Chapter 17. Education and Training Issues

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.

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 they have too little supervision for 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.

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.

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).

The third-year medical student was sent in to “preround” on a patient, a 71-year-old man who had had 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 the case for decades afterwards.

In his terrific book, Complications, Harvard surgeon Atul Gawande describes the fundamental paradox of medical training:

In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility…. But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections we put in place, on average, these cases go less well with the novice than with someone experienced.

This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.1

Traditionally, supervisors in medicine erred on the side of autonomy, in the belief that trainees needed to learn by doing—giving rise to the iconic mantra of medical training, “see one, do one, teach one.” We now recognize this paradigm as being both ethically troubling and one more slice of the proverbial Swiss cheese, a constant threat to patient safety (Chapter 2).

Supervising physicians (the issues also play out with other health professionals such as nurses, but the autonomy that trainees in other fields can exercise and the danger they can cause seem less than those of physicians) are terribly conflicted about all this. Supervisors know that they could do many things better and more safely, but also recognize that trainees truly do need to learn by doing. Moreover, providing the degree of supervision necessary to ensure that trainees never get into trouble would create job descriptions for supervising attendings that might not be compatible with career longevity.

On a scale that has, at one extreme, supervising physicians doing everything while trainees watch, and, at the other, trainees doing everything and calling their supervisors only when they are in trouble, until fairly recently most medical training systems were far too tilted toward autonomy. Prodded by some widely publicized cases of medical error that were due, at least in part, to inadequate supervision (the death of Libby Zion at New York Hospital in 1986 was the most vivid example2; Table 1-1), the traditional model of medical education—dominated by unfettered resident autonomy—is giving way to something safer. (As a side note, while the Libby Zion case is popularly attributed to long resident hours, the chair of the commission that investigated the case [Dr. Bertrand Bell] clearly saw the root cause more as inadequate supervision than sleepy residents.3) We now recognize that “learning from mistakes” is fundamentally unethical when it is built into the system, and that it is unreasonable to assume trainees will even know when they need help, particularly if they are thrust into the clinical arena with little or no practice and supervision.4

Our new appreciation of these issues has led not only to some system reforms (including the increased supervision requirements enacted by the Accreditation Council on Graduate Medical Education in 20115; Table 16-2) but also to a crack in the dike of academic medical culture. For example, many attendings now stay late with their teams on admitting nights, a practice that would have been judged pathologically obsessive only 20 years ago (during my medical school days, one such attending picked up a nickname among the house staff of “the world's oldest intern”).

In addition, the old culture of the “strong resident” or “strong student” (translated: one who never bothers his supervisors) is changing. Growing numbers of programs are building in expectations of oversight and creating structures to support it. For instance, around-the-clock attending presence (often with hospitalists and intensivists) to help supervise trainees at night is increasingly common. At UCSF Medical Center, for example, we now have hospitalists stay overnight with our residents. In addition to managing some patients independently, these faculty members supervise residents' care of critically ill patients and are available to help with more stable patients. I routinely tell faculty who take on these “nocturnist” roles that they should always ask the resident, “What would you be doing if I wasn't here?” before offering recommendations. I also ask these supervising physicians to emphasize to the residents that a call for help is a sign of strength and professionalism, not weakness.6

Ensuring appropriate communication is partly a cultural problem, but it also needs a scaffolding of thoughtfully developed guidelines. After analyzing a series of malpractice cases, the chiefs of surgical services at Harvard, working with the Harvard Risk Management Foundation, identified a series of “triggers” that should prompt direct communication between residents and attendings (Table 17-1).7 A study at four of Harvard's teaching hospitals showed that, in one-third of cases, attendings were not notified after such trigger events.8 The guidelines were subsequently codified, with promising results.9

Oversight is not a monolithic construct. Supervisors must modulate their degree of oversight based on their comfort with the trainee's level and demonstrated competency with the task at hand. After over 200 hours of ethnographic observation, as well as interviews with emergency department and general medicine teams, Kennedy et al. documented four types of oversight, each of which might be appropriate in different situations (Table 17-2).10

The challenge going forward will be to find the very narrow sweet spot between unfettered trainee autonomy and stifling attending oversight, varying the level of supervision to ensure patient safety while also permitting the graded independence that trainees need to become independent practitioners.11,12 Thankfully, we are now much closer to finding the correct balance than we were even a decade ago.

