Peter I. Buerhaus, PhD, RN, FAAN – November 20, 2014

This text is the full version of the post that appeared in the HealthAffairs Blog, November 20th, 2014 – click here to view that post.

Well before the Affordable Care Act was passed in 2010, efforts to expand interprofessional education (IPE) were beginning to change the mindset that permeated much of health professional education in the US. While familiar and comfortable, the educational silos that have produced the nation’s health care workforce were increasingly being viewed as failing to produce the health workforce needed for the future—teams of professionals learning and working collaboratively together.  Indeed, the idea of IPE was not new as many education programs had tried implementing IPE over many decades.  But widespread adoption of IPE was still a distant reality only a few years ago.

The determined and consistent efforts of the Josiah Macy Jr. Foundation changed everything.  Quickly, but not without struggle, IPE began to “catch on” as Foundation initiatives informed educators, policy makers and workforce analysts of the need to overcome many of the shortcomings of traditional health professional education.  The speed and intensity with which willing partners embraced IPE has resulted in what might be called an IPE movement not unlike the national focus on quality improvement that developed following the Institute of Medicine’s Report, To Err is Human.  Today, IPE is a serious activity embraced by rapidly growing numbers of health education programs.

Like other institutions, Vanderbilt University Medical Center had experimented with IPE.  Early attempts resulted in key leaders in the schools of nursing and medicine learning that establishing an enduring IPE program wasn’t easy, that a didactic approach to IPE did not engage learners and lacked authenticity, and that without the support of leadership, faculty and administrators, meaningful and sustained IPE would not become a legitimate part of the education curriculum.  Yet, a strong desire for IPE persisted and in 2010 the Vanderbilt Program in Interprofessional Learning (VPIL) was established with initial support from the Josiah Macy Jr. Foundation, and later from the Baptist Health Trust.

The VPIL takes place largely in student teams based in both community- and hospital-based primary care clinics and in sub-specialty-based clinics.  Medical and nursing students from Vanderbilt learn and work with pharmacy students from Belmont University and Lipscomb University, and master’s degree students in social work from Tennessee State University and The University of Tennessee.

To learn about the challenges, successes, and surprises experienced by those who developed and lead IPE at Vanderbilt, I interviewed Dr. Linda Norman, Dean of Vanderbilt University School of Nursing, Dr. Bonnie Miller, Associate Vice Chancellor for Health Affairs and Senior Associate Dean for Health Sciences Education at Vanderbilt University Medical Center, and Dr. Heather Davidson, Director of Program Development for VPIL.

Peter Buerhaus: What were the key challenges faced when you stated IPE at Vanderbilt? 

Linda Norman:  Although the School of Medicine and the School of Nursing had a history of trying to work together to develop IPE, we had never come up with a common and sustainable place to put IPE in our respective curriculums.  Everything we had tried previously ended up as an add-on to the curriculum.  We had numerous discussions about how to create IPE that would be meaningful to students and also contribute to clinical operations.  Initially, we thought only of nursing and medicine but the more we examined the clinical situation, the more we realized that other healthcare providers were integral.  So we looked at adding pharmacy and then social work. The challenge was to identify the place in the curriculum where our health professions students and interprofessional education would best fit.

Bonnie Miller:  We did not want IPE to be a new requirement for all students but rather, we hoped to figure out ways that IPE could help fill established requirements. For example, within the School of Nursing IPE would fulfill credits in community health, and in the School of Medicine IPE substituted for certain elective courses and now provides credit for a required course, Foundations of Healthcare Delivery (FHD). Not all of our students are required to participate in VPIL.  The notion of having one program that would meet requirements for four very different professions was quite challenging.

Heather Davidson: The challenge of integrating IPE into the curriculum also involved developing new roles for the initial VPIL faculty.  Faculty representing each of the four health professions had to become liaisons between VPIL and their home professional school. Their work included negotiating the alignment of the home school’s goals, objectives, competencies, credit requirements, etc. with the innovative vision of an IPE curriculum in order to eliminate the “add on” effect for the program. They had to be creative when identifying where a VPIL experience could be substitutive and simultaneously nurture their own role as part of the interprofessional faculty team charged with creating a meaningful educational program that met IPE goals.  The initial work at operationalizing the program had to be perceived as a “win-win” by everyone involved. Therefore, faculty from different institutions had to tackle a unique challenge of supporting a curriculum that would hit both their own needs as well as the needs of the IPE vision. Although their liaison role was vital in the early stages of design and implementation, it has continued to be extremely important as we have worked to make the program sustainable. Schools have gone through curriculum reform, shifting schedules and our own continual improvement.

