“See One, Do One, Teach One” A Medical Education Mantra and Issues of Patient Safety in Teaching Hospitals
From an article “Resident’s Suggestions for Reducing Errors in Teaching Hospitals” in the February 27, 2003 issue of the New England Journal of Medicine by Volpp and Grande:
"I put in a central line today that was complicated by a pneumothorax. I had never done this procedure before, and I am not sure the resident who was supervising me had much more experience than I do."
"See one, do one, teach one" has been a long-standing mantra of medical education.
Well, if it isn’t one, it may be only 3 or 4 or a few more but the person supervising the intern or resident performing the procedure may often be also a resident in training and not a seasoned attending physician who has done 1000 or more and has experienced all the necessary nuances of performing the procedure and has had the opportunity to develop reliable responses to any complications that may occur. Even if the intern or resident has performed a number of procedures, the issue arises as how to establish that the individual has become competent sufficiently to perform the procedure alone and without supervision as may be necessary.
“See one, do one, teach one” is only one example of the concerns regarding patient safety within teaching hospitals. Others involve “handoffs”, the transfer of the care of a patient from a resident physician going off duty to one who is just coming on. When there are many patients to discuss, some details in this relatively brief communication between the two physicians may be missed and the consequences of such “forgotten” information may be critical. Time available to take a thorough history and perform the physical exam may be limited and the time which is available may include distractions for the resident such as interruptions by “urgent” phone calls or paging. In addition, unsatisfactory system practices, also not uncommon to all hospitals, teaching or not, may lead to medication errors or surgical errors as examples. Long work hours, as set by the system, with resident fatigue has been attributed to errors. And errors can lead to patient deaths as publicized in the Institute of Medicine’s 2000 report “To Err is Human” with estimates of as many as 98,000 deaths occurring annually in U.S. hospitals due directly to medical errors. Though the high figure has been debated by some as too high and not an accurate estimate, nevertheless any death due to medical error is of concern.
Teaching hospitals will inform the patient, in print, on admission that they may be examined and treated by staff that are still in training but is this enough information for informed consent by the patient? Admission to a teaching hospital is often unavoidable and always there is the altruistic value to the patients of a contribution to society by permitting the training of physicians on themselves. How else do you think that physicians should be trained to go out into practice with the needed skills for their care of their own patients if not in teaching hospitals? And if teaching hospitals are necessary, what changes would you suggest to make them and all hospitals safer places to be treated? ..Maurice.
posted by Maurice Bernstein, M.D. @ 5:12:00 PM
11 comments
11 Comments:
The increasing use of computer networks throughout many hospitals should make it possible to help with this problem. The network may primarily be their for storing and retrieving patient information, but there isn't any reason why there couldn't also be a medical information library and drug interaction system available as well.
Give doctors the ability to rapidly locate detailed medical information beyond what anyone could ever expect to remember. Your memory may allow you to recall the more obvious info, but the computer could make entire medical texts available to assist a doctor.
I have been working in the electronics and computer programming field for over 25 years and there is no possibility of my remembering everything. That is why I have access to the internet and massive amounts of searchable information stored on my hard drive.
Give doctors access to something similar and errors should be reduced at the same time that doctors can more quickly learn how to carry out a procedure that they aren't entirely familiar with.
I would like to know if in Medical schools doctors/suregons and anyone else involved in a Surgical theatre is being trained in Surgical Fire prevention.
My mother was set on fire during surgery, and eventually died because a nurse left her connected to any empty oxygen tank two seperate events two differnt hospitals. I was stunned as a consumer I did not know about Surgical Fires. I created a website www.surgicalfire.org to help educate others about surgical fires.
My mother's suregon was a resident, and the doctor supervising was present how they allowed her to burn for over a minute....I just can't imagine.
The medical world is a complex system and there are many, many aspects of medicine I believe should change. Unfortunately I'm a consumer, and our voice is not loud enough yet, but I'm trying.
We all need doctors, and hospitals so I believe we should all try and work together for change.
Whether a hospital is a teaching hospital is not always evident to the patient who is having their first operation. My hospital was Cedars Sinai in Los Angeles. I thought it was a private hospital as its name didn't suggest that it was part of any university system. When I checked into admissions before the surgery, I was given a stack of papers to sign. They were already opened to the pages requiring my signature. I was rushed through with other patients waiting in line behind me. There was no way I could have given those papers any thoughtful consideration at that time. Some weeks later I did read my copies of those documents, one paragraph of the consent form stated that "people in training may be present and may participate in the operation". Little did I know that my signature after that vague description could give permission to an unlicensed, medical novice that I never met to actually perform the procedure, while the surgeon I contracted with prompting him from the sidelines.
