Finding safety in medical education

The doctor-patient relationship has been at the core of medicine for centuries. However, the last decade of the 20th century has seen radical accelerating change in the context in which that relationship is embedded. It is increasingly complex and hurried and, disturbingly, it is fraught with substantial risk to the patient. Similarly, the teacher-learner relationship exists at the core of medical education, which must wrestle with the same accelerating change. While the focus on patient safety gains increasing attention in the clinical setting, it is slow to gain strategic awareness among medical educators. Were it of biological origin, the discovery of an epidemic that results in 44 000–98 000 deaths annually in the US alone would quickly find its way to the formal medical curriculum, for changes in biology and technology (particularly of such magnitude) are readily incorporated by medical faculties. Patient safety pushes medical education into unfamiliar territory. Complex systems, culture, and teamwork are not mainstream topics in the traditional curriculum. So, where do we start? In this issue of QSHC Aron and Headrick set out an excellent proposal by offering a systems metaphor for discerning safety in medical education. They argue persuasively that the “organizational defences” of the medical education system fail, and the result is inadequate education for doctors to provide safe care. Students and, importantly, their future patients are at risk. The authors focus strategically on important elements of medical education that include entrance requirements, curriculum, organizational culture, assessment, and accreditation. The list is daunting but on target and highly strategic. All the same, the strategy might benefit from further reflection on deep seated trends that envelop medical practice and, inevitably, contemporary medical graduates. THE EVOLVING DOCTOR-PATIENT AND TEACHER-LEARNER RELATIONSHIPS Consider the relentless transformation that occurs in two essential bonds in health care and medical education—the doctor-patient and the teacher-learner relationships. The traditional doctor-patient relationship is frequently amended by the imperative for doctors to collaborate more effectively with each other and with other health professionals. What has traditionally been a “one to one” bond for the patient now may require effective integration with a “one to many” relationship. Another element that has dramatically altered the interaction between doctors and patients is the Internet. There was a time when medical knowledge was a principal source of authority for the doctor. Now both the patient and doctor have access to the same information. The doctor is now responsible for integrating and customizing information for the benefit of the patient. While professional authority still plays an important role in how the doctor provides counsel, the ubiquity of information brings about a substantial realignment. There exists little formal education for dealing with these inevitable modifications of the doctorpatient relationship. The teacher-learner relationship is also evolving. Leach suggests that the studies of Hubert and Stuart Dreyfus provide a valuable insight into how doctors learn. Working in the 1970s, the Dreyfus brothers studied how pilots acquire knowledge and skills. They described five progressive stages in the continuum of learning: novice, advanced beginner, competent, proficient, and expert. The novice learns by careful application of a defined set of rules. The advanced beginner demonstrates greater skill by applying those rules to new unforeseen situations. As learners acquire expertise, learning sheds rule bound behavior and becomes more intuitive. The Dreyfus model can be readily applied to the continuum of medical education. The process begins when medical students move from novice to advanced beginner during their medical school experiences. Trainees in graduate medical education progress to acquire competence, and expertise resides with the senior teaching faculty. The emergence of new knowledge, however, drives constant and dynamic reorientation of the teacher-learner relationship along the continuum. In the traditional teacher-learner relationship, senior (expert) doctors impart knowledge to (novice and advanced beginner) students and (increasingly competent) graduate trainees. That having been said, most would concede that expertise in information technology currently resides with the student and trainee, while the senior doctor is the novice. When it comes to patient safety, all learners along the continuum from medical student to teaching faculty are novices. In medicine, rapidly accumulating new knowledge increasingly merges the traditional roles of teacher and learner.