I am so honored today to give the Pauline Cerasoli Lecture and, from the bottom of my heart, I thank the Education Section of APTA, for selecting me as this year's lecturer. I also thank my dear friends Ruth Purtilo and Lee Nelson for nominating me. Preparing for this lecture has been a personal journey for me—exploring a topic that I am passionate about as an educator—and I often wonder why it's so hard to make substantive progress on teaching in a truly interprofessional atmosphere.
Before I share my ideas with you, let's all think a little about Polly. She was passionate about advancing the profession of physical therapy and was a risk-taker. Although change used to make her nervous and somewhat uncomfortable, Polly would overcome her discomfort if she believed in a new idea. She was a believer in interdisciplinary education, but as director of the Physical Therapy Department at Massachusetts General Hospital (MGH) she often experienced the tension of advocating for more physical therapy resources, versus playing as a team member. However, when she fought these battles, she did it with professionalism, humor, and compassion.
As many of you know, Polly was both a colleague and a personal friend. We worked together in the early days of the founding of the MGH Institute of Health Professions. One of the earliest parts of the mission statement was to educate students to practice in an interdisciplinary manner as well as to prepare leaders in the health care disciplines, including specialists in the various health professions. These goals were considered radical in those days, as it was the mid 1970s when the Institute was chartered and planning began. Polly was working on her doctorate in education at that time and her fellow classmates included health professionals from occupational therapy, nursing, dietetics, and social work. She experienced firsthand how learning together can help break down misperceptions of the roles of each others' professions and, from that experience, she enthusiastically developed (along with Nancy Watts) an interdisciplinary course in leadership for postprofessional students from nursing, dietetics, social work, and physical therapy. The course was taught in seminar format based on real clinical scenarios that the students were experiencing in their clinical day jobs. Polly's role was to help the students understand leadership theories that could help improve their leadership skills—theories such as locus of control and discussing other documented leadership styles were the foci of the course.
To make a long story short, this course was successful but was eventually dropped as a course offering, mainly because specialized curricula developed and there was little room for students to take electives. So with reluctance, we dropped the requirement that students, in order to graduate, must take at least two interdisciplinary courses. I still vividly remember that day in the physical therapy faculty meeting when we voted to drop the requirement, and I believe it was Dave Krebs that requested that the minutes reflect “that it was with great sadness that we drop the requirement because philosophically, as a faculty, we believed in interdisciplinary experiences.” We also added that we hoped this requirement would eventually be able to be reinstated. This story of dropping interdisciplinary requirements is all too familiar as I reviewed the literature on interprofessional or multidisciplinary education.
During the next half hour, I would like to briefly tell you the history of interprofessional education, including the why (reasons why we think interdisciplinary experience in education is a sound principle), cite several examples of successful interprofessional clinical collaborations and educational programs, cite the barriers for why most efforts fail—sounds a little like starting a new restaurant or business, and, finally, offer some ideas of ways to offer educational experiences (assuming I am somewhat successful in generating some enthusiasm for the topic).
So, with Polly's story in mind, like any researcher and teacher, I turned to the literature and read anything I could get my hands on. I found over 200 articles starting from the 1960s advocating for interdisciplinary education. As the years passed, the emphasis in the literature has moved from position papers advocating for interdisciplinary education to multiple papers defining what various terms mean (multidisciplinary versus interdisciplinary versus pandisciplinary—this literature reflects the need for faculty to conceptualize what interdisciplinary education truly is and isn't), to descriptive papers describing individual experiences, then to actual research reports documenting educational offerings' outcomes, and, most recently, to systematic reviews. I reviewed literature from all disciplines, although the majority of the work comes from nursing, medical, and educational journals and book chapters. I was surprised to find that many of the articles are from international experiences with both Britain and Canada, both of which have very sophisticated models in education, practice, and research.1-3 Apparently, much of this work was initially motivated by their health care delivery systems. Then, after months of cogitating and generating various ideas, I finally arrived at the following thoughts to share with you today.
What Is Interdisciplinary Education, and How Is It Defined?
The literature is ripe with position statements, and most of them have elements that are similar to the one I've chosen to share from Nursing Management. The part about the statement that I find intriguing is that this statement clearly identifies shared educational experiences as an important part of successful health care delivery.