I appreciate the importance of this issue in a very personal way. You see, in the case that began this section, I was the third-year medical student who missed the fatal pulmonary embolism.12

Although many discussions about medical simulation emphasize the ability of simulators to create realistic situations in which participants “suspend disbelief” (including supporting role plays that focus on teamwork and communication skills; Chapter 15), another key use of simulation is to allow individuals to traverse their procedural learning curves without harming patients. Even if we tested for procedural aptitude, like the military, novices' first few operations or procedures would still be hazardous to patients' health. Recognizing this, new surgeons traditionally work under the close supervision of a veteran—but not for very long. The adage of “see one, do one, teach one” is not much of an exaggeration: after a couple of years' training, apprentice surgeons or other proceduralists are largely on their own for all but the most complex cases.

The problem does not end once formal training is completed. After the completion of residency or fellowship, practicing surgeons and other interventionalists are essentially left to their own devices to acquire new skills or keep up with the latest techniques. In Complications, Gawande writes that his father, a senior urologist in private practice, once estimated that three-quarters of the procedures he performed routinely did not exist when he was trained.1 This means the issue of acquiring new skills safely is a lifelong challenge, not simply a trainee issue.

Consider the case of laparoscopic cholecystectomy, “lap choley” for short. Since being introduced more than two decades ago, this gallbladder removal technique has almost entirely replaced the much more invasive, and far more costly and risky, “open choley.” Laparoscopic techniques have also revolutionalized other surgeries, including joint repair, hysterectomy, splenectomy, and even some open heart surgeries.

The problem is that few surgeons trained before 1990 learned laparoscopic technique during their supervised apprenticeship. Is that a problem? Well, yes. One early study of lap choleys showed that injuries to the common bile duct dropped almost 20-fold once surgeons had performed more than 12 cases. And the learning curve didn't end there: the rate of common bile duct injury on the 30th case was still 10 times higher than the rate after 50 cases.13

Until recently, the requirement that a surgeon certify his or her competency in any new procedure was nil—the system “trusted” that professionalism would ensure adequate training before physicians began practicing on patients. Adding to the problem, there were few training models in which surgeons or other operators could efficiently learn new techniques without putting patients at risk. I spoke earlier (Chapters 8, 9, and 15) about what healthcare can learn from aviation when it comes to teamwork and communication. Here is yet another area in which aviation's approach to this problem—how to efficiently and safely achieve competency in high-risk situations using new equipment and procedures—seems far safer than medicine's.

In both commercial and military aviation, pilots prepare to fly new planes by first undergoing considerable formal training (in classrooms and in highly realistic simulators), followed by extensive, hands-on experience in the real thing, with an instructor pilot seated next to the pilot-in-training, manning a dual set of controls. After that, pilots must pass both written and flight tests to qualify in the new machine, and they are continually evaluated with annual “check rides” administered by senior instructors. If a pilot flunks a check ride, he or she is put back on training status until the deficiencies are eradicated. When pilots fail several of these checks or are involved in a serious incident or accident, they are evaluated by what the Air Force calls a “Flight Evaluation Board,” which has the power to clip their wings.

