Yarborough, Mark PhD; Jones, Therese PhD; Cyr, Thomas A. PhD; Phillips, Sally RN, PhD; Stelzner, Denise MBA, PT
The beginning is the most important part of the work. —PLATO, The Republic
I guess for better or worse, we're making history here. —First-year medical student, University of Colorado Health Sciences Center
Ethics is now widely recognized as an important area of learning in health professions training programs. For the past several years, interprofessional* learning activities have also been identified as an extremely significant but frequently absent dimension in the academic preparation of health professionals.1–3 Introducing interprofessional learning activities into existing curricula at academic health centers can be difficult for a variety of reasons, such as the lack of available curriculum time, the absence of a uniform academic calendar, and the resistance of some faculty to interprofessional education. Despite such challenges, however, the character and setting of contemporary health care demand the development and implementation of interprofessional education so that students are prepared to work with other professionals effectively and efficiently. In this article, we relate our experiences to date with interprofessional teaching of ethics at our academic health center.
INTERPROFESSIONAL ETHICS INSTRUCTION AT THE UNIVERSITY OF COLORADO
In the spring of 1998, a required interprofessional course in health care ethics made its debut at the University of Colorado Health Sciences Center. The course was taught to first-year students in the following programs: child health associates/physician assistants (CHA/PA); medicine (MD); nurse doctorate (ND); and physical therapy (PT). The first-ever required interprofessional course offered among these campus programs, it was the natural consequence of an interprofessional orientation on ethics and professionalism, a several-hour-long exercise that was offered to approximately 450 entering CHA/PA, Dentistry, Genetic Counseling, MD, Nursing, Pharmacy, and PT students.
Both of these interprofessional experiences—the orientation and the course—reflect campus-wide interest in promoting and implementing multifaceted interprofessional education. Plans at this point are for both classroom instruction and clinically based instruction. Planned as part of the classroom component is a campus-wide core curriculum in ethics and professional development (hereafter referred to as the ethics curriculum). As active participants in both the creation and the integration of the ethics curriculum at our institution, we have been both challenged and rewarded by our efforts in this arena. The ethics curriculum now serves as a model for faculty across the campus, demonstrating not only that interprofessional education can be successfully accomplished but also that it can add significant value to student learning in diverse ways.
THE LOGIC OF USING ETHICS FOR INTERPROFESSIONAL TEACHING
For both practical and pedagogic reasons, ethics and professional development are obvious content areas for an interprofessional curriculum. Because ethics and professional development are usually addressed to some degree in all health professions training programs, there are persuasive practical considerations. Faculty resources can be put to maximum use and, since time in the curriculum is frequently already devoted to these themes, additional curriculum time need not necessarily be found. Further, little revision of introductory-level course content is necessary to modify school or program ethics courses.
In addition to such practical benefits, we believe that the most significant reason for selecting ethics as a focus for interprofessional teaching is that teaching ethics in this way dramatically enhances learning it. Because all of the health professions are dedicated to patient service, the issues and concepts fundamental to ethics lend themselves to interprofessional teaching. These include the necessity for health professionals to treat patients with respect; the requirement that health professionals work together for the benefit of their patients; and the responsibility for health professionals to use appropriately the resources with which they are entrusted.
Treating people with respect and promoting their welfare require adequate knowledge of patients, their values, and their goals. Because individual team members communicate with patients in different ways about different matters, the complex of impressions and information must be synthesized in order to understand and appreciate fully patients' values and goals. This process of synthesis requires collaboration among professionals as well as respect for conflicting points of view. Since different team members are able to do different beneficial things for patients, knowledge among the team members of one another's talents and skills is required if optimum benefit is to accrue. The same knowledge of one another's talents and skills is also required for the appropriate use of resources.
We would argue that understanding the respective roles, responsibilities, and contributions of one's colleagues is very often a prerequisite for being able to discharge one's ethical duties to patients. Fulfillment of obligations to patients, then, is better assured through effective team care, and effective team care is promoted and practiced through interprofessional learning, recalling Aristotle's dictum that “the things we have to learn before we can do them, we learn by doing them.”4 Moreover, other desirable and lofty objectives of learning ethics, such as critical thinking, enhanced creativity, integrative thought processes, tolerance of ambiguity, and humility, have all been linked to interprofessional and interdisciplinary educational approaches.5
For these reasons, interprofessional education in ethics not only provides an opportunity for students to learn the basic concepts and fundamentals of ethical decision making; it also provides them the opportunity to learn, in the process, about themselves and about the roles and responsibilities of other health professionals. Because our course is offered in the first year, there is the additional benefit of developing students' familiarity with and respect for the contributions of various health professions early in their training so that they will be able to gain more from their future clinically based interprofessional learning experiences.
