Brian Nahed, MD, and Eric Chang, MD, aspire to spend their careers operating on patients at home and abroad, and wanted to help train neurosurgeons in the developing world who often perform the toughest of cases. So they went to Uganda. Jeremy Heit, MD, PhD, a resident in Radiology, wants to make strides in the growing national movement to improve patient safety and quality. So, together with a faculty mentor, he helped develop a safety curriculum intended for all Mass General residents.
It isn’t that these residents have plenty of spare time. But like so many newly minted physicians these days, they have career aspirations that don’t fit within the traditional boundaries of a single specialty or subspecialty. Indeed, they envision themselves having multiple skill sets in preparation for an increasingly complex medical landscape.
Destined to become leaders across all areas of medicine, residents and fellows are hungry for opportunities to make a difference, says Debra Weinstein, MD, vice president for Graduate Medical Education at Partners HealthCare, Mass General’s parent organization. “Many of them, like their predecessors, will have a major impact in health care, beyond the important value they bring to each patient encounter.”
In order to help physicians-in-training best develop their talents, in 2008, Partners launched an innovative program called the Centers of Expertise (COE), which offers residents and fellows the opportunity to explore, gain experience in and develop credibility in various thematic areas of medicine. The program, says Dr. Weinstein, who helped spearhead its design and implementation, “provides a way for individuals to indulge their passions and ‘customize’ their training. It also brings residents and fellows into a smaller community of colleagues from across all specialties who share common interests.”
The COEs include healthcare quality and safety, academic healthcare management, global health and health policy. COEs in research and medical education are also planned. Each COE offers educational sessions with Mass General and Brigham and Women’s Hospital (BWH) faculty members, opportunities for individual mentorship, and grants to support research, travel and/or attendance at national conferences.
Seeking Collaboration with High Impact
The interest has been “exceptional,” says Jennifer Goldsmith, administrative director for Partners Graduate Medical Education, which runs the COE. More than 700 trainees have expressed interest in participating in one or more of the areas. Agreeing that their collaboration’s greatest impact would stem from enhancements to the university’s neurosurgical capacity, Drs. Nahed and Chang set to work on a threefold plan that made the most out of the little time they had in Mbarara.
In Uganda, the team’s first efforts were dedicated to assessing existing resources and infrastructures and evaluating which limitations were dead-ends and which were simply invitations for creative clinical problem-solving. For example, surgeons at Mbarara University must operate without CAT scans to guide procedures; could Mass General residents and Ugandan surgeons team up to develop neurosurgical exam procedures that could effectively compensate for the absence of such equipment?
“This first phase was maybe the most difficult,” says Dr. Nahed. “Everyone involved needed to think flexibly, to be open to learning a new approach, to be critical and adaptable at the same time. That’s not an easy thing to do.”
Meanwhile, Drs. Chang and Nahed began a morning lecture series for participants as varied as experienced clinicians, medical students, nurses and surgical tech assistants. The lectures began by reviewing basic clinical lessons, such as anatomy and the neurological exam — lessons of the utmost importance in a technologically poor situation — and built up to practical demonstrations of new equipment and alternative procedures.
“We took every demonstration step-by-step,” says Dr. Chang, “going over everything from building and taking apart a new saw to using it during a procedure to troubleshooting. These lectures were as hands-on as possible because the end goal was urging participants to be very comfortable with new equipment in the hope that they’d actually use it when we went back home.”
Now back in the U.S., Drs. Chang and Nahed are part of an ongoing effort to maintain the relationships they built at Mbarara University in Uganda and to develop a strategy for the university’s future collaborations with Mass General. This third phase of their plan is the most critical one, dictating the success of the COE’s future efforts in Uganda. Remotely, the pair are involved in helping their former hosts improve clinical infrastructure, evaluate the extent to which new technologies are being incorporated in clinical care and gathering data on caseloads and surgical needs. This last aspect is very important for the future of the collaboration, as such data might very well dictate which type of surgeons should visit Mbarara University next and when.
Drs. Nahed and Chang admit that they would love to return to Uganda, but both agree that, more so, they hope that the COE Program sends the residents who will meet the most urgent needs in Uganda.
“The COE experience really has shown me a whole new world,” says a grateful Dr. Chang. “Just two weeks at Mbarara has made me become a better surgeon — a more efficient problem-solver with a healthier appreciation for the importance both of planning and remaining flexible.”
“And it was an opportunity to make good on our belief that we have a responsibility, not just to our patients in the U.S., but to all patients everywhere,” says Dr. Nahed.