Contrast this with medicine's laissez-faire attitude toward recertification. Until relatively recently, there was no requirement for recertification in any specialty in American medicine, no requirement for demonstrated competency in new procedures, and no formal, required apprenticeship in new techniques (although some individual hospitals have enforced more rigorous criteria, and most states require some form of continuing education). This situation has improved in recent years: all major specialty boards now require recertification (“Maintenance of Certification” [MOC]; Table 20-1) and a number of specialty societies have set minimum volume thresholds before allowing independent practice. Moreover, accrediting bodies (including the Accreditation Council for Graduate Medical Education and the Joint Commission) are beginning to enforce more stringent requirements for competency-based credentialing of trainees and practicing physicians, respectively (Chapter 20).14

Even before these more rigorous requirements were enacted, many physicians did receive some training before beginning to perform new procedures, driven by both individual professional integrity and the malpractice system. But the data are sobering: a 1991 survey found that 55% of 165 practicing surgeons who had participated in a two-day course on laparoscopic cholecystectomy felt the workshop had left them inadequately trained to start performing the procedure. Yet 74% of these surgeons admitted that they began performing lap choleys immediately after completing the course15 (Chapter 5).

Now that the patient safety movement has convinced most observers that learning on patients is unethical when there are practical, safer alternatives, healthcare is increasingly looking to simulation. Procedural simulators have been around for decades in other industries. Military fliers used them even before World War II, although these “Link Trainers” were only crude approximations of the real thing. Static aircraft simulators (in which the cockpit is fixed to the floor while instruments give the impression of flight) became more sophisticated during the jet age, allowing new pilots not only to learn and practice normal instrument procedures but also to handle a wide variety of airborne emergencies. By the age of jumbo jets, supersonic airliners, and space shuttles, “full motion” simulators that gave the illusion of true flight became available—pilots could actually look out the window and “take off” and “land” at any airport in the world. And the U.S. military now uses sophisticated training simulators, with 10-channel sound effects, voice recognition software (including the languages of potential enemies and allies), and “battle smells” (burnt charcoal) to prepare troops for war.

Such training and performance evaluation aids—in which trainees interact with other human beings as well as with machinery and virtual displays—may hold the highest potential for medical simulations, which, until a decade or two ago, were pretty primitive. During medical school in the 1980s, I practiced giving injections using oranges, and sutured pig's feet. A somewhat lifelike mannequin (nicknamed “Annie,” for unknown reasons) has been used for years to teach cardiopulmonary resuscitation (CPR). Recently, however, these models have become far more realistic. Today's training mannequins allow students to deliver electric shocks with defibrillator paddles and note changes to heart rhythms, insert intravenous and intra-arterial lines, and perform intubations (Figure 17-1). Surgical simulators are now available to provide basic practice for medical students and residents and to help experienced surgeons learn new techniques. The major hurdle for these systems is simulating the feel of real flesh, but new technologies and materials are helping to overcome even that obstacle.

Until recently the link between improved dexterity from simulator training and fewer errors seemed intuitive but was not fully proven.16,17 But modern studies have begun to demonstrate tangible improvements in meaningful outcomes. For example, one study found that giving surgical trainees standardized feedback on simulated laparoscopic surgeries resulted in lower error rates.18 Another demonstrated that anesthesia residents who underwent high-fidelity simulation training were more adept at weaning their patients off cardiopulmonary bypass than colleagues who received standard classroom-based training.19 A third found that surgical residents who underwent proficiency-based virtual reality training committed fewer technical errors during their first 10 laparoscopic cholecystectomies.20

A high-fidelity simulator program is expensive (some surgical simulators run over $100,000, and training practicing clinicians requires both paying for the instructors and covering provider “downtime”) and logistically complex to administer. Salas et al. have identified 10 principles and tips for a successful simulation program (Table 17-3).21 Because of this cost and complexity, the broad dissemination of simulator training will depend not only on evidence of effectiveness but also on regulatory requirements, cost sharing (e.g., some regions and professional societies have formed consortia to purchase simulators), and return-on-investment considerations. One study showed that, because novice surgeons are slower in the operating room (OR) and require substantial hand-holding by senior physicians, an average of $50,000 in precious OR time is “wasted” during each resident's four-year training period.22 In the end, the arguments for simulator training may hinge as much on clinical efficiency as on safety.

