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"What Do I Need to Know for My Clerkships?": A Look at the Lucian Leape Institute Report on Medical Education

By IHI Open School | Tuesday, May 22, 2012

In the world of medical school, spring is a time of transitions. First year medical students are returning from spring break and gearing up for the last stretch of class before summer. Second year medical students are getting ready to buckle down and study for the USMLE Step 1 board exam (good luck to all!). Third year students are on their last clerkship rotations before becoming fourth year medical students. And fourth year medical students are holding their breath as Match Day approaches (this Thursday!). Like any time of transition there are a lot of questions about the future floating around. One of the most honest and interesting questions I have heard recently was from a second year student to a resident, "What do I need to know for my third year clerkships?"

This may sound like a strange question to those outside of the world of medicine. The third year of medical school should be a logical progression from the second year, right? Not exactly. Most medical schools in the United States are structured so that the first two years are spent predominantly in lecture. The first year covers the normal physiology, anatomy, and biochemistry of the body systems and the second year delves into pathology and pathophysiology. These years are marked by long hours in class and little, if any, patient interaction. With at most a two week gap after the USMLE Step 1 exam, third year medical students are then thrown into the hospital wards to learn how to apply the basic sciences into the practice of patient care. Are these new third year medical students ready to care for patients?

The Lucian Leape Institute of the National Patient Safety Foundation says, "no." Just last week, the Lucian Leape Institute released its first of a series of reports on patient safety. The first report, titled: “Unmet Needs: Teaching Physicians to Provide Safe Patient Care,” finds that U.S. medical schools are not adequately teaching students how to provide safe patient care.

Although I have just 8 months of experience in the medical education system, I am not surprised by the conclusions of the report. A quick glance at the competencies tested in the USMLE Step 1 board exam that second year medical students ordinarily must pass before starting their third year clerkships will demonstrate the emphasis placed on the basic sciences of the body systems. While I don't disagree with the importance of understanding the basic sciences of the human body and disease processes, I agree with the Lucian Leape Institute report that there is a crucial dimension to patient care that is blatantly missing in an exam that signals that students are ready to be members of a patient care team.


The transition into a third year medical student is not easy: learning how the hospital operates, determining and establishing the medical student role on the care team, understanding and learning to anticipate the actions of the interns, residents, and attendings, and being prepared to answer any basic sciences question your attendings may ask you (a process called pimping). The third year is also an important learning opportunity. The more procedures and cases seen means a greater breadth of experience for future life-saving. Impressing your attendings is another facet to the third year of medical school. A good recommendation from attendings can go a long way in the residency application process. In the thick of all of that, medical students are probably too stressed to think about patient safety and definitely don't want to slow down the service just to ask "why?" when witnessing unsafe or needlessly complicated workflow processes. The chaos of third year makes asking questions about patient safety and quality improvement professional suicide.

So, how are medical students to learn the skills needed to deliver health care safely? The Lucian Leape Institute recommends restructuring medical education to include topics like safety science, human factors engineering, systems thinking, and the science of improvement into the basic science years of medical school. The report also recommends that medical students be given opportunities to develop interpersonal skills that include effective communication strategies for future interdisciplinary teamwork. In order to include these elements to medical training, faculty trained in patient safety and quality improvement who can model good patient safety behavior is essential. Unfortunately, most medical schools have not reached a critical capacity of faculty for training in patient safety and quality improvement to occur. Yet, from the student perspective, we can't wait another 10 years after the publication of the IOM "To Err is Human" report to reach that critical capacity.

Here at the University of Michigan, the few faculty we do have trained in patient safety and quality improvement are working hard to provide students with patient safety skills. In our first year of medical school, we've had a mandatory nurse shadowing experience and a sociocultural discussion case on medical errors to provide the first exposure to patient safety and effective teamwork. The University of Michigan also offers a second year two week elective on patient safety and a fourth year elective led by our very own, Dr. John Gosbee. At best, the University of Michigan has opportunities for students who seek to learn patient safety and quality improvement skills. This is a good start, but as the Lucian Leape Institute report would indicate, not enough. Patient safety needs to be prioritized formally from medical school through residency in order to make health care safer for all.

At the very least, concepts of patient safety and quality improvement should naturally become part of the answer to the question, "What do I need to know for my clerkships?"

Is patient safety a part of your curriculum? What do you think the best strategies are for making patient safety and quality improvement a bigger component to your health professions education and training?

- Eva Luo, MD/MBA Student at University of Michigan

Originally posted March 14, 2010 

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