Why Physician Trainees Don't Report Possible Medical Errors

There are several reasons for medical students' reluctance to speak up when they observe possible adverse events.

When medical students have questions about the safety of the care they see, most aren't comfortable challenging the providers who deliver it.

There are several reasons for that reticence, a survey published in the American Journal of Medical Quality finds.

A medical student is like a fly on the wall, said Lakshmana Swamy, MD, MBA, the lead author of the study and now chief medical resident at the Veterans Administration hospital in West Roxbury, MA. "We're not bearing the burden of care, but we spend many, many hours observing care," he said.

Unlike residents, medical students still have one foot outside the world of medicine, giving them a different perspective on the care they see. The study was designed to measure that perspective—it only asked whether the student's perceived problems, he said.

Why Doctors Lie About Medical Errors

Swamy and fellow physician trainees at Wright State University's Boonshoft School of Medicine, in Dayton, OH, surveyed their colleagues.

They found that 62% of the respondents perceived problems in safety and 44% saw what they considered lack of evidence-based care. Most striking to Swamy was that 90% of the respondents said they had observed adverse events, and 29% perceived avoidable adverse events on a monthly basis.

Although the survey gauged perception, not actual medical errors, only 51% of students said they were comfortable reporting incidents to their superiors and only 20% noted a change in response to their concerns.

But whether the quality issues were real or not, they should be addressed, said Swamy.

"The problem is that they are seeing things and they are not talking about them. They are not learning about them. Either they are missing the opportunity to learn about quality and safety, or they are missing the opportunity to learn about clinical medicine."

What Hospitals Need to Know

However, the situation is changing, said Swamy, who is on the evaluation committee for the Accreditation Council for Graduate Medical Education (ACGME) program to improve resident training in several areas, including safety and quality.

Under the program, known as the Clinical Learning Environment Review (CLER), ACGME staff review programs at nearly 300 hospitals. The program issued its first report in May.

Many residents and fellows who were interviewed for the report indicated they participate in quality improvement projects, but appeared to have a limited knowledge of QI concepts and the methods and approaches to QI employed by the Clinical Learning Environment.

ACGME reviewers also found that when trainees did file reports questioning the care they observed, the trainees "received little or no feedback."

Hospitals often welcome that information, said Kevin Weiss, MD, who heads the ACGME's CLER program.

Review staff meet with both hospital and ACGME leadership teams after each review and discuss the results. Programs that receive ACGME accreditation must participate in the review, but results are not a factor in the accreditation.

Now in the middle of a second round of reviews, the program is no longer seen by hospital CEOs as a regulation in disguise. Some hospital chiefs say the visits initiate needed conversations about quality, Weiss said.

Hospital administrators need to be bring their younger doctors into the quality improvement process, said Swamy.

"The important thing is to really engage your younger physicians who have trained in the broken system and encourage them to help you design a safe and more efficient system," he said. "You can't do it from the C-suite alone. You really need to go to the place where things are happening."