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The Case for Interprofessional Learning and Collaborative Practice in Graduate Medical Education

Brienza, Rebecca S. MD, MPH; Zapatka, Susan APRN; Meyer, Emily M. PhD

doi: 10.1097/ACM.0000000000000490
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Dr. Brienza is physician codirector, U.S. Department of Veterans Affairs Connecticut Healthcare System Center of Excellence in Primary Care Education program, West Haven, Connecticut, assistant professor, Section of General Medicine, Yale School of Medicine, New Haven, Connecticut, and assistant professor, Fairfield University School of Nursing, Fairfield, Connecticut.

Ms. Zapatka is nurse practitioner codirector and core faculty member, U.S. Department of Veterans Affairs Connecticut Healthcare System Center of Excellence in Primary Care Education program, West Haven, Connecticut, adjunct faculty, Quinnipiac University School of Nursing, Hamden, Connecticut, and associate clinical professor, Fairfield University School of Nursing, Fairfield, Connecticut.

Dr. Meyer was research coordinator, U.S. Department of Veterans Affairs Connecticut Healthcare System Center of Excellence in Primary Care Education program, West Haven, Connecticut, and research associate, Yale University School of Medicine, New Haven, Connecticut, at the time this was written. She is currently assistant professor, Norwich University School of Justice Studies & Sociology, Northfield, Vermont.

Funding/Support: This project has been funded by the Centers of Excellence in Primary Care Education of the Office of Academic Affiliations, U.S. Department of Veterans Affairs.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Brienza, VACHS Center of Excellence in Primary Care Education, Building 12, Room 201, 950 Campbell Ave., West Haven, CT 06516, Mail Code: 11ACSL1; telephone: (203) 932-5711 ext. 3651; fax: (203) 937-3427; e-mail: Rebecca.Brienza@va.gov.

There is a paucity of interprofessional collaboration (IPC) and team development training in graduate medical education (GME). To prepare trainees for practice in new systems of care delivery, effective IPC and teamwork are necessary. IPC in health care is associated with improved patient outcomes and safety,1 and proficiency in IPC is now an Accreditation Council for Graduate Medical Education core competency.2 Despite progress, true interprofessional learning and collaborative practice among health professional trainees is lacking in most GME training.

To address this deficit and better prepare health professional trainees for future practice, we propose seven transformative guidelines, which have emerged from our own experiences co-leading an interprofessional training program, including both postgraduate and undergraduate health professional trainees. Trainees must (1) learn with and care collaboratively for patients in interprofessional teams and partnerships; (2) maintain sustained and longitudinal relationships with patients, faculty, and teams in the ambulatory setting; (3) have training in health policy, leadership, and advocacy; (4) have a clear understanding of the roles and contributions of all health care team members to patient care; (5) achieve competency in team development, interprofessional relationships, conflict management, and facilitation skills; (6) remain actively involved in systems and performance improvement initiatives; and (7) regularly reflect on how proficiency in all of the above leads to improved patient care.

As codirectors of one of five U.S. Department of Veterans Affairs Centers of Excellence in Primary Care Education (CoEPCEs),3 we have developed, implemented, and updated these guidelines over the past three years using rapid change cycles. The foundation of our CoEPCE clinical model is interprofessional trainee, faculty, and staff core teams that provide shared longitudinal care for patient panels. Trainees include internal medicine (IM) residents; nurse practitioner (NP) fellows (postgraduate year 1); pharmacy and health psychology residents; and medical, NP, and physician assistant students. Interprofessional trainee teams are supervised and mentored by interprofessional faculty dyads (MD/NP), who also share patient panels with trainees. Patients within the CoEPCE model receive an overview of the team structure and practice partnerships and are introduced to staff team members. Our goal is no longer individual provider continuity but, rather, ensuring that patients understand that their care is provided by an interprofessional team that engages in safe care transitions.

It was necessary to make significant changes to existing health professions educational models and curricula to facilitate longitudinal educational experiences. For example, we adapted the IM resident structure to allow for an increased time commitment (from 10% to 33%) in the outpatient setting. During “immersion blocks,” trainees spend approximately half time caring for patients, and the remaining time in educational seminars focused on the tenets of patient-centered care (e.g., shared decision making, performance improvement, motivational interviewing). Our program also includes an innovative health policy/leadership/advocacy curriculum that prepares trainees with the knowledge and skills to actively participate in shaping the future of health care.

How do we know this model “works” and will actually prepare trainees for new systems of care delivery? Thus far we have learned a great deal about what trainees are looking for: innovative programs integrating nontraditionally covered knowledge, skills, and workplace learning that will allow them to participate fully in their future careers. Qualitative interview data suggest that trainees are not only hungry for this type of training environment but are also confident that it will better prepare them for future leadership in health care:

  • Compared to my peers training in outpatient clinics that do not create interprofessional teams or exist within a patient-centered medical home, I am better equipped to know what 21st-century primary care can be in our country and how we can create similar models for future generations of primary care clinicians.… I have come to believe this is a better alternative to our current primary care system and I am now empowered by experiences to spend my career disseminating this model of care elsewhere.
  • In this program, trainees are encouraged to redesign health care delivery in a way that best integrates the different health care professions and highlights their complementarity. We think about the health care system as something we can help shape rather than something that is simply handed to us.

The most pressing problem in GME today is the paucity of interprofessional training. While professional organizations and scholars have laid the groundwork for change, it was frontline experience designing and implementing this program that informed our seven guidelines to improve how new health care providers are trained for an ever-evolving system. We are confident that these guidelines will lead to improved, integrated, and safer health care delivery in the 21st century and beyond.

Acknowledgments: The authors wish to thank Dr. Malcolm Cox for his visionary leadership in conceptualizing and developing the Centers of Excellence in Primary Care Education (CoEPCEs). The authors also thank the Department of Veterans Affairs Connecticut Healthcare System CoEPCE faculty members who have contributed substantially to this program: Drs. Shawn Cole, Anne Hyson, Cara Kurlander, and Rachel Laff, and Ms. Susan Langerman. Lastly, thanks are extended to colleagues with the CoEPCE’s Coordinating Center, who have provided ongoing support and oversight—Drs. Stuart Gilman, Judith Bowen, and Kathryn Rugen.

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References

1. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes (Review). Cochrane Database Syst Rev. 2009;8(3):CD000072
2. Accreditation Council for Graduate Medical Education, American Board of Internal Medicine. . The internal medicine milestone project. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Accessed July 11, 2014
3. Rugen KW, Watts SA, Janson SL, Angelo LA, Nash M, Zapatka SA, et al. Veteran Affairs Centers of Excellence in Primary Care Education: transforming nurse practitioner education. Nurs Outlook. 2014;62:78–88
© 2014 by the Association of American Medical Colleges