Linda Norman: In the beginning we decided we were not going to let schedules stand in our way for getting IPE accomplished.  We agreed that we would do whatever was necessary to have the students from four disciplines be together at the same clinic with the same team on the same day for a two-year period. We knew that IPE could be derailed by scheduling issues and failing to have common expectations, common competencies for the students, and faculty who were champions. We sought to overcome these challenges by engaging the academic administrators of each of the programs and obtain their buy-in before we started planning the curricula. We intentionally partnered with people who had the same level of commitment that we did, and were conscious not to let extraneous things get in the way.

Bonnie Miller: Logistics are formidable and can become a seemingly overwhelming obstacle when programs do not have the energy or will to overcome them.  Without dedicated commitment at the ground level among the faculty members who are creating the program and key administrators supporting them, IPE won’t happen.

Heather Davidson: We have used words like creativity, tenacity and flexibility to describe the characteristics of the people who are committed to IPE and have decision-making power at the different institutions. This was not a one time, “let’s design the program,” and figure out all the logistics. Logistics is an enduring challenge as each school is continuing to improve itself, make curricula changes, and prepare for the implications of health reform.

Bonnie Miller: Even though these were start-up challenges, many of them have not completely gone away. We overcame them, but they continue to show up in a variety of different forms. It is not just the initial commitment but rather it is an ongoing commitment.  To be sure, the fact that the Macy Foundation was interested in the program and provided a large grant has helped sustained our commitment and enthusiasm.

Linda Norman: Our commitment was also strengthened by the accrediting bodies for each of our disciplines who were looking closely at how we integrated IPE into the curriculum.  Also, each of our academic professional organizations was urging the development of IPE.  Another challenge we faced involved determining the level of the nursing, medical, pharmacy, and social work student that should be included in our IPE model. Should it be a new learner or a more experienced learner? As a group, we decided that the new learner was the best place to start. We had not seen anything in the IPE literature about using new learners; most IPE at the time involved more experienced learners. We wanted to provide IPE when students had not yet developed notions about their own discipline.

Heather Davidson: Choosing the clinic placement sites was also a challenge because so few clinics are actually thinking about IPE.  Consequently, IPE was not going to be a “normal role modeling experience” where students are precepted in clinic settings. We had to find clinics that were willing to take on a group of four students and clinical faculty willing to teach those students who were not from their own profession.  This challenge has continued as we have expanded the number of students over the years.

Bonnie Miller: The things that should not be challenges actually become challenges, such as space. Even when you have staff and preceptors who buy into the idea, it turns out that having room for four extra learners in your clinic, with the required number of exam rooms, and the ability to manage and direct traffic, becomes a limiting factor.

 

Peter Buerhaus:  Did you follow an existing model when establishing IPE at Vanderbilt?

Bonnie Miller: We were unaware of any IPE models designed for incoming students who were going to be based in clinics and would be expected to make meaningful contributions to patient care.  There was a medical center retreat at Vanderbilt in 2008 that later led to the 2010 ‘Beyond Flexner’ article that was published in Academic Medicine.1  Several very important principles emerged from the retreat, namely that “all learners work, all workers learn,” and that learning should be team based, situated in an authentic context, and competency based.

Linda Norman:  In our earlier attempts at IPE, we tried the didactic course approach with nursing and medical students and used scenarios and role playing, but these did not seem to interest students or lead to meaningful engagement with students from other disciplines.  This approach lacked authenticity.

Heather Davidson:  Given that experience, we wanted our new IPE curricula to encourage students to go beyond acquiring knowledge, but to become more aware of their attitudes and promote their making behavioral change.  We also wanted learning to be transformative, to provide students with an authentic environment where risky questions and issues could bubble up, and students could wrestle with questions for which there are no clear answers, but which are some of the root causes of the difficulties typically experienced in our health care delivery environment.

 

Peter Buerhaus:  What are some of the successes of VIPL?

Bonnie Miller:  The program has gone through internal curriculum revisions, major curriculum reform at the medical school, and a variety of different reforms and leadership changes at our partner schools of pharmacy and social work.  Yet, VIPL has survived.  Additionally, we have also been able to demonstrate that students can add value to the clinic. Students have been able to cross train, reconcile medications, conduct behavioral interviewing, perform motivational coaching, carry out process mapping, implement quality improvement projects, and redesign clinic space and function.  We have proven that students are not just passive bystanders but that, even during the earliest stages of their education, they can add value to the clinic and to patient care.  Importantly, VPIL has also helped students become systems thinkers.

