Is Medical Education a Systemic Root Cause of Poor Quality?


I will try to be careful with this topic, since I'm obviously not a doctor. Criticism of doctors gets thrown around pretty easily around many hospitals, too much so, I think. You sometimes hear blanket criticisms about doctors being difficult, how they don't want to participate in Lean improvements, and how they don't follow proven practices around hand hygiene and checklists. Oh, and they are sometimes called jerks and accused of throwing things at nurses (and yes, sometimes nurses act badly.)

A new report from (news story, PDF of report) Dr. Lucian Leape, a noted patient safety expert, looks at medical education, the process and system for educating doctors as a root cause. Maybe that's more productive than blaming individual docs.  

Blanket statements are, of course, never true. I've never liked playing the “blame game” with doctors, since “they are difficult” is sometimes code for “they won't do what we tell them to do” (a sign of command and control thinking). I'd rather ask why they seem difficult, why they don't follow a proven process, why they are often not perceived to be team players… look for the root cause. It's usually far more complicated than the doctor being a bad person… they work within a system and they're human. Blaming docs only alienates them and that prevents us from working together for quality improvement (something I know doctors want badly).

There are two blog posts from people whose opinion is more meaningful than mine.

Dr. John Toussaint, the former CEO of ThedaCare, writes in his blog post (“Lucian Leape challenges medical educators“) that:

the shame and blame culture instilled in our medical schools is our biggest barrier to patient care improvement.

He adds:

For example, the fact that professors of medicine are allowed to berate,belittle, and attack medical students in public forums  is appalling. It is fundamentally disrespectful and it fosters ill will and a culture of hiding mistakes.

Yikes. As I commented on John's blog, I was never treated that way as an undergraduate engineer or in graduate school for engineering or business. But, as we always hear, medicine is different, I guess. In his response comment, John referred to the “tyrants” in medical education. As an outsider, doesn't that seem like a huge problem?

John cites the root cause factor, saying:

Lucian Leape is absolutely right in his analysis of the gigantic gap in medical education.In fact  this may actually be one of the root causes of  the entire healthcare cost and quality crisis.

The other key blogger, a non-physician CEO, is Paul Levy from Beth Israel  Deaconess  and his “Running a Hospital” blog. In the post “What does it take? (revisited),” Paul asks:

All things considered, are we in the health care professions moving fast enough to transform the delivery of care? And whatever you think about today's problems and this generation of caregivers, how about trying harder for  the next?

By citing and quoting from the Leape study, I'm guessing he thinks we aren't treating the next generation any better, in terms of training and creating the right environment for patient safety?

He quotes from the Leape report:

“Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, health care remains fundamentally unsafe,” said Lucian L. Leape, MD, Chair of the Institute and a widely renowned leader in patient safety. “The result is that patient safety still remains one of the nation's most solvable public health challenges.”

A major reason why progress has been so slow is that medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.

If there are physicians reading, what do you think?? If you're reading as a non-physician medical professional, what are your thoughts? As a reader who is part of the general public??

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Wow! I had no idea that kind of behavior occurred in medical schools. I thought it was a thing of the past and more common in primary and secondary schools. But, I could certainly see where it contributes to a culture of ill will and hiding mistakes – one significant root cause, I’d imagine. Also, I believe Toussaint earned his medical degree at the University of Iowa (I was born, raised, and still live in Iowa). That kind of behavior would not be viewed favorably by a great majority of Iowans, were it well-known.

  2. Hi Mark,

    I think there is something to this. As an example, I saw an article a few years ago published about LEAN in medical education in the AAMC journal Academic Medicine, and it struck me that in the discussion the authors saw their “customer” as students and faculty, not the communities/society who they would be training physicians to serve. It might be interesting for you to do an analysis and see what you think…

    One could imagine, then, if the way they measure themselves is by the satisfaction/respect that students get/provide them and/or quantity and size of research grants received, versus the health of the community, this will be the focus of their activity.

    My own personal experience in undergraduate medical education is of a system that’s really challenged to support diversity, bordering on one that is hostile to it – which I think is a problem still today ( ), and this by itself lends to a problem of acknowledging areas for improvement and different points of view to support the patient experience.

    There’s a NING site that has brought together people interested in changing this situation:

    Maybe a place to start would be an enterprising medical school to start a rotation in quality improvement / leadership in the 3rd/4th year and then cross all years. Or maybe there is a medical school doing this already.
    .-= Ted Eytan ´s last blog ..We’re speaking on Tuesday at South by Southwest. =-.

  3. I agree it is an important root cause that should be addressed, but it can feel like taking on “world hunger”. Given that many hospital have the “doctors they’ve been dealt”, I have seen some pretty substantial improvement in work-place culture. One organization that I worked with not only created a policy for addressing this kind of behavior (in collaboration with the Board and the Medical Staff), they also introduced some new ways of thinking and acting using some techniques of non-violent behavior. It worked and is still working.
    .-= Mike Stoecklein ´s last blog ..Net*Working =-.

