of medical training takes place, the report emphasized the importance of a culture of safety in teaching hospitals, stressing that unprofessional behavior and authority gradients prevent trainees from reporting and learning from errors. It also called for rigorous new evaluation methods to be developed and implemented in both medical schools (undergraduate medical education [UME]) and residency programs (graduate medical education [GME]).
There were significant advances in these areas in 2014, as well as the publication of new evidence evaluating the effect of duty hour restrictions on safety and medical education. In this Annual Perspective, we will review this new evidence and other key trends in the field of safety and medical education.
Improving Instruction and the Culture of Patient Safety in Teaching Settings
Medical schools are now required to provide basic instruction in patient safety for students and residents in order to meet accreditation standards. While many UME and GME programs have implemented didactics or online courses to meet these requirements, the real-world "hidden curriculum" that trainees experience—such as unprofessional behavior or failure to appropriately report or disclose errors—is much more powerful in shaping trainees' behaviors. In response, the Accreditation Council for Graduate Medical Education (ACGME) recently created the Clinical Learning Environment Review (CLER) program to evaluate teaching institutions in six focus areas: patient safety, quality improvement, transitions in care, supervision, duty hours, and professionalism. The intent of this program is to evaluate the degree to which trainees' work environment supports their ability to provide safe and high-quality care. The CLER Pathways to Excellence report describes discoveries from the first year of the program, including the finding that residents and fellows are often disengaged from institutional safety programs and rarely voluntarily report errors. A related commentaryidentified faculty development as the rate-limiting step in improving the culture of safety at teaching hospitals, as many (if not most) teaching faculty also lack facility with basic safety concepts. In response, the Association of American Medical Colleges has developed the Teaching for Quality program to develop a cadre of medical educators certified in teaching patient safety and quality improvement.
Improving the culture of safety at teaching institutions will also require that efforts are taken to eliminate disruptive and unprofessional behavior from the workplace. The culture of disrespect that pervades many institutions poses a major barrier to improving safety in general and is particularly damaging to trainees. At the institutional level, studies published this year demonstrated the effectiveness of a systematic approach to identifying physicians with repeated behavioral transgressions and implementing a structured approach for remediation. While overtly unprofessional behavior is easily detected (albeit difficult to address), students and residents are often exposed to more subtle harmful behaviors, as exemplified by a study showing that residents frequently witness poor role-modeling behavior by supervisors in disclosing errors to patients. Regulatory efforts such as the CLER program are now highlighting these deficiencies, and teaching institutions will need to continue to implement interventions to develop and maintain a culture of safety.
Evaluating Patient Safety Competencies Among Trainees
The Lucian Leape Institute's Unmet Needs report also called for development of evaluation systems for trainees based on the achievement of developmental milestones in patient safety—specific safety skills that trainees must demonstrate in order to be considered ready for unsupervised practice. In 2014, these evaluation systems were developed and implemented for both medical students and residents. At the UME level, the Association of American Medical Colleges has defined the ability to "identify system failures and contribute to a culture of safety and improvement" as one of the 13 core skills that all medical students should have achieved by the time of graduation. The ACGME has also developed patient safety milestones for all GME training programs—including residency programs and subspecialty fellowships—that were implemented for some fields this year and will be fully implemented by July 2015. For example, internal medicine residents are now required to demonstrate that they can recognize system error and advocate for system improvement through identifying systemic causes of medical error and navigating them to provide safe patient care and reflecting upon and learning from critical incidents that may lead to medical error.
The development of patient safety–specific milestones is important, both because of its inherent value and because it places the ability to provide safe care on the same level of importance as the acquisition of medical knowledge. Practicing physicians will also be held to the same standards, as the American Board of Medical Specialties has recently implemented standards for maintenance of certification (MOC) across many specialties. The MOC program requires that physicians demonstrate continued competence in patient safety after completing training and attaining board certification, providing additional justification for the need to inculcate trainees with these skills.
Resident Duty Hours Reductions
The most prominent intervention designed to enhance safety at teaching hospitals—the 2003 regulations restricting resident duty hours—has engendered controversy since its inception. Previous systematic reviewshave found no improvement in clinical or patient safety outcomes associated with the regulations and mixed effects on educational outcomes. Further regulations on duty hours for first-year trainees were implemented in 2011, and 2014 saw publication of longer-term outcomes of the 2003 regulations and early results examining the effects of the 2011 regulations.
A systematic review of the impact of duty hour restrictions on surgical resident training found no improvement in patient outcomes or resident education associated with either the 2003 or 2011 regulations, and mixed effects on resident well-being. Another single-site study found no improvement in patient safety outcomes after implementation of the 2011 duty hour regulations. What's more, a commentary by two noted patient safety experts raised concern that further restriction of duty hours has led to decreased autonomy for residents and limited their ability to make decisions independently. These concerns were partially allayed byanother study that compared the clinical outcomes of patients cared for by physicians who completed training after duty hour regulations to patients cared for by physicians who completed training prior to 2003. No difference was found in hospital mortality or length of stay between the two groups.
In response to continuing concerns about the impact of duty hour restrictions on trainee and patient outcomes, the ACGME has provided funding support for the iCompare study, a cluster-randomized trial that will compare the current regulations to a duty hour structure that preserves the 80-hour weekly work limit, but allows flexible schedules otherwise. The iCompare study enrolled participants in 2014 and will begin in 2015. The results of this study should help inform the optimal duty hour structure in order to ensure patient safety while maximizing resident education and well-being.
In summary, one of the major threads of the patient safety movement was rethinking many key tenets of medical education. In 2014, we saw the maturation of several programs that have been implemented in response to this important movement. In the case of duty hour restrictions—now more than a decade old—empirical studies testing whether the new standards have met their goals have yielded ambiguous results. They have also identified some potential unintended consequences. In the case of the more recent CLER program, empirical results are likely a few years away. The literature is offering some early themes and areas for teaching programs to focus on in the coming years. Whatever the results of specific initiatives, it is clear that the patient safety movement has targeted medical education as an area in need of new thinking and programs, and this trend is unlikely to change in the next few years.