Even though we are describing the benefits of interprofessional teaching of ethics, we do not believe that all ethics education for health care professions students should be interprofessional. There is still an important role for profession-specific instruction in ethics. That is why our ethics curriculum is put together so that individual schools and programs can supplement it with topics specific to their own students' needs.
Achieving the benefits of interprofessional ethics education can be a challenge, as we discuss below. However, evaluation of the initial offering of the course (also described below) showed it to be an overall success, although there was disparity between students' and faculty members' views regarding the overall effectiveness of the course as well as the value of its interprofessional nature.
THE INTERPROFESSIONAL ETHICS COURSE
Course Format and Participants
In the first offering of the course, approximately 250 students were enrolled, with MD students representing 52%, CHA/PA students 14%, ND students 9%, and PT students 25%. Class time was divided between large- and small-group meetings, a small group being composed typically of two faculty facilitators and, on the average, ten students. Participating faculty represented the four health care professions whose students were enrolled in the course, as well as the disciplines of education, law, literature, pastoral care, and philosophy. Whenever possible, a “clinical” faculty member was partnered with a “humanities” faculty member, and every effort was made to select clinicians who had some knowledge of health care ethics and humanities faculty who had knowledge of the clinical setting of health care. Forty-two small-group faculty participated in the course the first time it was offered, 57 participated the second time, and 64 participated the third time.
The learning objectives of the course (see List 1) were primarily developed by exploring such themes as the goals of health care; the role of respect in health care; the determination and role of patient benefit in health care; and the role of justice in health care. Objectives were identified based on the following assumptions.
First, if students are to graduate with a level of knowledge and skills in ethics necessary for them to be successful health professionals, a longitudinal ethics curriculum must be a part of their respective training programs. Designed as the cornerstone for such a curriculum, this course, rather than providing students with all of the essential knowledge and skills required to make good ethical decisions, prepares them to acquire that knowledge and those skills over the subsequent span of their professional training.
Second, if students are to be proficient at ethical decision making, they need to acquire a sense of professional presence, place, and direction in the patient care setting during their training years. In ethics parlance, “professional presence” refers to the virtues and obligations attached to the health professions. Professional place requires comprehension and appreciation of the moral context of health care: the relationships that define the health care setting, the particular vulnerabilities inherent in the patient role, and the patient's experience of illness. Professional direction presupposes knowledge and acceptance of what the goals of the health professions are and how those goals are determined. The activities of the course were designed to inspire students to acquire an independent understanding of each of these elements.
A third and final assumption shaping the learning objectives was the belief that students need to contemplate their transformation from lay people to professional health care practitioners. Because their education largely consists of learning science and acquiring skills, students often are neither able nor encouraged to focus on the humanistic aspects of their own development and the humanistic concerns of their chosen professions. This course was designed to instill, rekindle, or nourish in students a sense of curiosity and a habit of reflection about their professional transformation and identity.
Course Planning and Design
A team of faculty members, representing all but one of the training programs and both the humanities disciplines and the health professions, served as a steering committee for the first offering of the course. Meeting on a weekly basis for five months prior to the start of the course, the steering committee adopted three guiding assumptions:
▪ Inclusivity for all students
▪ Preference for small-group over large-group meetings
▪ Experience-based rather than lecture-based learning
As both small-group discussion and experience-based learning are standard methods of teaching health care ethics, we focus our discussion on why inclusivity was understood to be an important feature of this course.
It was the opinion of the steering committee that inclusivity was crucial for the success of the course. Because the required ethics course for first-year MD students had been expanded to include students from other training programs, every effort was made throughout the planning process to ensure that the course was focused equally on the learning needs of all of the students. For example, issues and themes relevant to all the represented health professions had to be addressed in order to ensure that all students felt that their experiences and viewpoints were relevant to the learning process. This required that the steering committee identify course materials such as case studies, stories, and articles that represented as many health professions as possible. Such materials were not always easy to collect. Existing case studies had to be rewritten so that various team members' roles were represented, and reading assignments from professional journals as well as stories and poems also had to be selected to represent more than just the physician's point of view. The steering committee had to be especially careful not to assume that the physician's role or the nurse's role in any form of discourse be used to represent a generic “health professional.” Rather, materials had to be selected or created so that students would learn that each professional role is distinct in important ways.
