One would think that by now nurses, pharmacists, doctors, social workers, behavioral health professionals, physical therapists, nurse practitioners, and physician assistants would have no problem being educated together. After all, they have the same goal: to help patients with health problems and to sustain and improve the health of entire populations. But when it comes to undergraduate education in the health sciences, interprofessional learning is still rare, and a long way off to becoming standardized.
What’s the hold up?
Part of the reason is logistics: coordinating the undergraduate schedules of medical, nursing and pharmacy schools can be a nightmare. It’s almost as though these separate schedules should be replaced by a new unified schedule so that medical, nursing, and pharmacy students take their anatomy, physiology, biochemistry and pharmacology courses together. This seems like an easy solution but the practical difficulties of doing this confound even the many education leaders who agree with the concept.
There are other barriers too. Some medical, nursing and pharmacy educators feel that each of these disciplines requires a separate curricular focus – that physiology is different for nursing students than for medical students, for example. Of course, there are topics specific to each discipline. But for some of the fundamental educational requirements, seeing classrooms and seminar rooms filled with medical, nursing and pharmacy students together is a goal to work toward.
Another barrier is the workload of medical educators. Some feel that they are unable to handle the added burden of teaching nursing and pharmacy students. The view has also been expressed, though less often than before, that nursing and pharmacy faculty are not sufficiently prepared to teach medical students.
Progress in primary care
Fortunately, we are making gains in interprofessional team-based care, particularly in primary care. This in turn is helping drive more interprofessional education: health science students may not be together in the classroom, but they are increasingly together in the exam room. No better example exists than medical residency clinics in primary care specialties – family medicine, general internal medicine, and pediatrics.
Over the past several years, with support from the Josiah Macy Jr. Foundation, a team from the Center for Excellence in Primary Care at the University of California, San Francisco, has conducted detailed site visits of over 40 primary care medical residency clinics. We have seen numerous examples of medical residents, pharmacy residents, nursing students, psychology students, and social work students working together in patient care. From our site visits, we became convinced that interprofessional education thrives when faculty and students from various disciplines see the same patients together at the same time in the same place. Logistical challenges can be overcome without too much difficulty, and problematic attitudes disappear in the face of caring for a sick patient.
Most of the medical resident teaching clinics we visited had a team structure including core teams and extended care teams. The core teams, or “teamlets,” usually consisted of a clinician (physician, nurse practitioner or physician assistant) and a medical assistant. Extended care teams – that supported several core teams — varied in their composition but often included an RN care manager, pharmacist, behaviorist, and social worker. The extended care team rather than the core team was the locus of interprofessional education and care. In some clinics, the interprofessional education and care was unstructured, with medical faculty requesting an RN or pharmacist or behaviorist – with their trainees – to consult with a medical resident on patients with health problems requiring the expertise of other disciplines.
The most advanced, and impressive, examples of interprofessional education and care were the regular weekly interprofessional care clinics pioneered by a small number of residency teaching clinics. In these clinics, a half day was set aside each week for patients with complex health care needs to be seen by a team of health professionals and trainees. For example, a patient with diabetes, hypertension, congestive heart failure, depression, and housing insecurity might have a visit including time with a pharmacy resident, psychology student, social work student and medical resident – all within 90 minute’s time. The encounter would include precepting of the various trainees by the appropriate faculty. These visits and precepting sessions might take place separately for each discipline or together. The key concept was having trainees from various disciplines together caring for a patient and learning from the patient – in the same space at the same time. Some interprofessional care clinics were initiated by the medical faculty, others by champions from pharmacy or social work.
Let’s focus on interprofessional care clinics
Medical resident teaching clinics are the ideal sites to house interprofessional education and care because these sites have learners from different disciplines working together: Some of the clinics have only medical and pharmacy residents, others have only behavioral and social work students, and some have a full complement of learners.
What we have observed is that interprofessional care clinics can be implemented without much difficulty as long as a champion from at least one discipline leads the way. The good news is that, without exception, all the learners we spoke to loved the unity of interprofessional care and education and hoped to continue their careers as members of interprofessional teams.
Bodenheimer T, Knox M, Syer S. Interprofessional care in teaching practices: lessons from “bright spots.” Academic Medicine 2018;93:1445-1447.