Eric J. Alper

Learning from Mistakes: Factors that Influence How Students and Residents Learn from Medical Errors

AbstractCONTEXT: Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE: To identify major factors and areas of tension in trainees’ learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS: Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS: Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS: Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey.

Purpose To describe current patient safety curricula at U.S. and Canadian medical schools and identify factors associated with adoption of these programs. Method A survey was mailed to institutional members of the Clerkship Directors in Internal Medicine at U.S. and Canadian academic medical schools in 2006. Respondents self-reported implementation of patient safety curricula and associated methods of instruction at the institution level. Results The survey had a 76% response rate (83/110). Only 25% of institutional members reported that their schools had explicit patient safety curricula. All respondents that reported having curricula use lectures and small-group instruction, and these were more likely to occur in preclinical settings. Topics and methods of instruction included reporting adverse incidents and analysis of medical errors; improvement of physician order writing to prevent medication errors; core measures; national patient safety goals; and standardization of medical care through the use of clinical guidelines and order set templates. Although only 25% of respondents reported having explicit curricula, 72% agreed that patient safety instruction should occur during medical school. Conclusions Despite calls from regulatory, medical, and educational organizations to increase patient safety training of medical students, internal medicine clerkship directors report that few schools in the United States and Canada have implemented specific patient safety curricula. Most existing patient safety curricula use lecture and small-group discussion as preferred methods of instruction.

Between two worlds: a multi-institutional qualitative analysis of students' reflections on joining the medical profession.

BACKGROUNDRecent changes in healthcare system and training mandates have altered the clinical learning environment. We incorporated reflective writing into Internal Medicine clerkships (IMcs) in multiple institutions so students could consider the impact of clerkship experiences on their personal and professional development. We analyzed student reflections to inform curricula and support learning.METHODSWe qualitatively analyzed the reflections of students at 3 US medical schools during IMcs (N = 292) to identify themes, tone, and reflective quality using an iterative approach. Chi-square tests assessed differences between these factors and across institutions.FINDINGSStudents openly described powerful experiences. Major themes focused on 4 categories: personal issues (PI), professional development (PD), relational issues (RI), and medical care (MC). Each major theme was represented at each institution, although with significant variability between institutions in many of the subcategories including student role (PI), development-as-a-physician (PD), professionalism (PD) (p < 0.001). Students used positive tones to describe student role, development-as-a-physician and physician–patient relationship (PD) (p < 0.01–0.001), and negative tones for quality and safety (MC) (p < 0.05). Only 4% of writings coded as professionalism had a positive tone. Students employed a “reporting” voice in writing about clinical problem-solving, healthcare systems, and quality/safety (MC).DISCUSSIONReflection is considered important to professional development. Our analysis suggests that students at 3 institutions reflect on similar experiences. Theme variability across institutions implies curricula should be tailored to local culture. Reflective quality analysis suggests students are better equipped to reflect on certain experiences over others, which may impact learning. Student reflections can function as a mirror for our organizations, offer institutional feedback for support and improvement, and inform curricula for learners and faculty.

Using standardized patients to assess professionalism: a generalizability study

Background: Assessment of professionalism in undergraduate medical education is challenging. One approach that has not been well studied in this context is performance-based examinations. Purpose: This study sought to investigate the reliability of standardized patients’ scores of students’ professionalism in performance-based examinations. Methods: Twenty students were observed on 4 simulated cases involving professional challenges; 9 raters evaluated each encounter on 21 professionalism items. Correlational and multivariate generalizability (G) analyses were conducted. Results: G coefficients were .75, .53, and .68 for physicians, standardized patients (SPs), and lay raters, respectively. Composite G coefficient for all raters reached acceptable level of .86. Results indicated SP raters were more variable than other rater types in severity with which they rated students, although rank ordering of students was consistent among SPs. Conclusions: SPs’ ratings were less reliable and consistent than physician or lay ratings, although the SPs rank ordered students more consistently than the other rater types.

Quality Improvement “201” Context-Relevant Quality Improvement Leadership Training for the Busy Clinician-Educator

Development of quality improvement (QI) skills and leadership for busy clinician-educators in academic medical centers is increasingly necessary, although it is challenging given limited resources. In response, the authors developed the Quality Scholars program for primary care teaching faculty. They conducted a needs assessment, evaluated existing internal and national resources, and developed a 9-month, 20-session project-based curriculum that combines didactic and hands-on techniques with facilitated project discussion. They also conducted pre–post tests of knowledge and attitudes, and evaluations of each session, scholars’ projects, and program sustainability and costs. In all, 10 scholars from all 3 generalist disciplines comprised the first class. A wide spectrum of previous experiences enhanced collaboration. QI knowledge increased slightly, and reported self-readiness to lead QI projects increased markedly. Protected time for project work and group discussion of QI topics was seen as essential. All 10 scholars completed projects and presented results. Institutional leadership agreed to sustain the program using institutional funds.

Disagreement Between Students and Preceptors Regarding the Value of Teaching Behaviors for Ambulatory Care Settings

Background: Medical students and preceptors commonly disagree on methods of clinical instruction in ambulatory care, although the extent of the problem is not documented. Purpose: The purpose is to identify disagreement and concordance between students and preceptors for teaching behaviors in ambulatory care. Methods: We surveyed students and preceptors at 4 U.S. schools. Respondents rated 58 behaviors on two scales. Disagreement was recognized when the percentage of students and preceptors who recommended a behavior and rated it important differed by over 15% (p < .01). Results: Disagreement was identified for 8 behaviors (14%). Six were valued less by students, including “watch the student perform critical tasks in history taking and other communication” (59% compared with 82%). Two behaviors were valued more by students, including “delegate responsibility to the student for the wrap up discussion with the patient” (82% compared with 61%). Conclusions: Students and preceptors disagree regarding the value of a minority of teaching behaviors. Because some are potentially important, however, early negotiation regarding their use may enhance teaching effectiveness and mutual satisfaction with learning.

Participation of internal medicine department chairs in the internal medicine clerkship--results of a national survey.

Purpose To characterize the involvement of internal medicine department chairs in the core third-year internal medicine clinical clerkship. Method In 2003, the Clerkship Directors in Internal Medicine (CDIM) surveyed its membership. Along with demographics, clerkship directors were asked if the departments chair participated in the clerkship, the number of hours per month the clerkship director and chair discussed clerkship issues, and if published job expectations were discussed. Results The response rate was 62% (158/254): 103 responses (89 clerkship directors) represented unique medical schools, which formed the basis of the analysis. Eighty-two percent (84/103) reported the chair taught in the clerkship: 54% as teaching attending, 53% as ward attending, 13% as ambulatory attending, and 20% other (e.g., lectures, student rounds, morning report). Of them, 36% performed two activities; 14% three activities; and 2% four activities. Thirty-six percent of the clerkship directors discussed published expectations with their chair. They spent 1.7 (SD 2.2) hours per month with the chair discussing clerkship issues. However, 17% spent zero hours per month with the chair, and 29% spent zero hours per month with a deans office representative. Chairs who taught spent more time each month with the clerkship director compared with chairs who did not teach (1.9 versus .82 hours, p = .01, Mann-Whitney). There was no association between the chairs’ teaching and clerkship directors’ demographics. Conclusions Internal medicine department chairs are significantly involved in the clinical education of medical students, both administratively and through direct teaching. Chairs who teach spend more time discussing clerkship issues with the clerkship director. Chairs and clerkship directors should discuss expectations, and chairs should continue to visibly demonstrate their commitment to students’ education.