The GME “Mitten”: Quality Improvement, Not Course Overload

By Scott Harris

How is a medical school curriculum like a mitten?

If the mitten in question is the enchanted handwarmer from the Ukranian folktale, the answer isn’t too hard to parse out.

In “The Mitten,” a mouse finds a single mitten abandoned in the snow and climbs in for warmth. By and by, other animals follow suit, all the way up to a bear. Eventually, the mouse sneezes, and the overstuffed mitten explodes, sending all its inhabitants tumbling out.

As with the mitten, so it goes with the curriculum. One more elective, one more topic, one more tiny module could be the back-breaking addition.

When the addition in question is quality improvement, many students these days are an easy sell, even at the medical school level. Nevertheless, integrating it into packed schedules and course loads remains something of a balancing act. Medical school leaders are looking for innovative ways to ensure students receive maximum benefit from their quality improvement lessons, without becoming overburdened.

“Medical students have very busy weeks,” said Mark Earnest, M.D., director of Interprofessional Development at the University of Colorado Anschutz Medical Campus. “So we try to make it cost-neutral in terms of time and effort for the students.”

The booming world of online education is one solution. The Institute for Healthcare Improvement’s Open School, which offers courses in quality and safety alongside other topics, is a leader in this area, allowing learners to move at their own pace.

Brick-and-mortar institutions have their own ways of maximizing bang for the buck. At the University of Chicago Pritzker School of Medicine, clinical data collection and analysis takes place using the American Board of Internal Medicine Practice Improvement Model (PIM), a standardized web tool. PIMs are attractive because they make the process more transferrable, rather than being bound to internal software or methodologies.

In a four-week elective block, fourth-year students at Michigan Medical School have the incentive of working alongside health system leaders to learn about problem solving and health administration.

At Colorado, small groups of medical and nursing students work alongside each other. As part of a quality improvement pilot taking place at University of Colorado Hospital and The Children’s Hospital, groups learn systems study and interprofessional education principles while working toward tangible clinical improvements. Projects to date have included fall prevention, improving patient transitions and discharges, and preventing common conditions such as decubitis ulcers. Students are now being taught a rapid cycle improvement technique, or measuring data quickly to see what works and what doesn’t.

“We don’t have to sell them on these concepts,” Earnest said. “In my generation, you sat silently and earned your stripes. But for this generation, the notion of a hierarchy is falling out of favor, and teamwork is one of the things they really want to do.

“It needs to be done. There has been a slow, 15-year awakening to the reality that we sometimes fail to do what we need to do.”