By Molly Siegel (Medical Student, Boston University School of Medicine)
Before starting medical school, I imagined medicine was what I saw on television: I would save lives by poring through textbooks to diagnose an obscure parasite, or by dissecting a rare tumor away from the carotid artery. But quickly I learned that healthcare is more than Dr. Meredith Grey or Gregory House’s heroic efforts. Yes, sometimes patients do have rare and bizarre conditions, and extraordinary levels of diagnostic and surgical skills are required for their care. But often in the hospital, patients are admitted for a diagnosable, manageable illness- and what endangers them is not their disease, but the systems issues they’re susceptible to while admitted for life-saving treatment.
During my third year of medical school, I frequently saw that patients admitted for a chronic or acute disease were kept longer or readmitted due to preventable medical errors and hospital-acquired infections. This is not to critique my home institution, as it is rather universal, as I rotated through multiple local hospitals and friends at other medical schools echoed my experiences. Initially, I was disillusioned by all the preventable morbidity. How could I help my patients get better, if their hospitalization could make them sicker?
Early in medical school, I had connected with a mentor, Dr. Jodi Abbott (Vice Chair for Education in the Department of Ob/Gyn and the Co-Director of Patient Safety and Quality Improvement Education at Boston University School of Medicine), who was passionate about quality improvement (QI). As I began the Institute for Healthcare Improvement Modules, with its Plan-Do-Study-Act (PDSA) cycles, run charts, and agents of change, I entered the world of patient safety. With this background and training, I saw many of the processes on the ground through different eyes. I saw how second-checks by nursing staff and pharmacists saved lives. I saw every one of our patients who suffered from opioid use disorder discharged with naloxone after receiving detailed training. I saw heparin ordered for many of our patients with high risk of thromboembolism. I knew someone had worked hard to design and advocate for these systems that were so effective.
But on the days that the systems didn’t catch errors, or adverse risk was not prevented, I found myself thinking about solutions, imagining interventions. When I saw preventable adverse events, yes, I was discouraged- but I also had the toolkit for change from my QI exposure, and this gave me hope. By improving quality, we – meaning doctors and future doctors, alike – may prevent far more morbidity and mortality than by learning the newest surgical technique. And most of us went to medical school to save lives, right?
I received most of my QI training from extracurricular involvement, but I believe medical school curriculums should teach all students proficiency in QI. Residency programs are increasingly requiring QI projects in their curriculum. Hospitals are rated on quality standards that patients use to choose their care, and in 2008 Medicare no longer offered reimbursement for many hospital-acquired conditions.. For better or worse, top-down financial interests are incentivizing hospitals to improve their systems. Physicians will be expected to comply with, and eventually understand and work in interdisciplinary teams to implement effective QI interventions. Training medical students in QI is essential in this changing climate.
At our institution, we have recently implemented QI courses into our first-year curriculum, and every third-year clerkship has its own QI project. I was part of this effort, creating a project to incorporate third-year medical students into an initiative in the Ob-Gyn department to increase venous thromboembolism prophylaxis using the PPAHS OB VTE Safety Recommendations. Our institution’s interventions are not perfect, and there is still more to be done – but it’s a start.
Medical students can be opportune agents of change in QI. Medical students are highly effective at identifying patient safety issues and developing novel interventions. Students should not only be participating in projects during their training, but should be involved in the initial design process to help develop innovative, lasting changes to improve care. Frequently on the wards, my peers are the first to notice medical errors, or remind the team to start a patient’s heparin. Students are curious, and they question the systems in which we practice: they ask, “How can we do better?”
I was grateful for my QI training on a personal level when a loved one was recently hospitalized with bacteremia following an elective procedure. Once I was reassured he had appropriate fluid management and antibiotic coverage, I became concerned about preventing further adverse events. Throughout his admission, he received attentive and compassionate care and recovered fully. But I noticed despite meeting the criteria, he did not receive any pharmacologic anticoagulation. He had an incentive spirometer but had not been taught to use it correctly. I was able to advocate to keep him safe while admitted, but it begs the question of why so many patients continue to face preventable complications. I believe the value in QI exposure in medical school lies in training future physicians to approach patient care through the QI lens. By integrating quality into the curriculum and teaching medical students to address systemic weaknesses, perhaps our patients- and loved ones- will be safer.
Molly Siegel is a fourth-year medical student at Boston University School of Medicine applying in Ob-Gyn. She is interested in advocating for improved patient care by educating and engaging students in quality improvement.