Tara Lamont: Where are the doctors in patient safety research?

Bob Wachter, a leading US clinical researcher and leader of “hospitalist” fame, came over here on a sabbatical last year and mentioned in passing his personal roll-call of influential figures from this side of the water on patient safety research. Jim Reason, Charles Vincent, Mary Dixon-Woods….but they are all social scientists. Where were the doctors? In the US, the leading lights combine research and clinical leadership—Atul Gawande, Peter Pronovost, David Bates, Lucian Leape, and Don Berwick.

A few exceptions come to mind, for example, Liam Donaldson, who is responsible for setting the agenda at a national and international level. Or Tony Avery, a GP, known for his work on prescribing errors, and Peter McCulloch, a surgeon, who has carried out popular studies on using Formula One handover techniques in operating theatres. Other professional groups have their research luminaries—particularly pharmacy, where Nick Barber and Bryony Dean Franklin are known for their work on medication safety in care homes to the evaluation of electronic prescribing. Nurse leaders have been prominent in safety campaigns and initiatives, for instance around infection control, but are perhaps less notable in research and setting the framework for debate.

But the absence of prominent medics as patient safety researchers and thinkers is puzzling. This may be part of a broader issue. Few trust chief executives in this country have a clinical background. In the US, Goodall’s work showed a positive association between high performing healthcare facilities and leadership by a physician. My quick googling of chief executives of high performing trusts (QUEST) on quality/safety markers show none with an obvious medical background, and only one with a nursing background. There’s a whole other debate around medical leadership and the interesting hybrid medical-managerial role from academics like Peter Spurgeon and Chris Ham.

Does it matter?  Look at it from another perspective and you could cite patient safety research as an example of social scientists leading the way—from Jim Reason’s analysis of latent threats and system weaknesses, to evaluations of complex safety interventions (Dixon-Woods, Benning). It has been exciting to see other, newer disciplines outside health come to the fore— human factors (Rhona Flin), design, and ergonomics (Peter Buckle). The important contribution of researchers with an understanding of organisational culture and sense-making is also vital/exciting. I particularly like the Currie/Waring observational study of hospital incident reporting systems, which showed how doctors determined what counts as safety incidents—for example, dismissing non-sterilisation of instruments as an issue. In this way, we know that top-down safety initiatives which overlook issues of professional and institutional cultures and hierarchies (pace Mintzberg) are doomed to failure.

So there is a good foundation for patient safety research in this country, driven by social scientists.  But Atul Gawande’s great insights into medical and surgical practice show so elegantly the dilemmas of doctors trained for a world that no longer exists.  Today’s clinicians need the ability to work in teams, communication skills, and checklists to navigate complex healthcare systems—and an understanding of how those systems work.  This kind of insight comes from the inside out.  So where are the UK’s Atul Gawandes who will shape the patient safety debates of the future?

Tara Lamont has worked for over twenty years in health services research, audit, and patient safety.  She currently works for the National Institute for Health Research and is an honorary fellow at the University of Warwick.

  • Aneez Esmail

    Tara, these doctors do exist. We have an active collaboration of primary care physicians who are researching and providing great insights into problems of patient safety in primary care – see for example http://www.linneaus-pc.eu/. Perhaps the problem is that there are none in secondary care!

  • Ken Catchpole

    Great blog.

    To pick out a few features, there is a cultural difference (the UK doesn’t promote “heroes” in the same way); there’s also an argument that there are lots of docs involved already; and that perhaps safety & performance improvement should be lead by people who are experts in those things. For example, Gawande is a great communicator, but his work also displays naivety about human behavior in complex systems.

    The solutions should be a partnership with all the required experts in the field. Working closely with Doctors everyday should be a goal of any scientist or expert involved in patient safety research; and leadership from well respected senior clinicians is vital to make it stick. In that respect, alone, we need better clinical leaders, and we need to make it easier for safety researchers to work closely with them; but clinicians are no more expert in systems safety than I am in healthcare, and we should not expect them to be. Indeed, the continued emphasis on training, communication, teamwork and checklists (at the expense of a wider range of solutions) illustrates in fact how little safety (and Human Factors) expertise is currently being used.

    To use a popular analogy, Jensen Button does not design and maintain his car or even lead the team; but works with other extremely skilled experts who are happy to work largely unacknowledged.

    PS. Allan Goldman would be very interested to hear about Peter McCulloch’s work with F1 on handovers. 😉

  • Patricia McGettigan

    Tara, your ‘quick Google’ was too quick and superficial. In secondary care, as in primary care, of course doctors are active participants in patient safety and research, locally, nationally & internationally. Take the issue of medicines – doctors are everywhere – and they work collaboratively with their MDT colleagues in this: Drug Safety committees; Drugs & Therapeutics committees; NICE & MHRA reviewers /contributors; Pharmacoepidemiology researchers; Clinical Pharmacology & Prescribing teachers; Medical education curriculum innovators; Adverse Drug Event reporters/researchers; Participants/leads on international patient safety/drugs use studies; Media reporting monitors – the list goes on and on and on.Revise your search terms and doctors’ enormous input to patient safety – from multiple perspectives – is evident.