Interdisciplinary Education and Practice: American Association of Colleges of Nursing (AACN) Position Statement 1996:
All health care disciplines share a common and primary commitment to serving the patient and working to the ideal health for all. While each discipline has its own focus, the scope of health care mandates that health professions work collaboratively and with other related disciplines. Collaboration emanates from an understanding and an appreciation of the roles that each discipline brings to the care delivery experience. Such professional socialization and ability to work together is the result of shared educational and practice experiences.4
This position paper goes on to identify general education skills common to all health professions and to suggest that teaching some of this content in an interprofessional atmosphere can help students from various disciplines to work together effectively in the future. These skills are: written and verbal communication, problem solving, understanding human behavior, and developing personal values, virtues, and morals.
From reviewing the literature, I learned that there are many terms used referring to educating or practicing in environments that include more than one health profession. For the purposes of this talk, I am going to use these terms put forward by the National League of Nurses (NLN) from nursing.5
- Multidisciplinary or Multiprofessional: learning together, groups of students from different professions learning common content.
- Interdisciplinary or Interprofessional: shared learning, learning together to promote collaborative practice.
A Brief History; or What Are the Lessons Learned From Past Experience?
In 2001, one of our physical therapy colleagues, Irma Rhubling, was one of the primary authors on a terrific article that is an historical review of interdisciplinary health professions education.6 Briefly, I am going to summarize many of the major points made in the article and for more details, I urge you to read the article.
As early as the 1960s, the importance of teamwork was cited as a means of providing cost-effective care. In 1968, Magraw,6 deputy assistant for Health Manpower in the Department of Health, Education, and Welfare, promoted the use of interdisciplinary health care teams in providing primary care in the community. Patient/client care had begun to be organized around diagnoses and specialty services, and interdisciplinary teams at that time were mostly in hospitals. Examples include services in medicine, general surgery, orthopedics, neurology, pediatrics, and oncology. I remember in my early days of physical therapy practice, advocating for the reorganization of the department (in the early days of specialization) so PTs were part of the specialty team.
Later in the decade, interdisciplinary teamwork extended into other health centers and into the community. Examples of teamwork included cancer care, nutrition, social medicine, mental health, and rural health care. Driving this team effort were changes in the health care delivery system; the shift from inpatient care to home care and outpatient services, and, of course, efforts to reduce costs.
In the 1970s, efforts expanded beyond practice to include the first documented attempts at interdisciplinary education. The educational literature focused on definitions, models for curricula, and clinical experiences. Early educational collaborations included nurses and physicians learning communication skills, collaboration, and group process strategies together. Practice teams emerged in gerontology, home health, pediatrics (child abuse, neglect), hospice care, and hand therapy. Research efforts became interdisciplinary with funding incentives.
During the 1980s and 1990s, there were more efforts to expand interdisciplinary experiences. The progress continued especially in the area of practice and research: federal funding was available in areas such as HIV, gerontology, pediatrics, and rural health, with priority given to grants with an interdisciplinary focus and collaborators. In 1993, the Institute of Medicine published that “we need to change the way health professionals are educated in order to improve quality and safety.”7 In 1998, the Pew [Health Professions] Commission8 cited “interdisciplinary team competence” as 1 of the 21 health competencies for all health professions. By the year 2000, interest in interdisciplinary education was being addressed in many of the health professionals' organizations.
In the literature, successful educational experiences emerged: educating students around a common content area, such as palliative care, gerontology, environmental health, informatics, and/or health care technology, is cited as beneficial in breaking down professional barriers.9-15 Most of the programs initially in the literature were taught at the postprofessional level. However, I did find examples of some courses instituted for undergraduate and entry-level students with varying degrees of success.16-22
In 2003, Health Professions Education: A Bridge to Quality23 was published, and this monograph defines 5 core competencies as the abilities to: deliver patient/clientcentered care, work as a member of an interdisciplinary team, engage in evidence-based practice, apply quality improvement approaches, and use information technology. I don't think there is anyone in this audience who wouldn't agree that we would like all PTs to have these competencies. The question remains, however, what is the best strategy to achieve these competencies? Most likely, there isn't just “one best method.”
