FIVE QUESTIONS

Teaching and learning from medical residents

Anjala V. Tess, M.D.
Anjala V. Tess, M.D.

Anjala V. Tess, M.D., is a leading educator in patient safety, currently designing and directing programs at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS) in Boston. At BIDMC she is Associate Chair for Education in the Department of Medicine and co-created the Stoneman Elective in Quality Improvement and Patient Safety. She is currently Primary Investigator and Co-Director of the HMS Fellowship in Quality at Harvard Medical School, and is Program Director for the HMS Master in Quality and Safety. Dr. Tess is a practicing hospitalist at BIDMC.

The Betsy Lehman Center: In keeping with the American College of Graduate Medical Education’s (ACGME) preference for experiential learning, BIDMC has been involving residents in improvement projects for nearly 20 years. What are some of the advantages and challenges of that approach from the perspective of the hospital, as well as the residents and senior staff members?

Dr. Tess: Trainees are the frontline experts at academic medical centers they know what actually works and what doesn’t, where the gaps exist, and where workarounds are necessary to get things done. By tapping into these under-recognized experts, hospital leaders benefit from their specialized knowledge, the process is better understood and potential fixes can be more effective. In the Department of Medicine at BIDMC, we encourage trainees to use the reporting system and expose them from week one to our system-oriented Morbidity and Mortality conference. As residents progress, we assign them to do live event reviews and participate in projects to fix the system.

Trainees are the frontline experts, they know what actually works and what doesn’t, where the gaps exist, and where workarounds are necessary to get things done

Challenges to integrating trainees in AMCs can include hesitation to “let the residents in the room” and, of course, logistics. At BIDMC we are fortunate to have leaders who not only recognize our trainees’ value but invite them to the table. We have also seen anecdotally that by letting them in the room to do the work, we are more likely to hear about other potential risks, and the system learns faster. Another challenge is the sheer number of trainees and strong competition with other priorities for their educational time. We have found one way to manage that is to make safety practice part of the everyday work by including attention to processes and integration of safety concepts into clinical teaching. But we still set aside a small amount of dedicated time for our residents to get the specific skills training needed to analyze effectively.

Advantages for the trainee include the opportunity to make their environment safer. When it works, it is incredibly empowering for young physicians and can set the tone for their careers. We hear this regularly from our graduates. We have alumni who come back and tell us they are now the “quality and safety person” at their new institutions because they had the basic skills and felt the need to contribute.

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The Betsy Lehman Center: Physicians have been traditionally trained to be autonomous, and now we’re encouraging residents to be team players and share responsibility for safety. Is this a generational shift? How do you manage the transition as you embed residents in current practice?

Dr. Tess: Because it is multidisciplinary, health care has always been a team sport. The change is that physicians are more aware of their role in teamwork, and we are training to it. As the field of patient safety has borrowed from other industries and matured in its own right, the importance of teamwork has become clearer and been adapted for the health care setting. The shift has been happening for a decade or more. It is terrific to see the Association of American Medical Colleges and ACGME recognize teamwork and communication as clinical competencies.

Interprofessional training is being integrated as well. Residents in many departments at BIDMC train in simulated settings to practice teamwork skills both in critical or near-critical contexts. A simple example from internal medicine is engaging residents in the process of working with different disciplines to coordinate safe discharges.

The shift is from physicians making decisions in a silo to working with others on the team, including the patient, to make the best informed decision at the time. I feel fortunate to work with educators who can see how everyday care presents opportunities to teach these non-traditional skills.

I feel fortunate to work with educators who can see how everyday care presents opportunities to teach these non-traditional skills.

The Betsy Lehman Center: What do you recommend for health care providers who want to learn about patient safety but may not be able to enroll in a fellowship or master's program? What about providers who already understand the basics and are looking for more in-depth training?

Dr. Tess: Most patient safety practitioners today have not had formal training in patient safety, and fellowships and masters programs are relatively new to the landscape. They can have major impact but, like most postgraduate training, they may not be for everyone. If you have been bitten by the patient safety bug, going to a conference like the Institute for Healthcare Improvement’s National Forum or a meeting of the International Society for Quality in Health Care can be energizing. You not only learn, you begin to build a network of like-minded professionals. There are many online courses and certificates, which require fewer resources, and some academic institutions, including Harvard Medical School and Northwestern University, offer programs that combine distance learning with in-person sessions.

However, I like to remind people that training alone is not sufficient. The power of building your new skills is in being able to apply them. You can do that in your own backyard by being curious, even if you don’t have a formal thesis project to complete. If something isn’t making sense in your own work environment, try to find out why it is set up that way. You may not be able to change it right away, but you may find the people who are trying to make things safer at your institution.

The Betsy Lehman Center: There is increasing concern about physicians becoming “burned out” in practice over time and the effect on patient safety, as well as on the health of physicians. Some say that process begins during residency. Do you address physician burnout and wellness in patient safety training at BIDMC?

Dr. Tess: As the connection between provider burnout and patient safety gets further attention, concern for workforce wellness is front and center. Like many large academic centers, we have a large initiative across our medical center to better understand the provider experience, including that of trainees. In many of our programs, we teach human factors and the role that contributing factors such as fatigue and distraction can play in unsafe care. In our event analysis, we make a conscious effort to explore the systems issues and the impact of the environment of care to identify unnecessary workarounds or causes of stress. I sometimes worry that when we find system failures, the natural reflex can be to add more steps, a checklist or a hard stop. These are important tactics to improve safety, but there are consequences to adding work to the work. We may be pulling staff away from other important work. We may be adding to the distraction in a way that not only makes care less safe but also increases burnout. Ideally the safety solutions would not increase clicks or stress in the environment. Ideally our fixes should focus on making it easier to do the right thing.

The power of building your new skills is in being able to apply them.

The Betsy Lehman Center: If there were one thing about patient safety you could remind your residents about after training — a key aspect you feel most providers need to remember — what would it be?

Dr. Tess: I would say to remember that safe care comes from everyday behaviors and routines, not just from reacting to adverse events and putting in fixes. The importance of reporting and analyzing events to discover holes in the Swiss cheese is critical. That is how we learn to make things safer and hospitals can work with providers to fill in those holes. I think every doctor should understand this. The reality of practice, however, is that we work in a chaotic environment where we have to adapt to evolving situations quickly. In those situations, good habits or “muscle memory” developed in everyday practice can help us focus and mitigate risk that builds when our attention is pulled away.

As providers, our duty is to participate and learn how to do things better, to be accountable to expected practice. But success in this requires we work in partnership with the system, which can be designed to help support safe habits every day. Supporting structures, such as huddles, can reinforce communication, and simply removing unnecessary barriers and workarounds can create space for thinking and caring for patients.

In the same way that most events have more than one root cause, protecting patients cannot be done by providers or systems alone. Balancing both with the resources we have is what pushes patient safety past its scientific roots. It is in some ways the “art” of patient safety.

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