In the United States, medical school is a four-year program after college. An undergraduate college degree provides no useful training related to caring for patients. Thus, when new doctors are licensed to practice medicine upon graduation from medical school, their knowledge base is obtained in the preceding four-year period.
Speaking from experience, medical students are bombarded with vast amounts of information and new clinical skills that they are expected to master in a short amount of time. While a new doctor can immediately start a medical practice, upon licensure after medical school graduation, most doctors choose to continue their training in an apprentice-style residency or fellowship program, which focuses on clinical skills.
While residency and fellowship programs are a great way for new doctors to learn the practical skills necessary to take care of patients, there is an urgent need to balance their need for training with the safety of the patients they are training on.
Blood pressure measurement
The Journal of the American Medical Association Network (JAMA Network) published an article yesterday that highlights this tension. Entitled, “Medical students fall short on blood pressure check challenge,” the article discussed findings from a 2015 research study, which found that only 1 out of 159 medical students tested could correctly perform all 11 elements of a blood pressure check with simulated patients. The average number of steps performed correctly was only 4.1.
Because you are probably wondering, the evidence-based technique for proper blood pressure measurement includes the following 11 skills: (1) resting the patient for 5 minutes prior to the measurement or expressing intent to do so; (2) legs uncrossed; (3) feet on floor; (4) arm supported; (5) correct cuff size; (6) cuff placed over bare arm; (7) no talking; (8) no mobile phone use or reading; (9) BP measurement taken in both arms; (10) correctly identifying BP from the arm with the higher reading as being clinically more important when asked; (11) correctly identifying which arm to use for future readings (the arm with higher BP).
Blood pressure measurement is the most common procedure performed in clinical practice, and an accurate blood pressure measurement is important to deliver quality patient care. One of the study co-authors, who is the director of the hypertension program at an Ivy League hospital said that in 10 years of clinical training, he has never had a single person in training—medical student (still in the four years of medical school ), resident (in the initial apprentice-like clinical training after medical school), or fellow (in additional clinical training after a residency)—who could correctly perform a blood pressure in his presence.
The next time you have your blood pressure taken, make a mental note of how many of these steps your doctor or nurse uses. The implications can be significant, and that in proper techniques affect the blood pressure reading. Research has shown, for example that a patient crossing his or her legs during the reading can raise the systolic pressure by 3-8 mm Hg, while incorrect arm placement can raise both systolic and diastolic readings by 10 mm Hg or more. In other words, poor technique could mislead a doctor into believing that a patient was hypertensive, triggering a decision to start unneeded medication therapy.
The bigger picture
While shoddy blood pressure skills on the part of medical students is concerning, to me, there is a bigger picture. What other clinical skills are not being mastered, and why? Some experts believe that poor blood pressure measurement competence is just the tip of the iceberg and that medical students and new physicians lack of basic skills for performing physical exams, for example.
As a Houston, Texas medical malpractice lawyer, I have handled countless cases where new doctors—whether residents or fellows— provided most of the hospital-based care that left patients permanently and seriously injured.
Based on this experience, I was pleasantly surprised and encouraged that The JAMA Network article recognized one of the big factors contributing to poor clinical skills is a lack of oversight. Oversight can come in the form of having fully-trained doctors supervising the care provided by new physicians, as well as implementing standards for better training and competency testing both in medical school, and throughout a physician’s career.
What you can do
By and large, residents, fellows, and new physicians are bright, hard-working professionals. Unfortunately, they sometimes do not receive adequate support in terms of supervision and oversight.
You can help improve patient safety by being aware of the different healthcare providers involved in your care. In other words, pay attention to titles. If you are at a large academic hospital, residents and fellows will likely be providing a lot of your care. It is a good idea to know what residents and fellows are participating in your care, as well as the fully-trained physicians, called attending doctors, who should be supervising things and making the ultimate treatment decisions.
In this type of system, residents and fellows perform most patient assessments and examinations, and then report their findings and recommendations to attending physicians. As you might imagine, the accuracy of the treatment plan formed in consultation with the attending physician is largely dependent on the quality of information conveyed by the resident or fellow.
I have handled a number of cases where I believe a resident completely botched an assessment, unwittingly misdirecting the attending physician’s attention and treatment plan in the wrong direction. Sadly, the attending physician never saw the patient before it was too late to correct the error.
If you have concerns about discharge planning or treatment decisions by a resident or fellow, I recommend that you firmly request to be evaluated in-person by an attending physician or, at least to speak to the attending physician by phone. You can make this request to the resident, fellow, bedside nurse, or charge nurse.
If you or someone you care for has been seriously injured as a result of poor medical or hospital care, call the experienced medical malpractice lawyers at Painter Law Firm, at 281-580-8800, for a free consultation about your potential case.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who files medical negligence and wrongful death lawsuits on behalf of patients and their families.