Today, the debate continues within and among the various health professions and policy makers of when to initiate interdisciplinary experiences (although evidence is emerging that it can be successful at any time, provided that the students are at the same level and experiences are carefully planned). However, despite the welldocumented need for more interdisciplinary education, there are many reasons why there are not more programs. Experiences over the past 30 years have identified important reasons why interdisciplinary education is difficult to implement. Perhaps understanding these barriers will lead to more successes.
So, we need to acknowledge that there is an elephant in the room! There are numerous articles stating that the barriers are daunting and most of the early efforts were failures or had less than satisfactory outcomes. According to Hall and Weaver,24 there are 3 primary reasons for the reluctance to implement interdisciplinary activities: academic and professional barriers, lack of administrative incentives at the educational institution, and a lack of faculty believers in changing the curriculum to include interdisciplinary experiences. Briefly, I will address each of these issues in terms of why educational efforts have failed.
Academic and professional barriers:
- Professional socialization within each specific profession is often a cause of turf battles. As care becomes more patient/client centered and limited, there are often overlapping and converging roles among the professions. This can threaten reimbursement to specific departments, and also can raise autonomy issues. However, I don't think there is anyone in this audience who will argue that we all want to provide the best care. Often there are trust issues among the professions and arguments about who can provide “it” better, or who is appropriately educated to provide the specific intervention. This is yet another area that requires more explicit research to answer the question.
- There is the need for faculty development in order to effectively teach in an interprofessional atmosphere, and we need enthusiastic faculty mentors who can serve as role models.
- Another huge challenge is identifying core content and shared experiences that will work, and appropriately selecting the right disciplines to participate in shared learning experiences.
Philosophical and sociological barriers:
- We need to acknowledge that there are gender and class differences among professions.
- There are also differences in professional respect and commitment to interdisciplinary approach. In addition, there are differences in professional focus and mission.
Organizational and structural barriers include:
- Scheduling and timing differences among programs; there is “no time” for additional coursework that will work across programs.
- Appropriate student mix and level of student.
- Geographic separation, especially in large universities.
- Lack of clinical sites for interdisciplinary experiences.
- Financial reimbursement: budgetary concerns of individual programs.
But despite these barriers, there have been some documented successes, and the number of successes reported in the literature is growing. There clearly is a renewed interest in establishing interdisciplinary experiences at some point (or at many points) in the education of health providers. I will now briefly highlight the examples in practice, research, and education. I know there are quite a few people in this audience that are actively participating in research and education using an interdisciplinary approach.
There are many examples of successful team approaches to patient/client management including hospice care, geriatric teams, pain management, specialty care, and primary health care services.25-34 Positive outcomes include improved job satisfaction, increased efficiency of care, and patient/client satisfaction. There is little data (yet) to support financial savings, as this outcome has not been explicitly addressed in the literature I found. The data suggests that a thorough knowledge of one's own discipline is essential, and the freedom to be truly interdisciplinary comes with security within one's own profession.
When reviewing the literature on interdisciplinary research, there are many successful examples. If you look at the authors of many clinical trials, you will notice that there is often representation from different disciplines. There are clear incentives that exist for health professionals to work together on research projects. Often, requirements for securing grant funding require collaboration among different health disciplines, and there is frequently the need for different areas of expertise to answer the research question. My passion for interdisciplinary education comes from my own positive experience in working on clinical research projects with other professions, including nurses, statisticians, behavioral psychologists, physicians, and occupational therapists. For many years I have had the privilege of working with Alan Jette on a Roybal Center Grant project, Strong for Life, which was funded by the National Institute on Aging. I have learned so much from working with other disciplines (plus the respect I have developed for others' special expertise). I honestly can't imagine conducting my research without seeking advice and collaboration with other disciplines. When we presented our work35 in 2004 at the Geriatrics Society of America (GSA), the conference's theme was interdisciplinary care, and there were over 400 papers presented. In fact, as I look around this room, there are many of us who have had successful interprofessional research experiences, and I frequently run into my physical therapy colleagues at professional meetings other than at the American Physical Therapy Association conferences.
There are several excellent examples in the literature of successful interdisciplinary educational experiences at both the postprofessional and professional level. I will highlight a few examples of postprofessional educational projects.
