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March 10, 2010

Patient safety not taught in medical school? Lucian Leape Institute releases Unmet Needs: Teaching Physicians to Provide Safe Patient Care

Ten years after the release of the IOM report To Err is Human, which documented the toll taken by medical errors in this country, the question remains: What can be done to reverse the trend of ever-increasing morbidity and mortality due to medical errors?  Last December, a look back over the decade since the release of To Err is Human -- and a steady medical error death rate of about 100,000 per year included a series of suggestions for tweaks to the health care delivery system that may help ameliorate the situation.  Earlier this week, a gadget that enforces good handwashing technique by sniffing caregiver and clinician hands for soap before a hospital patient may be touched has been touted as potentially saving significant costs related to HAIs.

Today, the Lucian Leape Institute released a report titled Unmet Needs: Teaching Physicians to Provide Safe Patient Care which focuses on moving back the point in time where an intervention is needed to reverse the trend documented in To Err is Human and since.  Leape and his colleagues at the National Patient Safety Foundation are now focused on reinventing the medical school curriculum, so that patient safety will be taught more effectively in medical schools.

In a press conference Wednesday, Leape and his colleagues expressed a desire to move medical education away from what I'll refer to as the elaborate hazing ritual model, rife with examples of disrespectful communications and humiliations, and forward into a model of education that is informed by teamwork, communication, conflict resolution, mindfulness, and asking for help when help is needed.

The AAMC representative in the group, John Prescott, said that educating physicians in training about patient safety has been a top priority for the past decade, noting that 80% of training programs incorporate quality, safety and error-reduction training into the curriculum, following a 2001 AAMC report calling on medical schools to change the curriculum.

While the issues raised in today's report may be recognized by training programs around the country, it is clear that they are not working off of a consistent curriculum in training students, and in fact many institutions offer a course here and there on patient safety rather than baking the concepts into the four-year curriculum.

As a pithy epigram attributed to Sir Cyril Chantler would have it, "Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous."

The pressing needs today are the development of patient safety curricula, and development of faculty who will be able to transmit this new ethos in a way that will make it part of the basic fabric of training as a physician, rather than an add-on.  Leape calls on ACGME (the accreditation body) to set clear requirements for curriculum and terminal competencies for graduating students, to set clear expectations for learning cultures in residency programs, and to assure that patient safety content is woven into medical textbooks and licensing exams.  Existing resources, such as Title VII funds could have a set-aside earmarked for patient safety training in order to address prevention of medical errors -- the eighth-leading cause of death in the U.S. -- in a more comprehensive fashion.

The press release highlights the three main themes of the report's twelve recommendations:

  • 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.

. . .

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.

In the end, Leape recognizes that this sort of profound shift will not be fully realized for at least a decade, but in his view the federales have an obligation to hold the educational institutions' feet to the fire, since federal dollars are funding medical education, and it is clear to the government and others that significant changes must be made in order to move well beyond the stage of documenting the problem to protecting patient safety.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


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I attended medical school in NYC in the 1980s where machismo and humiliation were prized and practiced respectively. After graduation, I chose a medical residency in Pittsburgh that had a different ethos. I never felt that fear and intimidation increased my performance, and I have never practiced it with others. During my medical school time, we weren't taught anything about patient safety. This would be a welcome and necessary reform in the current medical school curricula, and I suspect that more reforms would be needed.

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