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Residents are still mastering medicine. But can they fix health care problems too?

A new curriculum trains neurology residents to think like engineers in a factory — improving outcomes while reducing waste and lowering costs.

Kathryn Kvam, MD, wants the neurology residents to think not just like a neurologist, but also like an engineer at a car factory.

"Engineers are trained to think about processes, how they can cut waste and improve products," she said. "More and more, physicians are expected to have these quality improvement skills."

Kvam, a neurohospitalist at Stanford, has an undergraduate degree in health care management, so she has always had an eye on the patient care process -- how it can be improved to deliver better results for patients while saving money.

In 2016, two years after arriving at Stanford, Kvam launched a quality improvement curriculum: The neurology residents now attend monthly classes in which they're presented with a patient case and discuss ways the care could be improved. They also take part in three workshops annually in which they develop a systems-improvement project and learn the management skills to execute it.

The curriculum "really opened my eyes," said Nina Bozinov, MD, a neurology fellow who completed her residency in 2018.

"It's transformative," she added. "Instead of just feeling frustrated, you think, 'Let's get everyone together and figure out how to create change.' It really empowers residents to make a difference."

Several of the residents' projects are changing Stanford Health Care practices:

  • A new scoring system for evaluating the condition of neurology patients better predicts which ones will need a gastronomy tube, speeding up the decision over inserting a tube and leading to faster treatment.
  • When a patient with a pacemaker requires magnetic resonance imaging, cardio-electrophysiologists determine which patients' pacemakers can be safely paused during the MRI, resulting in many more patients who need MRIs receiving them.
  • Residents developed better questions for nurses to ask when people call in about epileptic seizures, ensuring that only the patients who need emergency care come in.

"The residents who are new to Stanford are an opportunity for improvement because they have fresh eyes," Kvam said. "They spontaneously come up with ideas."

She added that medical students and residents aren't usually taught to consider the cost of care. "They aren't trained to think about it," she said, "but we want them to think on that level. Health systems expect physicians to be partners in improving care."

Bozinov said that she's continued to work on projects during her fellowship and improve care for neurology patients. "Looking at the process and wondering how we can make things better -- it's so ingrained in my thinking now," she said.

Photo by Luke Girard

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