  4. Based on what my wife tells me, it’s not just medical school that has the shame & blame culture. She’s a physician at a major cancer center, and in her section it’s not uncommon to openly (and loudly) criticize Fellows when they err.

    She claims that getting chewed out is a good way to ensure that they learn the lesson. I suspect, however, that no one there has considered the long-term ramifications of the behavior.

  5. Mark, I think progress in patient safety and process improvement never feels fast enough, particularly for those strong believers who have come to appreciate and rely on the benefits that their patients receive. I am optimistic about the current pace of change though, and certainly find that these subjects are a more common conversation for all in healthcare. Our Internal Medicine residents are receiving Lean training and participate in improvement projects. The same will soon begin in Surgery. One of our MD PhD students is truly engaged and quite knowledgeable about Lean and will spend 3 elective months working in the ED focused on some innovative improvements led by one of our BA/MHA managers who is a real Lean thinker. The momentum is there at many levels of medical education. Patience and persistence are important virtues in the meantime.

  6. Dr. Jaques — thanks for the positive report. Last week, BIDMC here in Boston had a lean/QI retreat to educate 25 residents… yes, there are some positive steps being taken. Glad to hear the same is true in your organization.

  7. Mark –

    Here’s another thought (and a pile of questions): What about the system of PAYING for medical education?

    Does the fact that physicians are typically starting a long-deferred working life saddled with six-figure debt (I’m guessing at the number – someone can help us out here) affect their attitude and their approach to piecework pay?

    If I were that deep in debt for the privilege of practicing my profession, I might think my concerns were the most important in the room! One could easily develop the habits and practices that would keep the cash register ringing. Why stop after the loan is paid off?

    Does the prospect of this much debt serve as a psychological filter for the applicants to med school?

    If healthcare cost is driven to some extent by this concern and if healthcare cost is a national crisis, shouldn’t we be looking at how we pay for medical education?

    I studied an applied biological science – in agriculture – and the state paid for my advanced training, 100%, on into postdoctoral training. Was my training more important than the applied science of medicine?

    Is this one of the “undiscussables” that needs to be discussed if we are to move forward?

  8. Andrew – I’m certainly not the expert, but I really got a perspective on this from the book “The Healing of America” by TR Reid:

    Amazon link:

    The U.S. seemed to be the only country where medical school graduates have that huge crushing 6-figure debt. In other countries, the doctors earn less money, but they also don’t have the debt since school was paid for by the taxpayers.

  9. Mark – Very nice job with this blog re: what is a very touchy subject. I say this because you have managed to “more than scratch the surface” re: why healthcare hasn’t addressed its care/service quality problems more effectively – despite that it’s been more than a decade since the first IOM report. Which is not to say BTW that significant progress has not been made re: healthcare safety/quality.

    But to get even close to the “promised land”, healthcare will have to get much more honest and do something about its own insidious illness – that being “leadership/culture shortcomings” galore in many of our hospitals and other healthcare settings. The identified “patient” in this blog is MDs, but as you infer it could easily be RNs (the term lateral violence was coined to describe the way many nurses treat other nurses) or just about any other group of providers and/or administrators in most healthcare seetings. As Dr. Leape suggests, nothing will significantly improve in medical education without a renaissance that includes both culture and leadership transformation – across the board…and the same is true for healthcare. A few years ago I had the pleasure of hearing Dr Ed Miller, CEO of Johns Hopkins Hospital speak about just this issue. He shared that one tipping point in his hospital’s transformation (following the death of Josie King, a toddler age inpatient due to avoidable medical error) occurred when during a hospital-wide staff meeting, he responded to an OR nurse’s query regarding how she should next handle the oft abusive conduct of a well known surgeon at 2 am, by announcing his home phone number and telling her to call him the next time it happened. Now that’s leadership courage – quite frankly in very short supply in healthcare.

    That there are fast-track methods to proactively advance both culture and leadership transformations in healthcare, with very few takers says it all. Until this changes there will continue to be wide variation in healthcare outcomes between hospitals and other “like” healthcare settings…one will be lucky to live nearby a hospital with great leadership and a transformed culture, fully committed to patient safety and care excellence. After spending 35 years in acute care settings I know well that it doesn’t have to be that way…and with 5 children – I shouldn’t have to hope they are lucky should illness or accident come their way.

  10. […] by Mark Graban on April 15, 2010 · 0 comments tweetcount_url='';tweetcount_title='Lucian Leape Loathes Lean or "L.A.M.E."?';tweetcount_cnt=0;tweetcount_src='RT @LeanBlog';tweetcount_via=false;tweetcount_background='cc6600';tweetcount_border='DAE2F0';tweetcount_text='DAE2F0';tweetcount_api_key='d8f2363c00a05734d2ba0ea87b17c416c523acd1af22ead7f9ed47018ff2bfb7';Noted patient safety expert Dr. Lucian Leape spoke out recently spoke out about medical school culture being a root cause of poor quality (see my blog post “Is Medical Education a Systemic Root Cause of Poor Quality?“). […]


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