- The Network Project is a multidisciplinary cancer education and training program which is funded by the National Cancer Institute and designed for health professionals and graduate students from any health discipline. The course provides training and education in pain management, rehabilitation, and psychosocial issues in patients with cancer, and takes place at Memorial Sloan-Kettering Cancer Institute. Course outcomes from participants showed improved knowledge of pain management, psychosocial issues, and communication among team members.36
- Enhancing Entrepreneurship and Professionalism in Medical Informatics—A Collaborative Training Model Program brought together medical students, health professional students, and technology students (software and design engineers) to discuss creative solutions using technology. The outcomes of this impressive project were improved understanding of each others' roles, and this led to better product designs for delivering patient care.9
Both of these programs had sufficient resources (both privately funded) to allow for ample planning time and faculty buy-in. The educational experiences included hands-on experiences in the health care system. Outcomes of both programs demonstrated that students that learn together end up understanding each others' roles better, have more respect for each other's profession, and are most likely to work together in the future more successfully. The students were highly satisfied with the courses and achieved the content learning objectives.
Most of the examples I found with entrylevel education were clinical partnerships with professional academic educational programs. One excellent example is the Community Partnerships Experience. This involved a partnership with East Tennessee State University and rural health services and included students from medicine, nursing, and public and mental health working in teams, with clinical mentors to provide rural health services. The WK Kellogg Foundation generously funds this project. They have over 10 years of experience with this model and report positive outcomes for the students functioning as a team, employee satisfaction, and excellent patient care.37,38
Other successful examples I found documented in the literature included teaching content that goes across disciplines such as community health, mental health, pain management, end of life care, primary care, or general content such as communication and negotiating skills, research, ethics, and evidence-based practice.9-22
Now, I'd like to spend the next few minutes summarizing the findings of a 2001 systematic review on outcomes of interdisciplinary education by Cooper et al.39 This article summarized evidence of 30 educational interventions; there was a total of 47 papers between 1994 and 1999 which met the inclusion criteria out of 141 identified. Studies included interventions designed for entry-level health professions programs. The majority of studies had nursing and medical students; other studies included social work, occupational therapy, physical therapy, pharmacy, dentistry, speech, psychology, and/or health administration students. The numbers of students in the studies ranged from 9 to 5,000, although most of the studies had 10-50 students.
Types of educational experiences included in the systematic review were: increasing awareness of interdisciplinary understanding and cooperation, promoting competent teamwork, making effective/efficient use of resources, and promoting high-quality comprehensive patient care. Topics addressed in the various studies included coursework on: teamwork, primary health care, problem solving, chronic illness, clinical skills, communication skills, health behavior, continuous improvement, therapeutics, and labor and delivery. These topics are listed with the most frequently taught topics listed first.
According to the authors of this systematic review, there were 2 major themes that emerged as student outcomes:
- Students found learning experiences highly relevant and wanted more in the future. The most successful formats were courses that included activelearning activities.
- Timing of courses: Students felt that learning experiences early in their course of study were most beneficial because it made later experiences in interdisciplinary activities easier. The review also found that negative attitudes towards other health professionals were less entrenched and as previously stated, negative attitudes are documented barriers to successful teamwork.
The authors reported that there were administrative themes that helped make for successful interdisciplinary learning, such as:
- Success requires strong administrative support and resources.
- Scheduling and financial barriers must be minimized.
- Need for a consistent team of experienced faculty members who clearly believe in the benefits of interdisciplinary education.
As I reviewed the literature, many of the schools that offered substantial interdisciplinary courses or programs had an administrative structure dedicated for that purpose. (St Louis University, Case Western Reserve University, and University of Massachusetts Medical School are examples.)6,40,41
So, What Have We Learned That Can Help Us Plan Successful Experiences?
We need to acknowledge that there are obstacles such as:
- Lack of faculty time for proper planning.
- Scarce financial resources.
- Teaching assignments made specific to each discipline without coordination.
- Varying educational schedules.
- Discipline specific requirements for course registration leaving no room for electives.
If interdisciplinary education is going to be successful, it can't be an add-on work assignment to already overloaded faculty. The obstacles are solvable, but resources and time must be appropriately allocated. Administrative support is needed. Other keys for success include hiring faculty who are believers, and there needs to be resources for faculty development, including time for understanding of professional roles and professional socialization. Attention must be given to enable both faculty and students to truly understand each other's professional roles, skills, and responsibilities in addition to understanding their own professions.
