Liston, Beth W. MD, PhD; Fischer, Melissa A. MD, MEd; Way, David P. MEd; Torre, Dario MD, PhD; Papp, Klara K. PhD
Dr. Liston is director, Subinternship Clerkship, and assistant professor of internal medicine and pediatrics, Ohio State University College of Medicine, Columbus, Ohio.
Dr. Fischer is associate dean for undergraduate medical education, University of Massachusetts School of Medicine, Worcester, Massachusetts.
Mr. Way is senior research associate, Ohio State University College of Medicine, Center for Education and Scholarship, Columbus, Ohio.
Dr. Torre is associate professor and associate program director, Internal Medicine Residency Program, University of Pittsburgh, Pittsburgh, Pennsylvania.
Dr. Papp is associate professor and director, Center for the Advancement of Medical Learning, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Correspondence should be addressed to Dr. Liston, Ohio State University, 4980 Cramblett Hall, 456 W. Tenth Ave., Columbus, OH 43210; telephone: (614) 293-7499; fax: (614) 366-2360; e-mail: Beth.Liston@osumc.edu.
First published online May 25, 2011.
Interprofessional teamwork is important to patient care, as a decade of renewed interest in the quality and safety movement has grown. Reports from the Institute of Medicine have called into question patient safety, the quality of health care, and the efficacy of the educational system.1 Joint Commission on Accreditation of Healthcare sentinel event reporting has demonstrated that 70% of preventable medical errors are due to communication errors. From this, core competencies have been identified as needed by all health care workers, including physicians and nurses.2 The ensuing Institute of Medicine report describes working in interdisciplinary teams as one of the five core competencies for all health care professionals. There seems to be a consensus in the published literature on the need for an interprofessional component in health professionals' education.3 Such interprofessional education (IPE) has been defined by Hammick et al4 as those occasions when members (including students) of two or more professions learn with, from, and about one another to improve collaboration and the quality of care.
However, medical school education to promote interprofessional training has been inconsistent. Physicians and nurses, although probably the most closely aligned health care workers, have had a tumultuous history in terms of communication, cooperation, and joint decision making. Perhaps the most well-known description of this phenomenon was depicted in a 1967 article by Leonard Stein5 where he describes a “game” played between the doctor and the nurse. He explained a system where dominant physicians received subtle cues about patient needs given by submissive nurses in somewhat coded language. Nurses would give soft, respectful suggestions and thereby covertly participate in clinical decision making without ever appearing to do so. Although there have been substantive changes in the interactional style between these two groups since the publication of Stein's article,6 there are still remnants of this pattern, and often neither group is comfortable with the other.
Within internal medicine (IM), there is a growing body of literature to suggest that teamwork and collaboration have measurable effects on patient care. Multiple studies from intensive care units have demonstrated improved patient outcomes associated with enhanced interprofessional collaboration.7–11 Similarly, general medicine inpatient wards with structured care teams, including allied health professionals and clinical nurse consultants, have decreased in-hospital mortality, and patients on these services exhibit a decreased functional decline.11 Although there is no clear consensus on the ideal timing of an IPE intervention,3 many have suggested that this team training be embedded throughout health professions education. Active, patient-based learning through working together on patient care in a real ward context has been shown to be an effective means to increase collaborative and professional competence.12
Nonetheless, current IPE practices remain unclear. A 1995 survey suggested that less than 15% of medical schools and nursing schools had interprofessional programs.13 A more recent systematic review suggests that interprofessional teamwork curricula are growing but remain limited.14 The attitudes of medical faculty have previously been reported as a barrier to IPE.15 To understand current attitudes and practices within the United States and Canada, we thus queried clerkship directors in IM as part of the 2009 annual Clerkship Directors in Internal Medicine (CDIM) survey. We explored attitudes, barriers, and current practices with regard to interprofessional training during the IM clerkship and subinternship courses.
In June 2009, the CDIM surveyed its North American institutional members, which were 107 of 143 departments of medicine in the United States and Canada at that time. All CDIM institutional members were sent an electronic mail cover message that explained the purpose of the survey and contained a link to the electronic, confidential survey. Nonrespondents were contacted up to three additional times by e-mail and once by telephone. Participants were blinded to any specific hypothesis of the study. Our author group participated in formulating questions for the survey (B.W.L., M.A.F.), participated on the CDIM Research Committee (K.K.P., D.T.), and analyzed data from the CDIM survey with permission (D.P.W.), all of which formed the basis of our study and this article.
