‘Promoting Excellence in Training’
Professor Ian Curran
A Joint Meeting with the LMI
Past President of the LMI, Mr Graham Lamont opened the meeting and welcomed LMI & LSA members, he then handed over to LSA President, Dr Clare Howard, who introduced and welcomed Prof Curran to the LMI.
Dr Howard introduced Prof Curran who is the Assistant Director of Education & Professional Standards at the GMC, Professor of Innovation & Excellence in Healthcare Education at Queen Mary’s University Hospital, London and Hon. Consultant at Bart’s Health NHS Trust.
Prof Curran described his talk as a presentation of a series of ideas, concepts and thoughts which may leave the audience asking questions which we could subsequently explore. He asked if we were happy with UK postgraduate medical education and if there are other things we need to thinking about and if we had lost anything along the way? He quoted Winston Churchill saying ‘I am always ready to learn although I do not always like being taught’ which Prof Curran felt was the essence of understanding adult education.
Prof Curran explained the importance of remembering why we are here. He reflected upon the Mid-Staffordshire NHS Trust failings and the Winterbourne View Scandal and the examples found of professional incompetence. He said healthcare is very conspicuous but equally there are other industries that are as likely to fail but their failure is often less conspicuous.
He said professional excellence was difficult to describe and define. He told the audience the verb ‘to profess’ meant to commit or pledge to uphold a set of beliefs or values. He said excellence was even more difficult to define and that it can take many forms, but one can recognise what it is not, that is, not being ‘good enough’.
Prof Curran spoke about the London 2012 Olympics and gave the example of the British cycling team and their performance director Sir David Brailsford who’s notion of performance excellence was the famous phrase ‘the aggregation of all marginal gains’; that is doing everything to the best possible effect. He asked if we do this in healthcare and acknowledged the challenges in doing it. He commented that people can feel nostalgic about the ‘good old days’ and believe that healthcare education was better in the past with the ‘see one, do one, teach one’ technique, although in reality, those days weren’t so good for trainees or patients. He displayed a ‘novice-expert’ continuum graph and said that in the past, patients may have been put at risk by being treated by novice doctors who did not have the opportunity to practice their skills in a simulator before treating patients. He said that there are some blind spots in healthcare and displayed a diagram from the ‘Patient Safety First’ campaign demonstrating the number of encounters per fatality. It demonstrated that industries like aviation, nuclear power and railways are considered ultra-safe and healthcare is deemed hazardous. He said if you look at high reliability, performance critical industries, e.g. petrochemical, aviation, military or nuclear, they have become so safe because they pay attention to detail, they understand how and expect humans to make mistakes and they plan and programme around that. For them, performance failure is not only expensive but very conspicuous. These industries have common features: common language and understanding across all aspects of the workforce, common processes, standard operating procedures, common training in human factors, effective, assertive and humane leadership; they understand about dialogue, not monologue and have effective organisational culture.
Prof Curran spoke about the books ‘To Err is Human’ and ‘The Quality Chasm’. He said ‘To Err is Human’ estimated that 44,000-100,000 Americans die annually from iatrogenesis and that there was a more recent estimate of 210,000 deaths per annum (p.a.) due to iatrogenesis, which would make it the 3rd highest killer of Americans in terms of disease. He said the UK Sepsis Trust estimated that of the 37,000 sepsis related deaths p.a., one third are avoidable. He thought that with the high prevalence of patient safety incidents, we need to re-explore the notion of aspiring to excellence, do the right thing the first time because ‘good enough’ is not actually good enough. He said for him, ‘human factors’ is about optimising human performance, not just in terms of teaching and training, but across systems, culture and organisations. He suggested a renaissance in thinking about how we train in healthcare. He gave the example of St. Bart’s Hospital founded by Rahere who, after an early reckless life, became a monk and founded St. Bart’s Hospital. Rahere was considered a paragon of virtue. Prof Curran explained a paragon was a person or thing who is regarded as an exemplar of a particular characteristic or virtue. He asked the audience if they knew of any paragons in their own lives and challenged the audience to think if they were nurturing exemplary clinicians.
Prof Curran though that we should never mistake the measurement of an activity or process for its actual value. He asked what patients, employers and healthcare workers value? He thought that patients valued kind & capable carers, hospitals value a safe & efficient workforce and professionals want to be valued & effective. This led onto Prof Curran describing the ‘value paradox’ where value means different things to different people, e.g. when governments talk to clinicians about what they value, these are different things.
Prof Curran made the case that training people to be just ‘good enough’, they may be competent, but soon deskill and become incompetent. Therefore the aim should be to train people to their full potential to be experts. He compared healthcare to other high performing industries and how they continue to invest in, train and assess their workers during their senior careers.
He said doing the ‘right thing first time’ is highly cost effective and gave the example of a US hospital that used the ‘simulation training to excellence’ approach in CVP line insertion. They reduced line related sepsis by 60% and reduced unscheduled ICU admissions by 50% and managed to save almost $1 million.
Prof Curran said we need to understand what a professional is. He thought they should be a capable expert who can manage uncertainty, complexity and chaos and who have developed capabilities far beyond competence. He said work should be distributed according to its challenge and the complex, chaotic work should be managed by professionals. He thought that situational awareness was an important and defining characteristic of a professional.
Prof Curran asked what behaviours we should value. He gave the example of Dee Hock, founder of Visa who said he promoted first on the basis of integrity; second, motivation; third, capacity; fourth, understanding; fifth, knowledge; and last and least, experience. This was because without integrity, motivation is dangerous; without motivation, capacity is impotent; without capacity, understanding is limited; without understanding, knowledge is meaningless; without knowledge, experience is blind. Prof Curran asked how we can prioritise integrity, motivation and capacity, when generally we focus on experience, knowledge and understanding? If we want to produce professionals able to deal with uncertainty as opposed to technicians following algorithms, this must become the emphasis of training.
He concluded by asking if we are valuing the right things? He thought that we should focus on nurturing exemplary professionals and that psychological safety is at the heart of optimising human behaviour. He said we should value professionals, understand professional behaviour, develop professional capabilities, inspire and motivate and champion humanistic qualities. He finished with a quote from Derek Bok, a former President of Harvard University, ‘If you think education is expensive, try ignorance’.
He then took some questions from the floor and the vote of thanks was given by Simon Mercer.
Dr Gemma Roberts
Liverpool Society of Anaesthetists