Such efforts were made for a variety of reasons. First, it was important that non-MD students not have the impression that they were merely “sitting in on” a course for MD students. Second, it was important that the learning environment of the course be interprofessional, meaning that exercises had to address themes and issues that every student could explore. Third, and perhaps most important, faculty on the steering committee decided that the course should promote the positive aspects of teamwork in health care. The steering committee did not want to create class experiences that would reinforce the practices and expectations of a traditional hierarchical system. Instead, it hoped to create experiences that would foster appreciation for and awareness of the fact that proficiency in ethical decision making requires effective communication and collaboration—not only between patients and health care professionals but also among health care professionals themselves. William H. Newell, an expert in interdisciplinary education, writes that the most effective strategy for a successful course is to ask questions that are too broad for any one discipline (or, in this instance, any one profession) to answer fully. According to Newell, the tension between the voices of different disciplines provides a context through which new meaning springs and that contributes to respectful and positive interaction6—the exemplum of ethical decision making that our faculty wanted to foster in the small groups.
Despite these good intentions and special efforts, faculty responsible for the course have learned from its three offerings to date that creating an atmosphere where all students feel equally included is difficult. One illustration of this is case studies. The first two years of selecting, adapting, and using case studies that are representative of all of the health professions were met with mixed results. While such case studies provide every student with a “character” with whom to identify in small-group discussions, there remains the tendency for those discussions to privilege the physician. Such a tendency was confirmed by students' comments both in formal evaluations and in informal conversations with faculty, conveying the students' own sense of awkwardness when the main focus of the discussion is the physician's role and responsibility in the case at hand. Although the non-MD students described medical students and faculty as making an effort to include everyone in the conversation, they nevertheless frequently felt that they did not play an integral role in the discussion of the case.
To redress this problem in the third offering of the course, case studies that primarily involved only one of the represented health professions were added. For example, case studies featured a physician assistant or a nurse case manager or a physician or a pharmacist rather than all of the above. This approach was tried to ensure that all of the health professionals (and thus all of the students) were represented and to provide students and faculty (many of whom are also unfamiliar with the roles of other health professionals) with a more detailed and developed view of the roles of the various providers and practitioners. And, since the case studies address basic ethical issues such as the importance of honest communication with patients, an MD or ND student can still explore such issues even though the case study involves a patient and a physical therapist.
Such ongoing refinement simply continues the already-lengthy process of designing this course, a process that has required that the steering committee itself function as a kind of prototype or test case of interprofessionalism. Because the members come from different disciplines and from different professions, they not only have to understand one another's expertise and consider one another's contributions to the success of the course, they also must adopt new points of view and new terminologies. Many of the early meetings in the first year, for example, involved sensitizing members to the very words they used when they talked about the course, the students, and the professions. Eventually, the committee developed a vocabulary that was inclusive so that the initial, automatic references to students as “medical students” or to professionals as “physicians” or “nurses” were replaced with “health profession students” or “health care professionals.” By the time the course was officially under way, such language signified not “political correctness” but a genuine conceptual shift. More important, many students readily adopted the vocabulary, consistently using it in small-group discussions.
The steering committee, concerned that the behavior of a faculty member might reinforce rather than challenge stereotypical thinking about how health professionals relate to one another and work together, tried to be equally vigilant about such issues as terminology with the small-group faculty. For example, if a faculty member refers to all students as “medical students” or refers to group members as medical students and “the rest of you,” such language will not only offend the non-MD students of the group but also subvert the discourse and activities of large-group meetings, which have been especially created to send positive messages about the importance of each of the health professions. While there was no way to guarantee that such incidents did not happen without endangering either the autonomy or the dynamic of a given small group, small-group faculty were often reminded the first year the course was offered to guard against such slips.
By the end of the first offering of the course, the majority of the small-group faculty generally appreciated and approved of the move to interprofessional learning of ethics. Some faculty, proponents of interprofessional education, were enthusiastic at the outset; others, most of whom were participants in the earlier course for medical students, were neutral, apart from some early anxiety as the result of a shift in their roles and responsibilities.
However, as the course director soon learned, some physician small-group faculty who had initially disagreed with the decision to offer the course on an interprofessional basis remained unpersuaded about the wisdom of such a change. Their major concern stemmed in large measure from their awareness that, at the time, the first-year course was the only required ethics experience for medical students throughout the entire four-year curriculum. Consequently, these faculty felt that an interprofessional ethics course deprived MD students of both intensive instruction and the opportunity to explore issues exclusively in terms of the physician's role. In addition, some among these faculty reported that small-group discussions were more rich when only MD students participated in the course. For example, MD faculty recognized the importance of checking their tendency to slip into the physician perspective because, in doing so, they would exclude the non-MD students who had joined the course. However, MD faculty felt that checking this tendency diminished their ability to connect more closely with the MD students.
