Anywhere between tens of thousands and hundreds of thousands of Americans, depending on whom you ask, die of medical errors each year.
Now, universities are looking to address that fact by teaching clinicians and administrators to see medical problems in a new light, using coursework that might range from investigating the ins and outs of Medicare to exercises in communication, courtesy of peanut butter and jelly sandwiches.
Certificate and master’s degree programs in patient safety have sprung up over the past decade, and the first PhD track specifically focusing on patient safety and quality of care was launched in 2012 at the Northwestern University Feinberg School of Medicine. Its first graduate completed the program this summer.
The programs target clinicians and hospital administrators who want to learn more about how to improve patient safety. While medical residents nowadays are learning more about patient safety than their predecessors, older doctors have to play catch-up.
The PhD program does that with some innovative methods. For example, in order to learn about how challenging it is to communicate medical directions, students practice explaining how to make a peanut butter and jelly sandwich to an instructor pretending to be a Martian — someone who doesn’t have familiarity with basic English and the mechanics of peanut butter jars and bagged bread, said Donna Woods, an associate professor at the medical school who directs the PhD track.
“Invariably the student will write, ‘open the bag of bread,’” Woods said. “And so he rips the bottom rather than doing the little twist-tie thing.”
The instructor had threatened to smash open the jelly jar with a hammer, but has never followed through, Woods said.
This is meant to teach students that their directions might not be carried out as intended, which might lead to confusion or harm. Woods said she experienced something like this in her own research — when she was trying to convince liver transplant surgeons to use a different combination of painkillers to cut down on side effects, she found that, even though she distributed a clearly articulated set of directions, surgeons weren’t following her directions.
There were a few reasons, she said. A surgeon might have wanted to use the different painkiller, but hadn’t ordered it to be in the room for the surgery. When the surgeon got the painkiller in the room, she might not use it anyway because she was focused on the surgical procedure and not thinking about the painkillers. Woods’s solution was to have one of the nurses verbally remind the surgeon about the drugs and make sure they were used.
Another exercise highlights doctor-patient communication, courtesy of Legos. The class splits up into teams to try to build the tallest building possible. But they also have to hew their designs to one member of the team — the “customer” — who wants the building to look a certain way, perhaps to have a red base or a green spire. The customer is only to reveal their preferences if the rest of the team asks.
Woods said that, occasionally, team members will ask at the beginning of the exercise what the customers want — but for the duration of the half-hour building period, they’ll never check in with the customers again.
That lapse can highlight how, in the flurry of communication between doctors, nurses, surgeons, therapists, and more, the act of asking patients what they need and want is often sidelined.
These exercises are coupled with regular classes on research methods, so that students learn why the medical system is so complicated, and how they can work to make it better.
“There’s really a paucity of research on what is exactly effective for improving quietly and safety of care,” said Woods. “How are you going to get that research in order to understand what will be effective and meaningful? You have to develop people who can do research in that area.”
The first person in the country to receive a PhD in the field, Cynthia Barnard, is now the vice president for quality at Northwestern Memorial Healthcare. For her thesis, she surveyed patients on what they thought made for good medical care — and found a disconnect between what patients wanted and what hospitals were measuring. While hospitals keep track of readmission rates, what patients really care about is whether they are getting a correct diagnosis. And hospitals aren’t keeping good enough track of that.
The field of patient safety research, meanwhile, is small but growing. At the turn of the millennium, “patient safety became ‘a thing,’” said Dr. Albert Wu, an internist and director of the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health.
Wu said that researchers had been studying health care quality in general since the late ’60s, but it wasn’t until the past few decades that it coalesced into a coherent field.
President Bill Clinton mentioned a “Patients’ Bill of Rights” in his 2000 State of the Union address. A year later, an 18-month-old tragically died after a series of medical errors at Wu’s own institution. Researchers began to take patient safety more seriously, and hospitals began installing patient safety officers.
Medical education has responded in turn. Northwestern launched one of the first master’s programs in patient safety in 2006. George Washington University launched a master’s and certificate program in health care quality in 2010, and Johns Hopkins started a certificate program in 2012.
Some of these programs had optional research components, but professors at Northwestern decided that if they wanted to further advance the field, they needed to train more researchers. Thus the PhD track was born.
The program remains small. Barnard was the sole graduate in 2016, and one more student is on track to finish up next June. Barnard said it will take a few years to get the word out — just like it did with their master’s program, which now has over a dozen graduates a year.
And even with all the strides that the academic community has taken over the past decade, there’s still more work to be done. Barnard said that, for all the data we have collected, we still don’t know yet if patients are getting better — which patients think is the job of the doctor in the first place.
“[Patients] believe we ought to hold ourselves accountable to make them better over a long period of time,” Barnard said. “We don’t even have the tools in place to do that.”