What Is the Outcome of Truly Understanding?
According to the summary of the systematic review, interdisciplinary experiences helped raise awareness of overlap in knowledge and skills, facilitated realization of professional limitations, and identified specific skills related to each discipline. The literature supports that students need to be at a similar stage of intellectual and professional development in order for courses to “work.” Alteration of stereotypical images improved for both students and faculty when they learned together and attitudes changed about professional autonomy and competence. Teamwork improved by enhanced problem-solving abilities, and negotiating skills reduced conflicts and “turf battles.” Furthermore, the most favored learning methods were experiential learning, practical experiences, and problem-based learning courses. Students like to be active participants!
From personal experience, I developed an introductory course in diagnostic imaging with the MGH radiologists, and I suspect some of you in this room have taken this course with me. A very positive side effect of creating this course was an improved relationship with our radiologists. They now understand what physical therapy is about, and our MGH PTs understand what radiologists can do, resulting in improved communication and, hopefully, improved patient care. As a result of understanding what we want to know about patients, the radiologists routinely comment on muscle atrophy when reading musculoskeletal MRIs. Many of our PTs and radiologists routinely consult with each other to determine the most useful diagnostic study to order or to interpret the findings.
What Can Be Done That Will Work?
- We need champions and believers.
- Take small steps (amount of exposure to have benefits is not defined).
- In your programs: Take an inventory, define what you are good at and what you are interested in, come to consensus, set a goal, and go for it!
- Administrators need to be on board—make it part of strategic planning and secure adequate resources.
- At a national level: Offer planning grants and conferences to support interdisciplinary efforts, and develop means of communicating about experiences.
It's kind of like deciding on a thesis or research project; you need to work on what you are interested in and it must be feasible. I am not advocating “blowing up” our curricula! But perhaps some tweaking should be considered, depending on your environment.
Identify the Common Threads and/or Competencies That Go Across Disciplines
- Need to explicitly define objectives and level of the objectives—think Bloom's Taxonomy. This sounds easy, but it's very hard to get agreement within and across disciplines!
- Review professional accreditation standards for commonalities. Perhaps, to remove personal and professional bias, hire an independent reviewer to identify common objectives.
- Get help from existing literature. There are some helpful resources, even if they are not perfect.
For example, the American Geriatrics Society, in 1999, developed a model curriculum of geriatric interdisciplinary team care.41 They have specific competencies for each discipline, including medicine, physical therapy, occupational therapy, pharmacy, speech therapy, nursing and social work, and general competencies that cross all health care disciplines (which are recommended to be taught in an interdisciplinary manner).
As part of my clinical research efforts, I was taught the concepts of cognitive restructuring by Margie Lachman from Brandeis University as a method of improving adherence to exercise programs.42 This theory is a method of asking probing questions to identify negative thoughts about assuming a new behavior and helping the subject develop positive thoughts about the new behavior. It involves defining barriers and obstacles to engaging in a new behavior and identifying strategies for overcoming these barriers. In other words, carefully plan realistic, feasible experiences so you can experience success, which will encourage adopting the new behavior.
Other thoughts that may be worth considering include:
- Developing a database across disciplines to keep track of experiences. (I wonder if there would be money out there to do this from the professional associations.)
- Include the methods used and specific outcomes; evaluate the programs thoroughly for successes and challenges.
- Network with clinical teams. Conduct focus groups, encourage clinical interactions, and find out what's most needed in terms of education.
- You may be doing more than you think.
- Recognize that change is hard but energizing!
Many of us include group projects as learning experiences for students—many of the students have interpersonal conflicts when working together. Several of our graduates have recognized that learning to negotiate and work together effectively is excellent preparation for working as part of an interdisciplinary team when they are in “the real world.”
Polly loved a challenge, even if it was, as she often said, “making me a crazy person!”
When I was program chair, I always said a good idea takes at least 3 tries, but a really good idea takes at least 12! And to paraphrase Henry David Thoreau: “Reasonable people disagree.”
Thank you for letting me share my thoughts, and I hope I have encouraged you to think about alternative methods to educate caring, competent health care practitioners.
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