October 15, 2010

Interprofessional Education: An Argument for Starting Early

by Kimberly A. Toussaint, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center
When was your first professional encounter with a physician? What about a nurse? For me, it was during my fourth year of pharmacy school, on my first clinical rotation. Prior to that time, my collaborative experience with other health care professionals was merely theoretical – as abstract as the patient cases that we were given to write SOAP notes about during my therapeutics labs.  During pharmacy school, there are numerous opportunities to gain teamwork experiences.  Many schools require group journal club presentations, SOAP note write-ups, and case presentations.  However, this group experience typically involves only other student pharmacists.  Although many health professionals are educated on universities located on a academic health center that include pharmacy, medical, nursing and dental schools (within walking distance of one another), integration of the education of these various disciplines is rare.
Although health professional disciplines work together on a daily basis, at the beginning of their professional experiences they are often unsure of the extent of the other disciplines’ training and knowledge. This is likely due to the fact that health professionals have little exposure to the curriculum, knowledge base, and perspectives of other disciplines during school.  Familiarity with other disciplines typically improves after health professionals are licensed and begin practicing (and even then, misperceptions are common).  When I started my first clinical rotation, I had no frame of reference for how much instruction regarding pharmacology or pharmacokinetics the medical interns on my team had during their classes. For this reason, I was unsure of how to phrase my recommendations. Often, I was concerned that I was regurgitating information they’d heard numerous times. As it turned out, I probably wasn’t explaining things well enough because my knowledge and perspectives were different.
The “Seamless Care” model addresses the need for interprofessional practice experience during training, and has been studied in Canada and Australia.  This model prepares students in health professional schools to become collaborative practitioners by forming teams of students from different health disciplines (medicine, nursing, pharmacy, dentistry, and dental hygiene) and having them work together for eight weeks to plan one patient’s transition from acute care to home.  The primary purpose of this model is to create a unifying task and facilitate a real-life collaboration between health professionals.  The model also serves to address a disparity in the continuity of care between hospital discharge and home. The students work under the guidance of experienced preceptors that helped to facilitate the care of the patient as well as helping the student develop team work skills by serving as a role model and mentor.1,2
This model is built on several educational theories.  It is an example of social learning theory because the students are able to observe the ways that their preceptors work collaboratively with other disciplines, and model that behavior.  Constructivist learning theory is exhibited by the students working collaboratively to share past experiences and to increase their understanding of the patients’ care and their respective roles on the team.
A study done by Coster et. al published in the International Journal of Nursing Medicine in 2008 measured the readiness of health professional students to learn together, using a survey.  This study showed that students’ readiness for interprofessional education was high at the beginning of their professional education, but declined over time. These results support the notion that interprofessional education should start from very early in health professional students’ education.3
By integrating this interdisciplinary practice model early in the advanced pharmacy school curriculum, collaborative work habits, trust, and rapport would be facilitated between various health disciplines. Additionally, each discipline would enhance the knowledgebase of the others by contributing a new perspective. This would enhance experiential learning across all disciplines, and would benefit everyone on the team, especially our patients.  Interprofessional education involving pharmacists, physicians, and nurses providing continuity of care for patients will have long term benefits - increasing the quality for years to come.
Carlisle, Cooper, and Watkins summed it up best:
Teams have a collective responsibility that necessitates even closer interprofessional working relationships.  Complementary action is not enough.  It is essential to cultivate this working relationship, beginning in school.4
The future of healthcare relies on increased collaboration between health care professionals.  Collaboration is frequently limited by preconceived beliefs about other disciplines, and this is exacerbated by our limited exposure during our education.  This leads to a lack of understanding and trust among health care professionals.  Incorporating interprofessional learning into the curriculum of health professional students would increase trust and enhance collaboration between disciplines, and ultimately optimize patient care.

Mann K, McFetridge-Durdle J, Martin-Misener R. Interprofessional education for students of the health professions: The “Seamless Care” model. Journal of Interprofessional Care. 2009 May;23(3):224-233.
Nisbet G, Hendry G, Rolls G. Interprofessional learning for pre-qualified health care students: An outcomes-based evaluation. Journal of Interprofessional Care. 2008 January;22(1):57-68.
Coster S, Normal I, Murrells T. Interprofessional attitudes amongst undergraduate students in the health professions: A longitudinal questionnaire survey. International Journal of Nursing Studies. 2008;45:1667-1681.
Carlisle C, Cooper H, Watkins C. “Do none of you talk to each other?”: the challenges facing the implementation of interprofessional education. Medical Teacher. 2004;26(6);545-552.

[Editor's Commentary:  There has been increased interest in interprofessional education at most health professional schools over the past decade - but, unfortunately, there has been limited progress despite calls by many professional organizations and the Institute of Medicine to introduce interprofessional education early (and more often) within our curricula.  Deep in our hearts, we believe patients would gain from increased interprofessional collaboration.  The data to support this belief is accumulating.  Intuitively it makes sense to harness the power of people of various knowledge and skills into a cohesive unit.   But getting people to play in the same sand box isn't always easy - particularly when everyone has had their own sandbox in the past.  The patient-centered medical home or accountable care team model is emerging under health care reform as THE health care delivery model.  Under such models of care, payment structures reward interprofessional team work and meeting quality standards.  But how to get from here (silo care) to there (interprofessional care).  Its not going to be easy and its not going to happen over night.  Certain teaching our students in an interprofessional, collaborative manner will go along way toward breakdown barriers.  Dobson and colleagues at the University of Saskatchewan describe the work of interprofessional student teams including pharmacists, nurses, dietitians, and physical therapists in a paper entitled "A Quality Improvement Activity to Promote Interprofessional Collaboration Among Health Professions Students."  During this activity, small groups of students participated in a quality improvement project following the Plan-Do-Study-Act (PDSA) model.  Through this work, the students increased their understanding of their respective roles as well as the value that each member of the team brought to the project.  It is not difficult to imagine that these kinds of "hands on" projects could be implemented at various times throughout the curricula of health professional schools.  Moreover, guided by experienced practitioners from each discipline, the groups would design and implement projects that meaningfully contribute to the care of patients in a variety of settings.  The American College of Clinical Pharmacy has a strong policy statement regarding interprofessional education and recently published a white paper on this topic that I encourage everyone to read. - S.H.]

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