A call for questions was issued to CDIM members in the fall of 2008. In all, 11 topics were submitted for inclusion in the 2009 CDIM survey. Members of the CDIM Research Committee reviewed submissions and identified six topics of interest which clustered into three categories: required core clerkship and subinternship curricular design, grading, and promotion and status of the clinician educator. Questions were reviewed, organized, and edited by members of the CDIM Research Committee. Questions were then presented to the CDIM Council and further revised. The CDIM Research Committee members then completed an initial draft of the online survey and submitted this for another review by the CDIM Council.
The final version of the survey consisted of 127 items over 11 topics. Some topic sections contained items that branched (or involved skip-logic) so that respondents could bypass sections that were not relevant to them. Demographic data about institutions' public, private, or federal status were also collected.
The section on IPE in IM consisted of 26 questions including multiple-choice, open-ended, and Likert-scaled questions designed to assess the respondent's perceptions about the importance of IPE generally, and barriers preventing IPE and current educational practices specifically at each respondent's institution.
Our team of authors summarized responses from the IPE section using descriptive statistics. Questions using a five-point Likert scale were analyzed as either positive (strongly agree and agree), neutral, or negative (disagree or strongly disagree). Multiple barriers to IPE have been cited in the literature.16 Rasch analysis17 was used to investigate the relative strengths of 11 specific barriers to implementing IPE in the IM clerkship. These barriers were scored dichotomously: 1 = barrier, 2 = not a barrier. Then, scores were converted to Rasch logits (or log odds units) with the Winsteps Rasch Analysis Program.18 These can be interpreted as follows: The larger (and positive) the logit is, the more difficult or formidable the barrier would be to overcome. The smaller (negative) logits represent barriers which are more easily removed.
Sixty-nine (64%) of 107 institutional members responded to the survey. Opinions regarding the importance of IPE and whether it should occur in the clinical curriculum of medical schools were mixed. Forty-seven (68%) believed that IPE is important to the practice of IM (see Table 1). However, only 39 (57%) believed that it should become a part of the undergraduate clinical curriculum (during clinical clerkships or subinternships).
Participants were also asked to rate potential barriers to the implementation of IPE in the IM clerkship (Table 2). The three most significant barriers to IPE in the IM clerkship were scheduling alignment, time in the existing curriculum, and resources in time and money. The unifying theme in all three of these barriers is time: its availability, the ability to schedule training with other professional students, and the ability to fit it into an already full curriculum. The three items posing the least potential to be barriers to IPE in the IM clerkship were support from medical school leadership, identifying appropriate professional school partners, and support from the respondent's department.
Barriers in the middle of the scale were medical student interest and belief in the value of IPE. About a third of respondents thought that these two items were a barrier, and a third thought they were not. The remaining items asked the respondent to speculate about the position of other health professionals and other health professions students on interdisciplinary education, so there were many “don't know” responses.
Although more than half of respondents felt IPE should be included in the clinical curriculum, 55 (81%) indicated that there was no formal IPE curriculum in their institution's IM clerkship, and 57 (84%) indicated that there was no formal IPE curriculum during IM subinternship rotations at their institution. Of the 13 (19%) respondents reporting a formal curriculum at their institution, 3 described activities in which other disciplines such as psychiatry, neurology, radiology, and emergency physicians were involved rather than other medical professions, suggesting confusion between the terms “interdisciplinary” and “interprofessional.” The other 10 respondents reported the involvement of professions such as nursing, physical therapy, occupational therapy, pharmacy, physician assistants, speech, and nutrition at their institutions. Thirty-seven (53.6%) of respondents described their medical school as public/state, 28 (41%) as private, and 2 (3%) as federal. The remaining 2 schools did not provide data. Among the 13 respondents reporting a formal IM IPE curriculum in their institution's IM clerkship, 5 (38%) were public/state and 8 (62%) were private.
Only five respondents indicated that other professional students were involved during the IM clerkship apart from on rounds, and four indicated they were involved during the IM subinternship. Pharmacy students were the most frequently cited. Similarly, only six schools' IM clerkships and five schools' IM subinternships included other health professionals on rounds, the majority of whom were pharmacists. There were no differences in the reported demographics of respondent schools between those with interprofessional rounds and those without.