Linda Norman:  Unlike when we began the program, today we have a dedicated and engaged faculty who value interprofessional education and are working together from the clinical and academic sides to constantly improve the IPE experience.  We now have faculty who have developed expertise in IPE.

Heather Davidson: I believe that students have also become relationship-based thinkers.  I recently had a conversation with one of our third year medical students who said he did not realize that at the time he was in VPIL, but now that he has been in his clerkships, he realizes that 75% of what he does directly involves the relationships he has established with other individuals.  He explained that VPIL gave him the opportunity to learn how to build good relationships with other disciplines.  Students who come through the program have a broader and richer perspective of who is caring for people and the complexity of that work.  We believe this is beyond the technical skills they are learning through their home curricula. And we see that they have strategies and content on how to relate to other professions to share with other members of their own “tribe.”

Linda Norman:  I have received feedback from students who have completed the program who said, “Now that I am out in the work world, I realize how much I benefitted from VPIL.  It was an asset when I applied for a job and I was more confident and less hesitant to reach out to other disciplines.

 

Peter Buerhaus:  What surprises have you experienced?

Bonnie Miller: The traditional model for medical education had been two years of classroom learning and two years clinical.  At Vanderbilt we had always required a clinical preceptorship in the first year but it had been limited to 8 weeks.  Although we offered other clinicalelectives, there had not been opportunities for true clinical immersion during student’s first two years. Consequently, when we offered VPIL to incoming students, we wondered if students were really more interested in gaining additional clinical experiences versus being interested in interprofessional learning. The third year that we offered the VPIL program, the medical school introduced a separate clinical experience for all first year medical students.  Interest in VPIL fell off substantially.  Based on that experience it appears that much of the medical student interest in VPIL was motivated by gaining clinical exposure in their first year versus interprofessional education. We found that it was somewhat more difficult to sustain interest in VPIL among the third cohort of medical students because they observed their medical student peers in medical student only clinics, who were being mentored by physicians, and thought that perhaps they were missing out on something that was more important. We had to do a little extra work with that group and convey the message that, “No, actually what you are getting is more enriching and more important than what your peers are getting.” With the next entering cohort, the fourth cohort, we were better prepared to address these concerns.

Heather Davidson: This experience made me aware that our students are like race horses. They want to open the gate and run; they want to acquire the best clinical skills and be the best practitioner they can be.  They want to perform.  The concept of teamwork as a “clinical” skill is fuzzy to them.  We have been trying to think through how to better prepare students to understand the importance of teamwork as a clinical skill. However, this also requires that they acknowledge that the mental models that are being formed from their own professional perspective can hold a very different perspective than a colleague trained in another profession. The amount of effort and faculty guidance that goes into this is not trivial.  In the clinic setting, a very authentic environment, VPIL is not about showing up and listening to a case study and working together and then leaving and doing your own thing.  Rather the VPIL experience constantly asks students “What strategies can your team develop to learn together?” and “What strategies can your team develop to work together?”

Linda Norman: Differences in perception of power was something that was a little surprising as we worked with our non-Vanderbilt partners.  It turned out that Vanderbilt was perceived as being a little more powerful or more of the driving force in IPE even though we tried to be sure that all institutions had an equal voice.  It was not so much the non-Vanderbilt faculty but the administrators of the non-Vanderbilt institutions that had to be periodically reassured.  Vanderbilt administers the program and funds much of the support structures that underpin the program, but each institution has equal input into the curriculum.  Some non-Vanderbilt administrators felt that Vanderbilt was telling them what to do and we dealt with this by pausing and discussing our respective roles with these administrators.

Heather Davidson: Another surprise has been the success of our immersion program. The immersion week is our orientation to VPIL. It takes place before any of the other schools start their own profession-specific orientation and is designed to help students begin the interprofessional socialization process early.  Therefore, students get to know each other before they are indoctrinated into their own profession. Each day is dedicated to a different theme (Self, Professions, Community, Patients, and Interprofessional Care) with the aim of getting students’ cognitive pump primed for interprofessional work and getting comfortable interacting with different health professionals. We hope that a deeper dive into understanding the Nashville community will help them learn more about the neighborhoods that their patients come from, especially those from underserved areas. We have done everything from small group work to an experience where students go into the community to grocery shop in food desert areas with very limited funds, and then prepare a meal for the rest of the team.

 

Peter Buerhaus:  Was there a tendency of students to interact more with members of their own profession than with others during this early part of their IPE experience?

