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OVERVIEW

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Medicine has a unique problem when it comes to its trainees. Although all fields must allow trainees some opportunity to “practice” their craft before being granted a credential allowing them to work without supervision, legal, accounting, or architectural errors made by trainees generally have fewer consequences than medical errors do.

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Moreover, the demands of medical practice (particularly the need for around-the-clock and weekend coverage; Chapter 16) have led to the use of trainees as cheap labor, placing them in situations in which the supervision provided is sometimes not sufficient given their skill level and experience. Although this early independence has been justified pedagogically as the need to allow “trainees to learn from their mistakes” and hone their clinical instincts, in truth much of it flowed from economic imperatives.

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Yet the solution is not obvious. One can envision a training environment in which patients are protected from trainees—after all, who would not want the senior surgeon, rather than the second-year resident, performing his or her cholecystectomy? While such an environment might be safer initially, the downstream result would be more poorly trained physicians who lack the real-world, supervised experience needed to transform them from novices into experienced professionals. The problem would be similar for nurses and other caregivers.

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These two fundamental tensions form the backdrop of any discussion of training issues in the context of patient safety. First, what is the appropriate balance between autonomy and supervision? Second, are there ways for trainees to traverse their learning curves more quickly without necessarily “learning from their mistakes” on real patients? This chapter will address these issues, closing with a short discussion about teaching patient safety. Other important training-related issues, such as teamwork training and duty-hour restrictions for residents, are covered elsewhere (Chapters 15 and 16, respectively).

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AUTONOMY VERSUS OVERSIGHT

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The third-year medical student was sent in to “preround” on a patient, a 71-year-old man who had undergone a hip replacement a few days earlier. The patient complained of new shortness of breath, and on exam was anxious and perspiring, with rapid, shallow respirations. The student, on his first clinical rotation, listened to the man's lungs, expecting to hear the crackles of pulmonary edema or pneumonia or perhaps the wheezes of asthma, yet they were clear as a bell.

The student was confused, and asked the patient what he thought was going on. “It's really hot in here, doc,” said the patient, and, in fact, it was. The student reassured himself that the patient was just overheated, and resolved to discuss the case later that morning with his supervising resident. In his mind, calling the resident now would be both embarrassing and unnecessary—he had a good explanation for the patient's condition. An hour later, the patient was dead of a massive pulmonary embolism. The student never told anyone of his observations that morning, and felt shame about ...

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