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Untying the Interprofessional Gordian Knot

The National Collaborative for Improving the Clinical Learning Environment

Brandt, Barbara F., PhD; Kitto, Simon, PhD; Cervero, Ronald M., PhD

doi: 10.1097/ACM.0000000000002313
Invited Commentaries

The National Collaborative for Improving the Clinical Learning Environment (NCICLE) is a growing group of over 40 organizations representing a variety of health professions. NCICLE is beginning a discussion of issues related to culture in health care, specifically how the current culture inhibits optimal outcomes, and the discordance between current early interprofessional education (IPE) curricula in health professions schools and traditional practice models in health care. In October 2017, the Accreditation Council for Graduate Medical Education and the Josiah Macy Jr. Foundation sponsored an NCICLE symposium on optimizing interprofessional clinical learning environments. In this Invited Commentary, the authors observe that interprofessional practice and education is a decades-long field that has presented a “Gordian knot” of intractable, complex problems to solve because medicine has often not been at the table for conversations about IPE. The NCICLE symposium represented an important opportunity for medicine to signal that finding new solutions for unraveling the interprofessional Gordian knot and creating optimal clinical learning environments requires meaningful participation from all health professions. Those solutions need to build on the long history of experience and research in IPE and collaborative practice. After the NCICLE symposium provided a promising beginning, the authors propose three essential issues and one key practical step forward to move the interprofessional agenda forward.

B.F. Brandt is director, National Center for Interprofessional Practice and Education, and associate vice president and professor, Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota.

S. Kitto is professor, Department of Innovation in Medical Education, and director of research, Office of Continuing Professional Development, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

R.M. Cervero is professor and associate director, Remote Campus Education, Graduate Programs in Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Funding/Support: The National Center for Interprofessional Practice and Education is supported by the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the John A. Hartford Foundation, and the University of Minnesota. The National Center was founded with support from a Health Resources and Services Administration (HRSA) cooperative agreement, award no. UE5HP25067.

Editor’s Note: An Invited Commentary by T. Bodenheimer, M. Knox, and S. Syer appears on pages 1445–1447.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The content and opinions in this Invited Commentary are those of the authors and should not be construed as the official policy of, nor should any endorsements be inferred by, HRSA, the Department of Health and Human Services, the U.S. Government, or any of the National Center’s private founders or funders.

Correspondence should be addressed to Barbara F. Brandt, National Center for Interprofessional Practice and Education, MMC 501 Mayo, 420 Delaware St. SE, Minneapolis, MN 55455; telephone: (612) 625-3972; e-mail: nexusipe@umn.edu; Twitter: @nexusipe.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

Growing concerns in U.S. health care around patient safety, quality, costs, access, clinician well-being, and outcomes present new opportunities to link team-based approaches to health system change. Rather than treating teamwork as something affecting only certain disciplines or health professionals, recognition is growing that no one provider, profession, or care delivery model can successfully solve complex problems or change the processes of care independently. This realization is leading to renewed interest and new investments in bringing the over-50-year-old field of interprofessional education (IPE) into the mainstream. In response, the health professions are uniting in new ways and sharing leadership responsibilities in the effort to align IPE with clinical practice redesign.1 The formation of the Interprofessional Education Collaborative (IPEC) in 2011 to publish national core competencies for collaborative practice was a historic step forward in moving the needle for IPE.2 Originally co-led by organizations representing 6 health professions, the IPEC influence today has expanded as over 20 health professions education associations coalesce around important conversations about how students should be educated to work together for improved patient care and health outcomes.

Other current examples of collaboration and shared leadership roles across professions include the Health Professions Accreditors Collaborative (HPAC) and the National Academies of Sciences, Engineering, and Medicine’s Global Forum on Innovation in Health Professional Education (Global Forum). HPAC represents 24 accreditation agencies working to create a consensus document for academic institutions to provide guidance to health professions schools to meet accreditors’ IPE standards. The Global Forum comprises over 50 organizations to stimulate breakthrough thinking on a number of topics, including IPE and collaborative practice.

In the past five decades, health professions educators have primarily implemented IPE in the early classroom curriculum with the goal that students will be “collaboration ready” to enter practice after graduation. Today, for a variety of reasons, the impact of such activities remains unclear.3 As greater numbers of students who learned about interprofessional teamwork during their classroom course work enter their experiential rotations, many are placed in traditional practices that do not role model collaborative practice. Because much of what is learned in practice is informal and implicit, such environments can negatively influence students by reinforcing hierarchical beliefs as well as stereotypes and biases about other professions, contradicting what is taught in their early IPE curriculum. This situation raises questions: How do we prepare the workforce of the future to engage and shape new models of care when we are still practicing in traditional models? One implication is that health systems need to design learning systems in practice settings that support both the current health workforce and students learning about new models of care. While this systemic transformation is under way, how do we simultaneously “inoculate” existing students and residents against poor role-modeled behavior? Addressing problematic behavior is important for the individual learner but also enables the disruption of the culture of clinical learning environments that do not embody interprofessional values and behavior.

