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.