I'm curious about the saying that doctors make the worst patients. Could it be due to their knowledge of what actually goes on behind the closed doors of the operating room, and the twisting of arms to insure that their bodies not be used as a prop for training.
Mia, it seems to me that hospitals must assume that the patient already knows that the hospital is a teaching hospital and has full knowledge of the significance of that designation to the patient otherwise they would be expected to sit down and explain to the patient the facts for informed consent, just as a surgeon must sit down preoperatively with the patient and explain the benefits vs risks. In the case of the preop informed consent, simply having the patient sign acknowledment of a printed document is not legally nor even ethically sufficient. I have a feeling that hospitals expect their attending physicians to already have explained to the patient the details of a teaching hospital practice prior to admission. In my own professional experience as an internist, I have never had to admit a patient to a teaching hospital and therefore I don't know the hospital's expectations regarding physician communication. I do supervise first and second year medical students at Los Angeles County-USC Medical Center but I don't know what the patients there are told, however myself and my students always tell a patient the role of the student and only involve the patient for a history and physical exam if the patient agrees. If the patient disagrees to be examined, we thank the patient for listening and move on to another patient.
Has any other visitor have experiences as a patient in teaching hospitals? I would prefer for a number of reasons that the visitor not identify the hospital, physicians or others involved by name. Thanks.. ..Maurice.
Oops! I want to clarify my last request against naming names. If the comments are critical of the institution or person, I don't want the name of that institution or person disclosed. (My identification of LA County Hospital was OK because, I made no comments criticizing the hospital.) One of the reasons for this request is simply that this is a "discussion" blog and if there is no timely opportunity for the party criticized to respond, there fails to be any "discussion" of a view. ..Maurice.
I have been going to a teaching hospital since age 14, when I was diagnosed with cancer. I am 46 now, and I have never had a problem with the care that I have received.
I see a variety of different doctors for different problems and most of them are listed as professors who have responsibility for medical training. The med students that have examined me appeared to be well trained and it has never been a problem.
I see 3 different oncology doctors, a cardiologist and will be seen by an osteoporosis specialist in a few days. I was originally sent to this hospital from a much smaller hospital and the care and knowledge of the doctors has always been very good.
I teach in a medical school and I think there is a huge issue with not having enough experienced physicians who are paid to take the time to teach students. Most physicians take on students/residents as an extra load to their practice and have minimal time to spend supervising.Money is part of the problem, but physicians in a full time practice also feel responsible for providing the usual level of care to patients, so that also reduces time with students.
We need more physician faculty with reduced patient loads.
I have been going to a teaching hopsital for several years now and so do my children and spouse. We have never had a problem with this at all and I could not change it for anything.
It never ceases to amaze me that people want competent doctors with a lot of experience yet are not willing to contribute to the system that will get them there. Where in the world do they expect them to learn? It has to be on a human body. Why not theirs? Why not mine? The teaching doctors being few is the problem, not the students.
Are there any statistics that show there are more accidental deaths or complications in teaching hospitals as opposed to other hospitals?
Maybe you'll find this interesting:
I had my major surgery at a teaching hospital. I knew that's what it was, and that's why I went there for surgery. My doctor was there, the surgeon she recommended was there, and I've always gotten good care from it. I knew going in that stuff at a teaching hospital is done by residents. The interesting thing is that when I had a pre-op appointment with the resident, I asked him directly if he would be the one performing the surgery. His response was "Well... it's sort of a team effort." He did not answer the question directly. I didn't really care; I knew I was being operated on by residents under the supervision of my surgeon of choice, and that was fine with me. I learned about the actual dynamic in the operating room from a med student friend, who explained that usually the residents operate while the surgeon observes and scrubs in if it becomes complicated. I knew the deal when I decided to go ahead with the operation. Still, I find it interesting that the resident dodged my question when it came up.
To the poster, Anonymous (Nov. 15 3:21 pm) who asked for statistics about adverse outcomes caused by residents in teaching hospitals, here is an article on medical malpractical from Medical News Today, which states the following:
"Of the closed medical claims involving both error and injury, more than one-fourth (27 percent), or 240 cases, involved trainees whose role in the error was considered to be at least moderately important, the study found. Medical residents were involved in 87 percent of those cases; interns and fellows each were participants in 13 percent. Adverse outcomes were serious: one-third resulted in significant physical injury, one-fifth in major physical injury, and one-third resulted in death. Nearly a third of the cases took place in the outpatient setting."
The whole article can be found here:
http://www.medicalnewstoday.com/articles/86220.php
June/rn, thanks for the URL to the resource for the statistics on serious errors by residents, interns and fellows.
Again, the question is what should be done to minimize the error production? ..Maurice.
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