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The National Collaboration for Improving the Clinical Learning Environment

In 2017, the pathway to implementing meaningful and effective IPE took another historic turn. In implementing the Clinical Learning Environment Review (CLER) program in medical residencies throughout the United States, the Accreditation Council for Graduate Medical Education (ACGME) sends review teams into 600 to 800 primarily acute care environments annually. ACGME is perhaps the only organization with substantial boots-on-the-ground experience in observing how health professionals learn and work in the U.S. health care system. By incorporating nonphysician personnel, such as chief nursing officers and patient safety staff, in their interviews, ACGME has gained a unique perspective of not only the clinical learning environments for medical residents but also the culture of health care and learning in these environments. On the basis of the findings from CLER visits, ACGME leadership has taken steps to enhance the clinical learning environments of U.S. medical residency education to emphasize team-based care and learning and focus on patients and families as important members of the team.4

With this goal in mind and with the Josiah Macy Jr. Foundation as a cosponsor, the ACGME invited over 40 organizations representing different health professions to form the National Collaborative for Improving the Clinical Learning Environment (NCICLE). In October 2017, NCICLE held a symposium to explore current issues and create a vision for optimal interprofessional clinical learning environments, with an eye toward action.5 The NCICLE symposium represents a groundbreaking initiative cosponsored by ACGME, who is taking a leadership role in convening this interprofessional endeavor. Why was this symposium such a watershed moment for moving interprofessional conversations forward? It was not simply because of the amazing strength of the interprofessional composition of the participants from across the United States and Canada. It also provided a powerful space for the opening dialogue around interprofessional approaches in health care and learning, and an endorsement of it by an influential medical education accreditation body. Additionally, it was important that other physician groups, such as the American Medical Association, the Association of Physician Leadership, and the Joint Accreditation for Interprofessional Continuing Education, with endorsement by the Accreditation Council for Continuing Medical Education, were visibly involved as collaborators and in inviting other professions to the table. Equally important is that the symposium leadership was cochaired by the vice president for accreditation services of the American Society of Health-System Pharmacists.

We (the authors) have often attended (and indeed convened) symposia on advancing IPE over the last two decades around the world, sometimes with partners from medicine, oftentimes not, to various degrees of success. For IPE to succeed, the focus needs to move to practice, and specifically clinical learning environments. It is important that a prominent medical education accreditor with responsibility for postgraduate education in clinical practices played a convening role for the NCICLE symposium by inviting an interprofessional group to tackle systemic health care issues collaboratively, specifically in health care settings across the professions. It truly is a unique moment. Too often in the interprofessional scholarly literature outside of medicine, medicine itself has been portrayed as a problematic factor in the creation of interprofessional innovation and implementation to address increasingly complex challenges in team-based health care. Like the other efforts (i.e., IPEC, HPAC, and the Global Forum), this NCICLE initiative demonstrated that medical leadership has a definitive, powerful, and positive role in designing solutions to the interprofessional problem.

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What Is It Going to Take to Get There?

As a sociologist and two educators who have long been students of the health professions, we believe that NCICLE’s joining other prominent large-scale interprofessional efforts has the potential for true national change. What we experienced at the NCICLE symposium reminds us of the legend of the Gordian knot—an intractable problem, or impossible knot, that can be solved by creative thinking to find just the right loophole to easily disentangle it. To move the interprofessional agenda forward beyond a one-off symposium, we see three essential issues and one key practical step forward.

First, we need to seriously consider the cultures that exist across the professions, acknowledging that medicine itself has a particular culture, framed by a particular history and structure. For over 100 years, these cultures and traditions have been codified by specialization, subspecialization, scientific advances, accreditation, licensure, scopes of practice, financing, and fee-for-service payment systems. The reality is that medicine structurally and legally has the preeminent position today that entails and requires responsibility and accountability for the profession and health care service delivery. This situates it as the profession with the ear of health care policy and decision makers. Furthermore, team-based care is also a systems issue and requires equal attention at that level. Medicine also has the power to shift the conversation by creating interprofessional leadership roles within itself and empowering leadership roles in other health professions. The real or perceived slights felt by other professions are important to acknowledge and address, but not to the detriment of a recognition of the capacity of medicine to both lead and follow in the creation of sustainable interprofessional practice. To find solutions to untying the interprofessional Gordian knot, the focus must be on the mission—patients, families, and communities—as the primary focus of collective efforts beyond rhetoric, and not on local grievances. With the formation of NCICLE, we need to celebrate and push the shared-value proposition that medicine appears to be finally and substantively joining by enabling new interprofessional conversations about cultural change in health care and education.

