For most medical students, formal teaching of quality improvement probably involves little more than identifying the differences between audit and research. Certainly for me it didn’t, but the rising question today is whether there is need for more than this in medical student education.
Helen Bevan, Chief of Service Transformation NHSIQ, promotes the philosophy of junior doctors as change agents and those who will be driving improvement science in the future, and I agree wholeheartedly with this. Engaging clinicians in organisational quality improvement gets results. But should this engagement start at university? The answer must be “yes”, but within a proper context.
Atul Gawande, American surgeon and professor of surgery at Harvard Medical School, identifies five lessons for medical students in his book, “Better”. These lessons are aimed at preventing those new to medicine feeling like small cogs in a vast machine. He holds to the philosophy that “better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”. Of Prof Gawande’s five lessons, three are directly transferable to quality improvement and I would like to stress their importance in medical education. My selected three are:
- Ask an unscripted question, interpreted as ”get to know your patient”
- Count something. Here we need to consider what we are counting, and a changeable variable would be the obvious
- Change an element of your practice based on your observation and counting. Then count again.
If we rephrase these three lessons in a different way, we could say that all doctors should promote change in a measurable, variable in response to the psychology of the patient whom they now consider in more ways than just their disease. Put like that, is that not clinical audit? In fact, is that not all of clinical and organisational quality improvement in a nutshell? So here we have a simple strategy for teaching medical students that is itself transferable to all aspects of quality improvement.
Having said that though, when I try to remember what I was taught about quality improvement as a medical student, I draw a fairly large blank. Now however I find it is a very active part of my practice and career. Clinical quality improvement is encompassed in the regular audits, and participation in morbidity and mortality meetings that must be every doctor’s aim. The more elusive organisational quality improvement is something that I am exposed to through a teaching program called ImERSE and my job as a clinical research fellow for patient and family centred care. ImERSE is a quality improvement and medical education tool developed and used at Alder Hey Children’s Hospital. It utilises patient shadowing as a method to capture qualitative care experience data that is thematically analysed to allow for regular feedback into service and quality improvement. The shadowing is undertaken by medical students in the surgical daycase unit, the accident and emergency department, and soon outpatients. The student is removed from any clinical responsibility and encouraged to think about the patient and their family as the centre of a care experience, considering how much the hospital and the care offered affect the psychology of the patient and their family. ImERSE identifies five major themes of medical education:
- Patient and family centred care as the most important concept for practice methodology
- Preparation for practice by encouraging authentic early years exposure, and by asking students to consider the psychological aspects of hospitalisation so that the emotive bombardment from patients and families when they graduate isn’t an unknown
- Identification and addressing of the “hidden curriculum”
- Inter-professional education and finally
- Patient safety and quality improvement.
ImERSE allows the students to partake in a quality improvement program run by others. It promises to feed back at the end of the placement the findings that that cohort has identified. It promises to explain how we the hospital aim to address them, and it promises that if the students return to Alder Hey they will see those improvements made. It lets them see that quality improvement can be easy, and not something to be feared.
Herein I think lies the approach to medical students. I don’t think we need to bombard them with detail, they do not need to know about Lean and Six Sigma; armed with the three lessons extracted from Atul Gawande, and with willingness to try, they will understand that they can bring about improvement.