There is a thick stack of visiting nurse reports piled in a physician’s inbox. He skims through the officious, dense documents, vaguely recognizes most of the patients, and signs his name attesting to their veracity.
Later, a patient calls after hours. Apparently, there was a drug-drug interaction with her prescriptions that were faxed in earlier in the day. The pharmacist would not fill the prescriptions, and could the physician help?
Often I find myself thinking: Surely there must be a better way to practice medicine? A system that is less fractured, where patient care is collaborative, in real time. But what would this look like? And are we doing enough in medical education to foster such a vision of patient care?
A Core Competency: Interprofessional Education
In 2003, the Institute of Medicine (IOM) published the book Health Professions Education: A bridge to quality. The authors highlight 5 core competencies — not to be confused with the ACGME core competencies — that they think all clinicians must possess to provide high-quality care in the 21st century:
- Patient-centered care
- Interdisciplinary teams
- Evidence-based practice
- Quality improvement
The second item on this list, interdisciplinary teams, falls behind only patient-centered care. Why would the IOM highlight interdisciplinary teams as nearly the most important core competency? It recognizes the disjointed way we practice medicine. The authors write:
“There is generally a great lack of understanding among the professions for what each profession does, its level of training and education, and its existing or potential competencies….This situation is exacerbated by the fact that in the vast majority of educational settings, health professions are socialized in isolation, hierarchy is fostered, and individual responsibility and decision making are relied upon almost exclusively.” (p. 79)
At my medical school, the PA students had a test every Thursday. I would see them cramming in the library. We shared a few anatomy labs together. Later, on the wards, we would serve as clinical clerks – separately. Only as an attending, on the fly, did I learn about the PA’s scope of practice and collaborative care-giving. I never worked with a nurse practitioner. During residency, the pharmacist would call me only when I placed an order incorrectly.
Now, as a medical educator, I wonder if there is a better way.
What Would an Interdisciplinary Team Look Like?
The call from the IOM is to model these teams through interprofessional education. Only by training together, they reason, can a culture of communication, mutual respect, and shared values be fostered. We all practice in the same place. We all should learn in the same place.
There are only a few examples in medical education literature that describe successful interprofessional training experiences. One study created student teams in medicine, nursing, physical therapy, and occupational therapy. The purpose of the project was for the teams to provide interprofessional care plans for orthopedic and rheumatology patients, including interprofessional hand-offs. How did it go? Using qualitative analysis, the students were generally positive. One medical student responded, “You need to adapt to understand that training ward is about holistic patient care… so you need to be a team player.”
A similar finding was discovered among medical and social work students in caring for geriatrics patients.
The gist of these studies is that the learners grow to appreciate each other’s perspective, recognize the unique role each discipline can offer, and work collaboratively for the best outcome of the patient.
Is Interprofessional Education the Way to Go?
Although this research is promising, I am not aware of any findings that conclusively demonstrate improved patient outcomes resulting from interprofessional education. A Cochrane Review of 15 studies was inconclusive about the superiority of interprofessional education on health care outcomes and professional practice.
There are also some philosophical issues at play here. On the one hand, there may be some economies of scale: if APRN students, PA students, and medical students all need to learn anatomy or physiology, then perhaps all could attend the same lectures. History taking, the physical exam, and professionalism — so much could be taught to all disciplines simultaneously.
On the other hand, the professions are different and perhaps blurring the roles of each is not in each one’s best interest. When I asked the opinion of a colleague at another medical school — one that has rolled out a comprehensive interprofessional curriculum where medical, nursing, and PA students interact early on in their training — she remarked, “The medical students are training to be doctors. The nursing students are training to be nurses. The PA students are training to be PAs. But in this curriculum, it looks like everyone is being trained the same. How are they different?” A fair question indeed.
In the past, the health professions may have been “socialized in isolation” as the IOM says. And yet, is it possible for too much collaboration and not enough identity formation?
At this point, the Med Ed community are still trying to figure it out. Pharmacists are showing up on morning rounds more. Social workers, medical home nurses, and physicians “huddle” before the morning clinic session. We look each other in the eye. We ask clarifying questions of one another in real time to smooth over bumps in patient care. To me, this feels right and makes sense – certainly more sense than blindly signing those “in basket” VNA orders.
Benjamin R. Doolittle, MD, is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.