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Clear expectations make better doctors

From the April ACP Hospitalist, copyright © 2010 by the American College of Physicians

By John Matulis

In my short years of clinical training, I’ve noticed most hospitals try to emphasize (some may say coerce) quality health care practices. In a typical day, even the most obtuse among us can identify at least a half-dozen posters and warning labels imploring us to wash our hands, use contact precautions or not give patients medications to which they are allergic.

Bluntly pointing out what you are and are not supposed to do makes a lot of sense to me. It works for most of us on the road, in grade school, and even in some marriages. There are enough gray areas in medicine as it is, and so much to keep track of, that when simple things are clearly pointed out, it makes life a little bit easier.

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The focus on health care safety has gained a lot of momentum over the past decade, mostly because of the seminal paper of the quality movement, “To Err Is Human: Building a Safer Health System,” published by the Institute of Medicine. This paper, which recently celebrated its 10th birthday, showed the medical world exactly how poorly it was doing by allowing preventable hospital errors to occur. As a result, medicine is reorienting itself around an axis of quality care delivery with a new focus on patient safety.

Perhaps the same principles could be applied to medical education. Although it would be impossible to tell us all of the things we need to know about being good students, I can think of a few easy signs to follow. A sign on our cars saying “Don’t go home early” or a note in our white coats saying “Do not priority page the attending to ask about a patient’s Lovenox renewal” could help, and would be appreciated by many on ward rounds.

Maybe these could even be wired into our PDAs, which seem to have replaced stethoscopes as the most essential clinical tool. It would be perfect for a surgical student to see a bright orange reminder flashing on his iPhone—”Do not be late to the OR at 6 a.m.”—just before he calls his girlfriend for the night.

Since hospitals have taken on the onerous task of trying to define and implement quality, it is time for medical education to do the same. There certainly appears to be a disconnect in clarity of expectations between the preclinical and clinical years.

The first two years of medical school are clearly outlined and smoothly implemented. The general theme? Know what’s going to be on the test, and know all about it. The third and fourth years are more nuanced, which more closely reflects clinical reality. They are more important to a student’s education.

Attributes like being on time, respecting the hierarchy and following through for your patient are not easily quantified. In fact, quantifying them may not be possible. I’m also not sure that more objectively measuring clinical performance makes better doctors. It is clear to me, however, that medical educators need to start thinking about medical education in terms of quality health care delivery. I hope future medical students under my tutelage will have some signs to look at in the call room, and a few benchmarks in their evaluation that honestly assess what they need to improve.

Mr. Matulis attends the University of New England College of Osteopathic Medicine in Biddeford, Maine.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated