Integrating Quality Into Medical School Curriculum: One Student’s Perspective
By Anne Press
The traditional medical school curriculum has a heavy scientific focus, especially in the first two years. In an already jam-packed curriculum, it can be difficult to replace any of the materials with improvement science. To combat this, Hofstra-North Shore-LIJ School of Medicine launched—with the school’s inaugural class in 2011—a four-year curriculum in patient safety, quality, and effectiveness. The following is an example of the impact this curriculum had on me, a student in that first class.
As I sat through a lecture on biochemical pathways and the pathology that can cause diseases like cystic fibrosis (CF), I was enthralled by the mechanisms of the human body. However, the human element of the disease was missing from the lecture. I was unable to take what I was learning and apply it to actual patients, in real-life settings, and understand how it affected their care.
Following the lecture, a physician from our local healthcare system entered the room and began to speak about the disease in a completely different context. We were given a real patient scenario of someone with CF admitted to the hospital for an unrelated problem. Because her physicians didn’t know how to properly treat CF, complications arose. Following her stay, the patient wrote a heartfelt letter to the hospital encouraging it to change the systems currently in place when caring for CF patients.
The physician asked us to review the case and identify gaps in care and methods that could have been instituted to improve the care provided. Although we were only a few months into medical school, we were able to look at the case with a fresh perspective and identify suboptimal care in the patient’s hospital stay. We viewed the healthcare system as a whole in order to identify practical points where care could have been adjusted. It was this exercise that enabled me to see the bigger picture. The patient became more than simply a patient with CF, and I began to understand how everything in the system affected her care. From the timing of meals to her ability to take her home medications while in the hospital, everything played a role in her outcome. We were able to identify multiple areas that could be targeted for improvement.
Following this exercise, we were told that an interdisciplinary microsystems team had been developed to address gaps in care for patients with CF such as had occurred in this case. The clinical microsystems approach is a conceptual framework that has been applied to various departments in the North Shore-LIJ Health System in order to improve patient safety. The basis of this approach is to identify a need in the hospital that may be targeted to improve the efficiency and efficacy of healthcare quality and delivery. Obstacles may be identified with root cause analysis, a systematic method of identifying the root causes of problems or events. Once the objective for healthcare improvement is determined, a multidisciplinary team is created, spanning one or more microsystems to target the specific barrier.
The CF team consisted of everyone from the patient’s parents to the nursing staff and physicians who cared for her. As a result, the team was able to identify various opportunities for improvement. Following implementation of these changes, patient satisfaction and outcomes for those with CF improved dramatically. That was not due to a new, innovative scientific discovery, but simply a willingness to review the processes in place and identify areas for improvement.
Following this introduction, I was intrigued by the ability of interdisciplinary teams to effect change. I knew that I did not have great breadth of medical knowledge as a first-year medical student, but I also knew that the different vantage points of every person involved gave the team meetings unique value. Therefore, I began to inquire about ways in which students could participate. However, because the school was in its inaugural year, there was no institutionalized process for that.
I decided to establish a chapter of the Institute for Healthcare Improvement’s Open School at our school. Through this organization, we were able to hold lectures for students on the importance of quality improvement. Furthermore, we established a mechanism for students to become involved in healthcare improvement initiatives. For example, we decided to initiate hands-on student involvement by having them participate on interdisciplinary healthcare improvement teams.
I joined a multidisciplinary team at a sickle cell clinic that was formed to improve the quality of care given to sickle cell patients, who often feel marginalized due to socioeconomic factors. The team was created in response to improper care of sickle cell patients who were admitted for acute care and received no pain relief for days.
We identified two main obstacles to improving care for these patients: (1) the time frame for pain reduction for patients admitted to the emergency department, and (2) a general lack of knowledge among clinicians regarding the excruciating pain sickle cell patients endure. After joining this team, I was able to help tackle these barriers by interviewing patients and collecting data to assess their satisfaction with care they received, including pain management, in the emergency department. Therefore, my introduction to hospital medicine was to address quality related to sickle cell patients, working with patients and physicians alike to improve care.
Being part of a new medical school, I was fortunate to have a curriculum based on quality improvement integrated into my education. It has afforded me an understanding of the importance of quality research and helped me garner the skills necessary to implement change. I have learned how to identify a problem, address it through a microsystems approach, and measure its response. I will take my passion and the skills that I have learned into the next stages of my training, in whichever specialty I choose.
Most importantly, I have learned to constantly challenge the status quo. As Atul Gawande stated in his New York Times best-selling book, Better, “Success can be found….with a readiness to recognize problems and a determination to remedy them” (p. 246).
Anne Press is a member of the class of 2016 at Hofstra-North Shore-LIJ School of Medicine in Hempstead, New York. She may be contacted at anniepress@gmail.com.
Reference
Gawande, A. (2008). Better: A surgeon’s notes on performance. New York: Picador.