A little more than a decade ago, the patient safety movement hit both the United States and the United Kingdom like twin avalanches. In both countries, high profile cases of medical mistakes led to growing anxiety, and early research outlined the vast scope of the problem and identified some solutions. All this was prelude to two key reports published in 2000 (the Institute of Medicine’s To Err is Human in the US, and An Organisation with a Memory in the UK), which blended data and angst to galvanize movements in both countries.
When an avalanche strikes, its path is determined by the underlying terrain. So too have the structures and culture of the US and UK systems influenced their responses to the harrowing recognition that patients are often harmed while receiving healthcare.
In this blog, I’ll highlight some of the key differences in the role of physicians—in particular, their engagement in the safety enterprise as both clinicians and researchers—that I’ve noticed in the two countries. In my next post, I’ll discuss how the centralized vs. decentralized instincts of the two healthcare systems have influenced the policy responses and their effectiveness.
First Observation: Physician Engagement in Safety Seems Greater in the US, at Least in Top Hospitals
Whether we like it or not, physicians’ attitudes set the agenda on issues like quality and patient safety. This is definitely true in the US and, perhaps to a slightly lesser degree, in the UK, where professional managers hold more of the chips. But even in Great Britain, the level of physician buy-in is critical. And my sense is that American physicians have engaged somewhat more strongly with the safety agenda.
Before amplifying this observation, let me immediately qualify it. When it comes to physician engagement in anything other than direct clinical practice and the business of medicine, the US is far more bimodal than the UK. So when I refer to high levels of US physician buy-in, I’m referring to those American hospitals that have either employed physicians (i.e., the VA, many hospitals with hospitalists) or docs who are strongly linked to their organizations (i.e., Mayo and Cleveland Clinics, Kaiser Permanente, Geisinger, most academic health centers). As for independent physicians and those in small group practices? Not so much.
In other words, my point of reference here is what happens in places like UCSF and Kaiser versus what happens in high-quality English hospitals.
Why might safety engagement among physicians be spottier in the UK? Interestingly, I think it’s partly related to the differences in the two countries’ malpractice systems. Here’s why:
Doctors in the UK don’t worry much about being sued for malpractice. This doesn’t mean that there isn’t a malpractice issue here, but rather that most lawsuits are directed against the Trusts (the hospital or the primary care practices), whose administrators worry quite a bit. But the docs are usually, happily, left out of it.
In the US, of course, every physician frets about being sued: a recent study found that nearly all American physicians will be sued at least once during their careers, and nearly 20% of high-risk specialists like neurosurgeons are sued each year. So when the IOM report was published, the instinctive response of US physicians to the idea of talking about medical mistakes was nearly Pavlovian: Mistakes = Malpractice = I-Don’t-Wanna-Talk-About-It.
But then came the notion of systems thinking and the Swiss cheese model. “No, we’re not talking about individual fault,” went the mantra. “We’re looking at dysfunctional systems.” Many American physicians were greatly relieved, and some dove into the safety pool. In the UK, in contrast, the patient safety movement was seen by many doctors as yet another of the National Health Service’s admonitions to do better, just one more beat of an oft-struck drum. I think this combination of US physicians embracing this new way of approaching mistakes and UK physicians seeing the patient safety movement as another occasion for the bureaucracy to pressure them to follow another set of rules led to a more enthusiastic reception on the left side of the Atlantic.
Second Observation: Trainees Here Also Seem Less Smitten With Patient Safety
While engaging practicing doctors is vital, so too is capturing the hearts and minds of the next generation. There is a structural issue in the UK that influences the ability to educate residents in crosscutting areas such as patient safety.
In the US, kids go to four years of college, then to medical school for four more years. From there, they enter a residency in the specialty of their choice and, for some, additional fellowship training. Training programs are run by individual academic medical centers, such as NYU or Johns Hopkins, or smaller teaching hospitals. While in training, American residents work under the wing of a single program director and rotate through a limited set of training experiences, usually in 2-3 hospitals (I ran UCSF’s internal medicine residency in a former life, so I know this world well). Because the training director is responsible for the residents and can track them easily, he or she has the tools to create new curricular experiences in crosscutting areas like patient safety. At UCSF, for example, all our interns now have a two-week safety/quality rotation, during which they learn core principles and begin working on a project.