Second, we must recognize that these health professions cultures may contain characteristics that act as barriers to interprofessional collaboration and, in particular, patient-centered interprofessional care.6 This kind of nuanced understanding work means untying, rather than cutting through, the interprofessional Gordian knot. For instance, in medical education and IPE, there has been a tendency to use technical solutions to solve complex, “wicked” educational and clinical practice problems (e.g., competency-based education, plan–do–study–act cycles, team-based checklists).7–9 These are structural and process interventions that contain an implicit assumption that they, by themselves, will result in positive cultural transformation (belief system and behavior change). Today, this conflation between structure and process manipulation as necessarily resulting in the intended positive cultural transformation is founded on implicit belief and not on evidence. No amount of traditional technical intervention will necessarily solve intergroup and interinstitutional collaboration problems without understanding the nature and characteristics of the cultures involved.

This brings us to the third problem, which is much closer to home for medicine itself. Now we are starting to work within a frame that recognizes that medicine is part of the team-based practice problem, but can also lead itself and authentically invite in other professional and disciplinary partners toward possible solutions. Members of social science disciplines such as sociologists, organizational psychologists, anthropologists, and educators can help us understand the culture(s) of the clinical learning environment and cocreate new strategies for dealing with them in real time. Part of this process is to take what we know already from the last few decades of interprofessional study and distill that knowledge into actionable strategies from which medicine then can take a lead (in a “first among equals” sense). This approach was demonstrated by medicine’s role during the NCICLE symposium in facilitating meaningful, and often courageous, conversations. This also means applying the best practice strategies from implementation science to help us implement the knowledge and evidence gained from decades of interprofessional research in health care and education that has, until now, tended to live on the margins. In other words, interprofessional optimization is both an implementation science problem (requiring evidence-based structural and process redesign) and a sociocultural problem (requiring a “diagnosis” of the cultural pathology existing within and between the different health care professions). These are the key factors that constitute interprofessional collaboration as a “wicked” problem, and they must be treated symmetrically within the interprofessional intervention design approach.

Practically speaking, we can make major strides working together with new research approaches that leverage data collection systems already in place. For instance, in using the Institute of Medicine Interprofessional Learning Continuum Model3 as a framework for program development and research, the National Center for Interprofessional Practice and Education is identifying an IPE core dataset to standardize data collection using existing and new measures to begin to answer long-asked questions in the interprofessional field. Given conversations around the interprofessional clinical learning environment and the concomitant rise of the burgeoning science of operational databases, can data collected around the ACGME CLER and other health professions postgraduate programs be leveraged to inform the design of truly interprofessional health care settings? This will require revisiting the data collection processes of such programs to properly sensitize them to cultural as well as structural/process issues that disrupt or undermine interprofessional learning opportunities. Creating research databases, rather than just operational educational administrative databases, will allow for the upscaling and spreading of successful interprofessional factors in the ACGME CLER program and in other postgraduate and preprofessional programs through ongoing real-time evaluation and redesign.

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Untying the Gordian Knot

Those who are new to the field of interprofessional practice and education likely do not know that we have a decades-long history of striving to untie the interprofessional Gordian knot. We prefer to solve the puzzle by carefully untying rather than cutting or starting anew. With NCICLE joining other national efforts to move the focus closer to health care and patients, families, and communities, we are hopeful that we are getting closer to finding the crucial, elusive loophole that will lead us to the solution.

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Acknowledgments:

The authors wish to acknowledge Kevin Weiss, MD, MPH, senior vice president for institutional accreditation, and Morgan Passiment, director of institutional outreach and collaboration, at the Accreditation Council for Graduate Medical Education, for their review of this Invited Commentary.

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References

1. Cox M, Naylor M. Transforming Patient Care: Aligning Interprofessional Education With Clinical Practice Redesign. 2013.New York, NY: Josiah Macy Jr. Foundation;
2. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 2011.Washington, DC: Interprofessional Education Collaborative;
3. Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. 2015.Washington, DC: National Academies Press;
4. Wagner R. vice president for Clinical Learning Environment Review, Accreditation Council for Graduate Medical Education. Personal communication with B.F. Brandt, February 15, 2018.
5. Hawkins R, Silvester JA, Passiment M, Riordan L, Weiss KB; for the National Collaborative for Improving the Clinical Learning Environment IP-CLE Planning Group. Envisioning the optimal interprofessional clinical learning environment: Initial findings from an October 2017 NCICLE symposium. https://storage.googleapis.com/wzukusers/user-27661272/documents/5a5e3933a1c1cKVwrfGy/NCICLE%20IP-CLE%20Symposium%20Findings_011218%20update.pdf. Published January 12, 2018. Accessed May 24, 2018.
6. Taylor JS. Confronting “culture” in medicine’s “culture of no culture.” Acad Med. 2003;78:555–559.
7. Goldman J, Kitto S, Reeves S. Examining the implementation of collaborative competencies is a critical care setting: Key challenges for enacting competency-based education [published online ahead of print November 21, 2017]. J Interprof Care. https://doi.org/10.1080/13561820.2017.1401987.
8. Kitto S, Grant R. Revisiting evidence-based checklists: Interprofessionalism, safety culture and collective competence. J Interprof Care. 2014;28:390–392.
9. Hawick L, Cleland J, Kitto S. Getting off the carousel: Exploring the wicked problem of curriculum reform. Perspect Med Educ. 2017;6:337–343.
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