Indeed, significant differences among the students were a factor in the dynamic of the small groups. For example, many of the CHA/PA students had more life and clinical experiences than did the other students and brought those experiences to bear in discussions. Because the MD students outnumbered the students from other programs and subsequently represented at least one-third of each small group, they tended to feel more comfortable about participating than did the ND students, whose smaller number meant that they were apportioned one to a group. However, we would argue that it was this very diversity and disparity that enriched the discussions rather than diluted them.
Subsequent to the first offering of the course, the course director also learned that some medical school faculty who were not involved in the course believed that changing the MD ethics course to include other students was a change significant enough to require approval by the school curriculum committee. Other faculty, including the course director, believed that it was enough to report back to the curriculum committee about the impact of the change on the course, a plan that had been agreed upon by the course director and the head of the MD curriculum committee when the course director first decided to open the course to the additional students. This disagreement highlights interesting matters regarding control of school-required curricula. While faculty should protect academic freedom and reserve a course director's right to teach a course in the way that the individual faculty member deems most appropriate, it is also important to acknowledge the role of the faculty as a whole in governing the curriculum. Opening up the ethics course to students outside the MD program brought this latent tension to the surface in our school of medicine's curriculum committee.
Another challenge that has emerged since the course was first offered is how to maintain continuity and control. The cohesiveness and shared vision achieved and enjoyed by the original steering committee gave way when that committee changed. The second time the course was offered, there was a new course director, as well as new faculty members on the steering committee, and these new people brought new philosophies of teaching and leadership that had to be processed by all. To add to the confusion, unexpected curricular changes in individual programs and schools have also had an effect. For example, one participating program altered its curriculum, requiring the course for second-year rather than first-year students. Made “in house” with no consultation with the ethics course director, this decision appears to be unproblematic, but it illustrates how neither the course director nor the course steering committee has full control over their own course. And as our institution at the time had no curricular review process with a global or campus-wide charge, it further illustrates how necessary it is for faculty from individual schools and programs to think outside their own domains when it comes to curricular matters in interprofessional education.
Another matter of interest that the course has highlighted, and thereby permitted questioning of, is the primacy of the MD program at the campus. One illustration of this was the decision made by the first course director to try to have as many physicians as possible serve as clinical small-group faculty. This decision, which was made with some ambivalence, was explained to the other members of the steering committee in advance. One primary justification was strategic in nature. The course director was in the process of working with colleagues to introduce a comprehensive ethics and humanities curriculum throughout the MD program. The success of that curriculum hinges in large part on having those physician faculty involved in those rotations be knowledgeable about the ethics curriculum so that they can promote and foster ethics learning in the clinical rotations. The course director also believed that medical students would be very desirous of having physicians rather than other health professionals as their clinical role models (a view later confirmed by a written course-evaluation report prepared by the MD student representatives), coupled with the belief that the other students would be able to relate adequately to physicians as role models, whereas perhaps medical students could not relate as well to other health professionals. This is but one example of the types of judgment calls required to balance competing needs, as well as an example of how traditional thinking and stereotypes influenced the decision making process.
Scheduling decisions provide another illustration of how the institutional hierarchy can hamper efforts to implement an interprofessional curriculum. The MD curriculum schedule requires that the course alternate days each year, causing considerable work and inconvenience for faculty in the other participating programs.* This, coupled with a series of scheduling decisions around the orientation session that were made for the benefit of MD and pharmacy students, promotes a sense among faculty from many of the non-MD programs that the MD faculty are less committed to interprofessional education, thereby reinforcing attitudes about traditional hierarchies.
EVALUATION METHODS AND RESULTS
The institution's Office of Education conducted an extensive evaluation the first year the course was offered on an interprofessional basis. Using the course's goals and objectives as the guide for designing and developing the instruments, the evaluation project systematically collected from a variety of sources data on the educational efficacy of the course. Data were gathered from mid- and end-of-course questionnaires; focus-group sessions with small-group faculty; focus-group sessions with students; small-group discussion records; students' self-assessment forms; standard class/instructor evaluations; and follow-up phone surveys of faculty.
In general, evaluations show that the course met its goals and objectives. However, in every specific instance, MD students had a higher percentage of negative responses to evaluation questions than did other students. For example, when asked whether the course was an important part of the academic programs on campus, 94% of CHA/PA students, 89% of ND students, and 75% of PT students said it was, while just 38% of MD students thought it was. (See Table 1.) Moreover, only 49% of the MD students thought the course had been effective in helping them learn the ethical responsibilities of health care professionals, while 85% of CHA/PA students, 74% of ND students, and 68% of PT students agreed that the course had been effective in this regard. (See Table 1.) Survey data further revealed that gender was not a determinant in these findings.