Despite growing data underscoring the importance of interprofessional teamwork in quality health care, IPE in IM remains limited. Over two-thirds of respondents to the 2009 CDIM survey who addressed statements about IPE indicated that it is important for IM practice. However, only slightly more than half responded that this should be part of the clinical curriculum. This finding may reflect the debate regarding the optimal timing of teamwork training, although the preponderance of the literature suggests that such training should be embedded throughout health professions education. Although the survey did not ask when IPE should be conducted, it is possible that some respondents believed that IPE is a more appropriate curricular topic for graduate as opposed to undergraduate medical education. Our survey only asked clerkship directors in one discipline to self-report educational practices at their own institutions. Their responses thus may not reflect the prevalence of IPE within the entirety of the undergraduate medical curriculum.
Although the majority of clerkship directors agree that IPE should occur in the clinical curriculum, very few respondents reported formal IP teaching or experiences at their schools. Of those who did, three described educational interventions that involved other disciplines, not other professions. This suggests that the number of schools actually offering IPE in IM may be lower than indicated by our survey results. Although this finding underscores the confusion between the terms “interdisciplinary” and “interprofessional,” a limitation to our study, it also suggests that the confusion would result in overestimation of IPE. Thus, our data likely demonstrate even a wider gulf between those who agree IPE is important and the prevalence of IPE in the medical school curriculum.
Faculty attitudes have previously been cited as a barrier to IPE, which our respondents have confirmed. The majority of responding clerkship directors believed that IPE should be a part of the IM clerkship, but at 57% this was a small majority, and there was still a significant number of respondents who were noncommittal or who disagreed. Given the competition for curricular time, IPE may not be included without a strong advocate. In fact, the perceived barriers were predictably related to time, scheduling, and money. In Accreditation Council for Graduate Medical Education standards, the need for training in interprofessional teams is clearly delineated, whereas Liaison Committee for Medical Education (LCME) standards are more vague with regard to teamwork. More precise language about the need for IPE within LCME requirements would help gain additional administrative support to address these perceived obstacles.
Of note, about a third of our survey's respondents cited “medical student interest” as a barrier to IPE. Responses to the 2010 Association of American Medical Colleges (AAMC) Graduation Questionnaire19 demonstrated that only 3% of graduating medical students felt that time devoted to instruction on teamwork with other professionals was excessive, whereas 10% of responding students indicated that this time was inadequate. This may suggest that clerkship directors underestimate medical student interest in this topic. Further study to explore medical student interest and perceptions is warranted.
Perhaps the most concerning finding is that medical students in less than 10% of responding schools round with other health professionals. This likely reflects the relative infrequency with which interprofessional rounds are conducted throughout IM training. As a growing body of literature demonstrates improved patient outcomes associated with interprofessional teamwork and collaboration, health care practices and educational strategies will need to adjust in order to ensure quality and patient safety.7–11 Additionally, AAMC workforce study data suggest that IM is one of the disciplines facing a workforce shortage. Adding midlevel providers such as nurse practitioners and physician assistants to the patient care environment has been suggested as one way to address this shortage while maintaining quality of care. Strong interprofessional communication and teamwork in our trainees will be paramount in the changing health care environment.
In other settings, models of interprofessional clinical care are gaining success and momentum. Within pediatrics, interprofessional rounds with nurses and family members are often conducted. In ambulatory practice, one of the core principles of the patient-centered medical home is interprofessional health care teams to improve care.20,21 Some subspecialties within IM frequently involve nonphysician health professionals in patient care. For example, tumor boards often bring together physicians, social workers, and technologists. There is a growing body of literature suggesting that practice-based interprofessional collaboration interventions can improve health care processes and outcomes.22 Identifying successful models of interprofessional teamwork within clinical practice and the lessons they provide will thus be important next steps for training learners in this crucial competency.
In summary, IPE is important to improving health care systems, patient care, and patient experiences. Our analysis of data from the CDIM 2009 survey suggests limited penetration of IPE into one of the foundational clinical training episodes for medical students at LCME-accredited schools in the United States and Canada. This may in part be related to confusion regarding the definition of IPE, comparative undervaluing of IPE in student training, and misconceptions of barriers to IPE. Educators should build on other initiatives such as the patient-centered medical home and models from other fields in designing opportunities for didactic and experiential learning.
The data used in this survey are the property of the Clerkship Directors in Internal Medicine and used with permission. Authors acknowledge the Alliance for Academic Internal Medicine staff for their help in creating an online survey, as well as in survey distribution, collection, and data entry.
The IRB at Case Western Reserve University determined that the CDIM survey research protocol did not fit the definition of human subjects research per 45 CFR 46.102 and declared the protocol exempt from further IRB review.
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