The Canary in the Coal Mine…Resident Physicians As Moral Agents

David Leach MD, the former CEO of the Accreditation Council for Graduate Medical Education (ACGME), always had a knack for seeing things a little differently. His unique insight provided a new perspective on resident education, leadership, or just life in general. In one of his annual ACGME talks, he discussed how having the courage to pick up the phone and call anyone — even someone at such a high level that they might never take your call — could turn out unexpected and positive results. He shared how he had learned through the years that many people at high levels will take your call simply because they are as passionate about the very topic you are reaching out to them about. This seemingly small, but important, insight has helped me throughout my career, and as such, I have continued to follow his work.

A number of years ago, I read a medical education book in which Dr. Leach had written a chapter on Professionalism. He covered what he felt was the most important role of the graduate resident physician – that of being the “moral agent” for their patients. He discussed how residents must be the gatekeepers for safe, high quality care –  a sentinel on watch for the many unsafe conditions they might encounter while trying to provide optimal patient care, prepared to alert faculty and leadership to these unsafe conditions, and then work with their institutions to find solutions to remove risk from the patient experience. The analogy Dr. Leach used was the canary in the coal mine – taking on the role of guardian and protecting others from harm before it is too late. I loved this “moral agent” concept. It was so simple, yet so important in the quest for safer, higher quality, patient care. In academic medical centers, resident physicians spend more time in the hospital, have more direct contact with patients, and see many more unsafe conditions during days, evenings and weekends than most caregivers — except possibly nursing.

As an extension of this “moral agent” concept, I was excited to see the new ACGME program requirements in response to the 2008 IOM report highlighting problems in graduate medical education associated with duty hours, supervision and patient safety. As a component of the new accreditation process, the ACGME has established the CLER (Clinical Learning Environment Review) program to assess the graduate medical education (GME) learning environment of each sponsoring institution and its participating sites. One key focus of the CLER program is the requirement that resident physicians now need to be submitting near miss and unsafe condition reports through their hospital’s occurrence reporting system – exactly what Dr. Leach was proposing many years ago when he brought forth the “moral agent” concept. The over-arching focus of CLER however will be the emphasis on the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. Note the emphasis and accountability is now on the sponsoring institution, as well as the residency program directors. The CLER program’s ultimate goal is to move from a major targeted focus on duty hours, to that of a broader focus on the GME learning environment and how it can deliver both high-quality physicians and the higher quality and safer patient care to the healthcare system as a whole.

With CMS, HRSA and others investing close to $9 billion dollars annually in graduate medical education, the day has now come for greater accountability in graduate medical education around safety and quality. Imagine what would happen if academic medical centers were “reimbursed” for their graduate medical education the same way hospitals are now being reimbursed for patient care with penalties for lapses in safety and quality education, similar to readmission or infection rates.  A reimbursement model based on Value-Based Education and HCAHPS for graduate medical education…where organizations like Consumer’s Union, Healthgrades and Leapfrog would publish annual “grades” for GME quality and safety programs across the country. That would surely raise the stakes, get institutional leadership’s attention, and change the graduate medical education landscape. Is that type of educational “transparency” heading our way in the not-too-distant future?

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