Although one clever experiment showed that trainees improved as much on a urologic simulator costing less than a dollar (rubber tubes standing in for the urethra, styrofoam cup for the bladder) as on a high-tech version costing tens of thousands of dollars,23 today's trend is clearly toward more realistic, technologically sophisticated simulators. Modern virtual reality simulators are beginning to input actual human data, such as those drawn from an extraordinarily detailed digitized cadaver model known as the “Visible Human.” Other simulators are being developed that, rather than using generic anatomical data, use real patients' anatomy drawn from computed tomography (CT) or magnetic resonance imaging (MRI) scans. The day may come when surgeons will practice their patient's operation virtually (based on actual anatomy) before scrubbing in for a complex procedure.

While it is easy to get breathless about this futuristic technology, simulators are unlikely to completely replace having a well-prepared young learner observing, then doing, and then being corrected by a seasoned veteran. The line between learning and doing will be further blurred as simulations become more realistic and real surgeries become less invasive and more like the simulations. As more and more surgeries and procedures become “virtual,” it will be important to remember that simulators can help augment trainees' technical competence, but are highly unlikely to fully replace the need for trainees to learn their craft—as safely as possible—with real patients.

Over the past few years, the central importance of teaching patient safety and its related competencies has come to be appreciated. Without high-quality and effective educational programs for health professionals, the progress we need to make in safety will be stunted. Of course, this book is one small part of many efforts to fill that gap.

While the needs are broad and encompass practicing clinicians as well as trainees in medicine, nursing, pharmacy, and healthcare administration, medical students have been a primary focus of efforts to transform education. In an influential 2010 white paper, the Lucian Leape Institute at the National Patient Safety Foundation offered a series of thoughtful and ambitious recommendations, including the need to modify medical student selection criteria, provide foundational knowledge in patient safety and associated areas through a core curriculum, and alter trainees' clinical experiences to reinforce safety-related competencies (Table 17-4).24 Importantly, the latter recommendation takes heed of the informal “hidden curriculum,” which is closely linked to the overall safety culture (Chapter 15) and whose lessons can easily trump those of even the most well-intended formal programs.25 For example, educating students about teamwork and professionalism in the classroom will mean little if they rotate onto the wards and see their supervising residents and attendings modeling noncollaborative and disrespectful behavior.

A number of key patient safety resources are listed in Appendix I. Individuals interested in learning more about patient safety can take advantage of many Web-based resources, such as AHRQ WebM&M,26 a monthly case-based safety journal (Figure 14-1), and AHRQ Patient Safety Network,27 a weekly update of studies, Web sites, conferences, and tools in patient safety (Figures 22-2 and 22-3). These free resources, along with additional sources of information for patient safety leaders, are described more fully in Chapter 22.

Many training programs have begun offering a wide variety of safety curricula, and several descriptive and empirical studies of these innovations have been published.6,28–32 In addition, some larger organizations, such as the Institute for Healthcare Improvement (IHI), the VA's National Center for Patient Safety, and the Risk Management Foundation of the Harvard Medical Institutions, have made their curricula available.33–35 As one measure of trainees' hunger for patient safety education, at this writing more than 65,000 students and residents are registered on www.IHI.org and thousands have taken courses through IHI's Open School for Health Professionals.33

Many other issues related to patient safety education, such as improving diagnostic reasoning (Chapter 6), computerized decision support (Chapter 13), teamwork training (Chapter 15), and using malpractice cases to teach patient safety (Chapter 18), are highlighted throughout this book.

• Medical training has always needed to balance autonomy and oversight, but has traditionally tipped this balance toward trainee autonomy, largely for economic reasons.
• Driven in large part by the patient safety movement, the scale is moving back toward oversight, reflected in more available and involved supervisors and efforts to encourage trainees to admit their limitations and call for help.
• Particularly in procedural fields, the use of simulation will help trainees—and practicing clinicians who need to learn new procedures—traverse their learning curves with fewer risks to patients. Emerging data support the logical premise that simulation training leads to fewer errors and improved efficiency.
• Training the next generation of health professionals in patient safety–related competencies is crucial, and many curricula and resources have been developed for this purpose. Such training will need not only to provide foundational knowledge but also to pay attention to the “hidden curriculum” that trainees experience during their clinical rotations.