Small-group faculty rated the course higher than did students, with the majority of them (95%) stating that the course enabled students to understand the moral significance and ethical responsibilities of being a health care professional.
While there probably is no single reason for the discrepancies between the responses of the MD students and those of the students in the other programs, there are several possible explanations. First, the discrepancies might be attributable to different curricula. For example, MD students entered the course having participated in fewer learning exercises devoted to ethics and professionalism, making them both less prepared and less accustomed to addressing such themes. Second, the discrepancies might reveal that MD students place less value on interprofessional interaction than do their counterparts. And finally, the various demands made on students' time may be a factor in the discrepancies.
One other evaluation result of note was the preception, as reported by 35% of all students, that the course focused too much on interprofessional health care, with those students reporting that, in their opinion, interprofessionalism was the primary objective of the course. This response was unexpected given that the syllabus—in both its stated learning objectives and its explicit instructions for small-group activities—consistently reinforced the major focus of the course as ethics. A comparison of the interprofessional course syllabus with the syllabus for the previous year when only MD students had participated revealed that two class sessions in the interprofessional course included an interprofessional learning objective, an increase of one class session from the previous year. A word count on the term “interdisciplinary” (interprofessional was not used in the syllabus the first year) reveals no occurrences in the prior year's syllabus and only seven in the following year. Of these seven instances, two occurred in one of the course's learning objectives, two occurred in the title for one of the class sessions, two occurred in the learning objectives for the sessions devoted to interprofessional issues, and the remaining occurrence was in an introductory section of the syllabus explaining why the course was being taught on an interprofessional basis.
Speculating on why some students determined that interprofessional themes overshadowed ethics themes, the steering committee reached two conclusions. One was that the students were very curious and motivated to learn about the educational programs of the various health professions represented in the course, and because they had freedom to initiate and steer small-group discussions, students may have used time to explore the roles and responsibilities of the other health professionals at the expense of the learning objectives. The other was that many faculty were personally invested in a fuller exploration of interprofessional themes than was specified in the syllabus, and they may have stressed these themes over ethical issues. Indeed, most faculty highly praised the integration of students from different professions, commenting especially on the initiation of crossprofessional social interaction, the expression of empathy, and the development of teamwork.
LOOKING TO THE FUTURE
As a result of our experience with expanding a first-year ethics course for MD students into a required interprofessional ethics course at a health sciences center, the steering committee elected not only to continue offering the interprofessional course but also to recruit other students from the PharmD program (who joined the spring 2000 course). Insofar as the concerns expressed by some students and faculty that the emphasis on interprofessional approaches to patient care detracted from a focus on the foundational knowledge and skills required for ethical decision making, the assessment was made that minor changes could be made to offset the tendency. Moreover, the steering committee judged that future students would be likely to perceive the course as less novel and more routine, further mitigating the tendency to foreground interprofessional issues rather than adhere to the course's concentration on ethics. This judgment proved correct when evaluations from the second and third course offerings demonstrated a broad consensus among students and faculty that the interprofessional nature of the course was a strong asset rather than a primary focus.
The steering committee made two other decisions. The first was to increase interprofessional learning opportunities at our institution, and we are currently planning the expansion of interprofessional education in ethics for second-year students. When this expansion is implemented, the campus-wide core curriculum in ethics and professional development will permit students to work collaboratively in interprofessional groups during the first two years of their training. The second decision was to disseminate our findings and describe our experiences to encourage interprofessional learning at other academic health centers.
Describing our experience has reinforced our commitment to interprofessional education. Over the past three years, we have demonstrated that it can be successful despite institutional barriers; we have identified faculty from across the campus and in the community who have equally strong commitments to it; and we have elicited a scheduling change in the MD curriculum that will accommodate the needs of the other participating schools and programs.
At the same time, describing our experience has revealed a key paradox. The bulk of institutional resistance we have experienced has emanated from our university's school of medicine, although curiously more from its basic sciences than from its clinical sciences faculty. Further, much of the dissatisfaction expressed by faculty from other schools and programs resulted from a perceived inflexibility of MD program faculty in addressing logistic problems and a perceived lesser commitment on their part to interprofessional education. At the same time, the course director and the other members of the steering committee have most vigorously sought the support and approval of the MD program faculty, reflecting the prominence of that program at the institution. In short, a curricular reform effort to lay the groundwork for increased teamwork and interprofessional collaboration (and thereby diminish some of the negative influences of the traditional hierarchy) has required efforts to appease some of those at the top of that hierarchy.