Sustainable Solutions in Mbarara
In their fifth year as Neurosurgery residents at Mass General, Eric Chang, MD, and Brian Nahed, MD, were eager to put their skills to the test in a challenging environment unlike any either surgeon had worked in before. The recently launched COE Program in Global Health provided them the perfect opportunity to do that and more during a two-week visit to Mbarara University of Science and Technology on the banks of the Rwizi River in southwestern Uganda.
Through the work of David Bangsberg, MD, MPH, head of the MGH Center for Global Health, Mbarara University has long-standing ties to Mass General; more than 10 years have passed since Dr. Bangsberg and his team partnered with the university’s clinicians to make great strides in research and treatment of HIV-infected populations in Mbarara municipality. For Drs. Chang and Nahed, Dr. Bangsberg’s example in Uganda set the gold standard for them to strive toward.
“Initially, we hoped to jump right in, lend a hand, teach our hosts at Mbarara everything we could,” says Dr. Chang. “But the COE Program emphasized the goals of collaboration and sustainability.”
“A successful trip wouldn’t be about dropping off updated equipment, presuming to instruct Ugandan surgeons who have been practicing for 15 years, or even operating on as many cases as we could in two weeks,” agrees Dr. Nahed. “Instead, we focused on complementing our hosts’ expertise and, ultimately, pinpointing strategies for sustainable future growth.”
Never having practiced medicine in a resource-poor setting such as Uganda or Rwanda, both residents were deeply impressed by how much their hosts at Mbarara regularly accomplished without the technology that American neurosurgeons have come to rely on — including peri-operative antibiotics or basic imaging and patient-monitoring equipment. Despite these limitations, clinicians at Mbarara University serve as the only caregivers treating patients with neurotrauma for hundreds of miles in any direction, stabilizing countless victims of head injuries and traffic accidents. Yet these experts could do more for critically-ill patients in need of brain surgery in order to survive.
Preventing Medical Errors
Tejal K. Gandhi, MD, MPH, was trying to solve a problem. As executive director of Quality and Safety at BWH and director of Patient Safety at Partners, she understood the need to boost safety education for residents. Medical school curricula is so chock-full of critical information about anatomy and physiology that graduates were entering medicine with little knowledge of the myriad of quality and safety challenges that arise in hospitals every day, like dosing errors, miscommunication between physicians and lapses in sterilization of hands and equipment.
So, together with several colleagues, she began to put together a quality and safety curriculum that would be transmitted to residents over the course of several months, via e-mail, rather than in the classic lecture-based approach or via an online course. “The idea was that we think residents will be able to retain the information better if they are receiving and digesting it longitudinally, instead of in a single lecture or course,” says Dr. Gandhi. Together with Mass General’s senior vice president of Quality and Safety, Gregg Meyer, MD, MSc, she heads the Centers of Expertise in Quality and Safety. She invited intern Jeremy Heit, MD, PhD, to join the group of authors and he received COE funding to help perform a research study on the effectiveness of the safety education. Dr. Heit, now a Radiology resident at Mass General, helped develop the course, which is based on case studies of clinical scenarios where things could easily have gone wrong. He created cases that “a resident could easily identify with,” says Dr. Heit. “We want residents to read these and think, ‘I could see that happening to me,’ which will capture their interest and focus them on these safety concerns.”
As a resident, he continues, “you’re very tired, you’re in the hospital a lot, and you’re the one who’s doing most of the ordering of medications — so you’re kind of the epicenter for potential medical error. When I was in this situation for the first time, I realized where things could go wrong or go very wrong, and it was a scary thought. That’s when I felt like I wanted to spend part of my time working on quality and safety issues.”
Dr. Gandhi says that it’s essential to have a resident working on this project because he or she can be a good judge of what is a realistic scenario versus an unrealistic one that residents could then easily brush off. In addition, if young doctors understand the value of top-notch quality and safety early in their careers, they’ll transmit that mindset to the next generation of doctors, she adds. Meanwhile, her mentee benefits because, Dr. Heit says, he’s learning about the latest and best techniques to ensure safety through a one-on-one close working relationship with a leading expert in the field.
Making Quality and Safety More Interesting and Relevant
Drs. Gandhi and Heit and the other working group members are now deploying the course among a group of residents as a pilot. The group will study the outcomes with the ultimate goal of deploying it across the Partners system. Many of the cases deal with communication problems between caretakers, particularly in the handoff process at a shift switch, a potential source of medical errors. Communication problems between caretakers and patients are a second source of errors, as in cases when patients misunderstand drug dosing information, get confused between a generic name and brand name of a drug or when new dosing information isn’t received by a patient’s primary care physician. Cases also address potential mix-ups between patients, such as when two patients on the same floor have the same last name. “The goal of this project is to make quality and safety more interesting and more relevant and to show young physicians that it is essential that they incorporate safeguards into their daily work,” says Dr. Meyer.