Malcolm Cox is the Chief Academic Affiliations Officer at the Veterans Health Administration. The Veterans Health Administration manages the largest medical education and health professions training program in the United States. VA medical centers are affiliated with 129 allopathic and osteopathic medical schools, 55 dental schools, and more than 1,800 other health professional schools across the country. In 2011, nearly 117,000 health professionals were trained in VA medical centers. About two-thirds of the physicians practicing in the United States have some of their clinical education in the VA health care system.
Macy: What is the VA doing to advance interprofessional education (IPE)?
Cox: The VA goes back several decades in terms of providing interprofessional team-based care. We’ve been able to modify the delivery model for geriatrics and palliative care, for example, creating an interprofessional environment that, by default, provides an opportunity for interprofessional education. The downside is that the number of trainees in geriatrics and palliative care is relatively small.
Now we’re building on the opportunity that the interprofessional environment offers for primary care training. We have eight million outpatient visits a year at the VA. In general, primary care teams in the VA have been expanded and enhanced over the years with a focus on more patient-centered, team based care, but until recently there has been no intentional, directed, team-based learning for our health professional trainees.
Macy: How is the VA expanding IPE in primary care?
Cox: About a year ago, the VA established five Centers of Excellence in Primary Care Education. These centers are developing and testing innovative approaches to preparing internal medicine residents and nurse practitioner students for practice in the 21st Century. A lot of IPE in the past has been very classroom-based, which ignores the importance of workplace learning.
Some centers are also beginning to incorporate other trainees into their primary care teams, including mental health professionals and pharmacists, amongst others. My dream, within the next year or two, is to incorporate medical students in their core clinical clerkships into these teams, as well as baccalaureate level nursing students.
We’re using these centers to examine the complexities of introducing education into the clinical workplace and to find out what is needed for trainees to flourish in an interprofessional outpatient environment. This whole project is designed to learn how to spread the lessons learned across the whole VA primary care system.
Macy: What are some of the barriers you’ve encountered?
Cox: There are three major barriers:
•Prevailing culture. The VA has a history of relying on primary care teams, but we need to be more intentional. Just putting people together, doesn’t mean they will learn effectively. Professional cultures are not easy to overcome, achieving psychological safety across the professions is difficult, and cultivating shared decision making and distributed leadership is complex.
•Infrastructure. We have a problem with space at all five of our sites. While you need a certain number of examine rooms for patients, you also need a place where trainees, staff and faculty can sit down and work as a team. They can’t be ships passing in the night. They need space for reviewing patient issues, sharing complementary expertise, and just getting to know each other. Our clinics aren’t built that way presently.
•Accreditation. Each profession has its own accreditation body, so with interprofessional education that number is multiplied substantially. Scheduling and other logistical challenges arise as we try to meet the sometimes conflicting requirements of individual accreditation organizations.
Macy: Why is IPE so important?
Cox: There is a general understanding that unless we provide team-based care we’re never going to have an efficient, high-quality health care system. With interprofessional teams—where we bring together complementary skill sets and have everyone working at the top of their expertise—we can change our health care system to one that is more patient-centered and affordable.
Macy: What are some of the challenges IPE faces at large?
Cox: IPE has had a checkered history over the last 40 or more years, but it seems to be climbing toward a tipping point. It has a real chance of getting there, I think, but numerous challenges remain.
• Leadership. Without leadership at executive and top management levels, IPE won’t take root.
• Student Comfort. When you bring multiple providers together, at what level of their training do they mesh best? What is the right hinge point? We’re seeing that our nurse practitioner students may need more clinical experience before they can optimally link to internal medicine residents. You don’t want one group more comfortable making diagnostic and therapeutic decisions, and understanding the system of care, than another.
• Faculty Comfort. Many faculty are not able to navigate easily between two or more health professions. We will need to train existing faculty to do so or create a new group of faculty with special expertise in IPE.
• Interprofessional practice. Nothing that students learn is useful unless it can be translated into the practice environment. And workplace learning is the most effective form of learning. Without an emphasis on workplace learning, the IPE movement may fail to take off once again.
• Scaling up. How do you take a successful demonstration project where doctors and nurse practitioners in training work together in one particular clinic, and move it to the whole system?