Patient safety: time for a transformational change in medical education

To the Editor: The pace of improvement in the safety and quality of health care has been disappointing. However, the recent enthusiasm for medical education providing a new solution is troubling.1,2 The safety and quality movement has been regrettably dismissive of the need for creation of evidence.3 Indeed, it now seems that the focus on “dramatic” errors has been a distraction from the major volume of harm due to the poor care of patients with chronic disease.4

There is substantial literature on the development of professionalism, which attests to the difficulty of teaching medical students non-technical skills (or of selecting students with “appropriate” attitudes). There are three major reasons for this difficulty.

The first is the problem of defining the desirable standard — whether of safety or professionalism.5,6

The second is the so called “hidden curriculum” — the ubiquity of error, unsafe practice and unprofessional behaviour that students are exposed to in clinical environments.

Third, many of the safety and quality issues and skills just do not seem relevant to the students, despite the care that has been taken in the development of safety and quality curricula. To provide “experience that is arranged to be both motivating in the moment and consequential for capabilities in the long run”7 will require a new and more pragmatic approach to education. We need to select safety and quality issues that all doctors can influence by exercise of their personal knowledge and skills. This is the stuff of medical education. Errors in clinical reasoning8 form an excellent teaching topic, but many safety problems are simply too hard for medical students (neither do we expect medical students to learn the details of intensive care or casemix funding).

Provision of appropriate experiential learning requires links to the people who understand and manage governance and safety in the clinical workplace. Rather than a stand-alone communication syllabus, the medical students in Queensland, for example, should receive the same teaching about clinical handover as the junior (and senior) medical staff of Queensland Health. Handover is then perceived as a highly relevant skill.

If competencies in safety for medical stu-dents are to be required they must be linked to both fuller competencies for graduate training and the introduction of safer workplace practices. Without these parallel and more important activities, the proposed reform in medical education is likely to be disappointing in its impact.