In the UK, students enter medical school right after high school, a 6-year experience that includes less liberal arts than American pre-meds get in their college years, a point I’ll return to later. (British kids also finish med school two years earlier with essentially no debt [versus the average US med school graduate, whose debt averages $158,000), so there are some real advantages to the British model.) After graduating, they enter a four year period of rotating residency experiences, and then a “registrar” program in a specialty (i.e., such as medicine plus a subspecialty, or surgery or pediatrics), which lasts for anywhere from 3-6 years. So far so good.
But registrars in the UK are assigned to a “deanery” (a regional organization with overall accountability for training) and can rotate through as many as half a dozen hospitals, particularly when they’re in large cities like London. (Think about doing your medicine residency in a “Philadelphia deanery,” with potential rotations in some combo of the Penn, Jefferson, Temple and Drexel academic centers or community affiliates and you’ll have a sense of the structure here.) This makes their experience more fragmented, with a lot of hopping from one clinical rotation to another, without the same degree of oversight or integration that a good US program enjoys. Nor do British residents tend to form strong bonds to individual clinical sites the way many do in the US. While all the deanery’s residents may get together for a unified regional curricular day once or twice a month, this structure makes it hard to deliver a core curriculum on a crosscutting topic like safety. And so, by and large, there isn’t one.
Third Observation: The Striking Difference in National Leadership in Patient Safety
Perhaps the biggest difference I’ve noticed is in the background of the leaders in safety research and policy. In the US, the vast majority of the leaders are physicians, most of them based in academia and still seeing patients part-time. In the UK, most of the prominent and highly published patient safety experts are PhDs—mainly in psychology and sociology.
How to explain this striking difference? I’m guessing it reflects several factors. The first is the US college-before-med school system, which allows kids with a social science intellectual sweet tooth to pursue their passion in college, yet still become physicians. Atul Gawande, for instance, has a Stanford degree in biology and political science, and then studied philosophy at Oxford. Johns Hopkins safety expert Peter Pronovost double majored in biology and philosophy at Fairfield University, and I majored in political science at Penn. One can’t really do this in Great Britain; kids here begin their professional education at age 17. In England, a student like me probably wouldn’t go to med school in the first place, and if he did, he wouldn’t have had much time to study politics during his university years.
Second, the US has a strong tradition of physicians receiving additional social and political training after their clinical years, through the Robert Wood Johnson Clinical Scholars and similar fellowship programs. In the UK, while many MDs pursue additional training in biomedical research, relatively few receive (or have access to) the kind of training that promotes leadership in safety or quality. Just as importantly, there isn’t an obvious pathway for physician-leaders in quality or safety research to be promoted, funded, or valued by their academic institutions, as they increasingly are in the States, and so there are few role models with this phenotype.
Don’t get me wrong: the social scientist perspective that these British safety experts have brought to the field has been crucial, and it is a joy hanging out with them on my sabbatical. Just read anything written by James Reason (such as this and this),
Charles Vincent’s wonderful safety book, or Mary Dixon-Wood’s superb ethnographic analysis of the Michigan checklist study and you’ll see how staggeringly insightful they are about healthcare generally and patient safety more specifically. I wish we had more folks like them in the US.
But this lack of clinician, particularly physician, engagement comes at a cost. In US institutions that have embraced patient safety, I see substantial synergy between those studying the field and the troops on the ground. From what I’ve seen of the UK, there is this fantastic research engine (I recently had the privilege of listening to the members of Charles Vincent’s research group at Imperial College present their projects, and the breadth and quality of this work could be matched by very few programs in the US), and there are good operations people struggling to improve safety on the wards. But these worlds seem to be engaged in parallel play.
Final Observation: It’s Somebody Else’s Problem
In my next post, I’ll talk about some of the benefits and downsides of the UK’s more centralized approach to safety and quality. One of the downsides is that safety doesn’t feel like something that clinicians, or clinical teams, design and implement, but rather a set of prescriptive guidelines and rules being handed down by branches of the National Health Service. There is a palpable feeling of resignation, sometimes bemused resignation—the sense that many of these guidelines don’t make much sense, and there’s not much that one can do about it. Of the several problems with an overly prescriptive, top-down approach, the lack of caregiver engagement it tends to promote is one of the most troubling. This is a major cautionary note for the US, since we are moving rapidly in this very direction. More on this next time.
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As always, these thoughts reflect the research I’ve done during my two months in London, scores of conversations, several conferences, a handful of hospital rounds, and a number of delightful afternoons in pubs and coffee houses. With this limited database, my analyses are sure to be colored by my own biases and influenced by my limited exposures. I welcome any comments—particularly by UK locals—to set me straight.