BACKGROUND: Mindfulness-based stress reduction (MBSR) and massage may be useful adjunctive therapies for chronic musculoskeletal pain.

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Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Sign on a print shop door:BWe can do it fast, we can do it well, we can do it cheap. Pick two. 78-year-old widow with hypertension, osteoarthritis, a recent stroke, elevated cholesterol, and a 50-pack-year smoking history comes to her primary care provider for a mild cough and weight loss. She lives alone and loves to chat with her doctor. The physical examination is unrevealing. Chest xray shows a lung nodule. A CT scan is ordered. A long discussion ensues about what would happen if the CT scan shows cancer: how would she undergo evaluation and treatment with her family far away? For what became a 40-min visit, only 15 min had been allotted. Now the doctor is behind schedule. She feels guilty and gives more time to each patient, thus falling further behind. Screening issues are postponed and personal interactions are diminished. A walk-in patient is added. One waiting patient leaves angrily. At the end of the day, facing a large pile of forms and documentation needs, the doctor feels drained and questions the quality of care she provided.The Time Crunch. While Mechanic demonstrated that routine primary care visits (averaging 15-20 min) were 1 to 2 min longer than before, 1 the complexity of clinical issues addressed during these visits has increased. In 2010, the CDC reported that one-third of elderly patients had three or more chronic medical conditions, with 40 % of patients taking three or more medications. Providers may respond by cutting corners on the history and physical examination and by ordering more tests, which lead to a cascade of follow-up tests. Providers describe behind-the-scenes burdens of documentation, phone calls, emails, refills, consultations, and lab reports, while careful calculations show that guideline-driven preventive care would add 7 h to each primary care clinician's workday. 2 The work of primary care simply cannot be completed in the time allotted.Consequences for Patients. Increased work during short (<20 min) visits means appointments in which fewer health care issues are addressed and the depth of understanding is diminished. Time-consuming psychosocial determinants of health are left unaddressed. These consequences translate to decreased patient satisfaction, excess emergency room usage and non-adherence to treatment plans. 3Consequences for Providers. Fifty-three percent of primary care providers report time pressure in the clinical encounter. 4 Many providers describe emotional exhaustion and the fear of making clinical errors. Students observe harried primary care providers and choose alternative career paths.Root Causes. In the early 1990s, Medicare adopted the relative value unit (RVU) payment model. In a budgetneutral system, the introduction of new procedures at substantially higher RVU levels has resulted in the devaluing of cognitive care such as evaluation and management services. When private insurers and managed care contracts reduced compensation, providers increased daily volumes to maintain stable incomes. Health systems followed with daily visit

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BACKGROUND:Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.