Bonnie Miller: Students did not know each other prior to their arrival.  Because there is gender balance in the program and across the professions, you cannot look at a guy and think, “He’s a doctor,” or look at a woman and think, “She’s a nurse.”  There is no easy way of being able to spot someone and say, “Aha! You’re like me.”

Heather Davidson:  Another surprise concerns some of the clinicians who have been involved as preceptors in our program.  Our students are placed together in a team of four and work and learn together in clinics one half-day per week. We’re hearing some evidence that student teams change clinic operations and even the preceptors’ practice habits.  We have heard many different accounts from preceptors, such as the nurse practitioner who has her own clinic and not long ago told me “I have been practicing for 20 years and I never really knew how to work effectively with pharmacists.  Now I realize what I am missing and I am actually changing the way I practice and interact with pharmacists.”  This is exciting.

Bonnie Miller:  I have heard many similar comments from medical students about social workers.

Heather Davidson:  One of our physician preceptors was skeptical about IPE and did not think it was going to work but was willing to give it a try.  He has since become one of our biggest champions.  He told me that his students are working so well and he has built so much trust with this interprofessional group that he felt comfortable attending to another issue during clinic hours.  He said, “Can you believe it? I had to run a quick errand, and I left my students in my clinic because I trust them and they know how to work with my staff.”  This is an amazing transition from where this physician started with VPIL, and speaks highly to the student team transitioning from just shadowing to full integration into the work of caring for patients.

I have also been surprised by the relationships that have been established among many of our VPIL students.  For instance, students interact socially outside of our program. Recently a former VPIL social work student told me “I had this case where the client was revealing complex pharmaceutical problems and I was able to call a pharmacy student to get advice.”  Or the medical student who said, “I am so excited by what I am learning.  Now, when I walk into the clinical environment, I know how to talk with the social worker.  I know what they are thinking, I know the types of problems they are trying to solve.”  We are seeing relationship from the personal, meaning going out for a drink together, all the way to professional relationships.  And that is totally outside of the program.

 

Peter Buerhaus: Looking ahead, how do you see IPE developing at Vanderbilt?  What’s next? 

Linda Norman: Because there are not enough clinics involved or available to provide IPE for all our students our IPE program, we are investigating other opportunities to provide IPE.  In other parts of the medical school curriculum, there are one-month immersion rotations in various clinical areas and the school of nursing is exploring how our nurse practitioner students may be assigned at the clinic at the same time. We currently have a small pilot program in a maternity service at a nearby Vanderbilt clinic.  We are also involving divinity students who are in a clinical pastoral care program in simulation exercises with our nursing students to help prepare them for the shock of being in intense clinical environments. As the nursing and divinity faculty were working together, we realized that this simulation experience will not only benefit the divinity students as it became clear that the nursing students did not know what to do when the chaplain walks into the patient care room.  We plan to involve the medical students and are working with the department of Bioethics to create scenarios where students will work through emotionally charged situations.

Bonnie Miller: We have the opportunity for a natural experiment.  We strongly believe in our clinic model but when Linda says that we cannot do that for everyone right now, it would be wonderful if we could work out some way of measuring impact in both the short and long-term.  Does a bigger dose of IPE result in a greater response or a better outcome? It would be nice to be able to answer that question.  IPE is now required for all students by the Liaison Committee on Medical Education so we have to figure out a way to expand IPE. We are considering our mission trip to Nicaragua where for one week Vanderbilt medicine and nursing faculty lead approximately 25 nursing and medical students to Nicaragua.  Prior to the trip, students undergo a four-month weekly curriculum of preparation.  We are also redesigning our master’s degree in health professions education to focus more fully on the faculty skills needed to be an educator in interprofessional settings.

We’re finding that our Shade Tree Clinic, which is a student-run free clinic, is providing another interprofessional care setting.  Many of our nursing, medical, pharmacy and social work students who started out as VPIL students now volunteer at Shade Tree, which expands the IPE student network.

And our clinic at Mercury Courts apartments provides much the same.  These are volunteer activities for students and a high proportion of medical students participate.

 

Peter Buerhaus: How do you see IPE developing across the country?

Linda Norman: IPE is spreading like a wildfire.  Several years ago The Health Resources and Services Administration established the Center for Interprofessional Education, the Josiah Macy Foundation continues to provide vision and support innovations, and the Interprofessional Education Collaborative, among many other efforts, have fundamentally changed the health professional education landscape. A national IPE movement is well underway across the country.

Heather Davidson:  We’re seeing institutions assessing IPE models and eager to learn from others about how best to implement IPE in their institution.  There is a tremendous amount of work to develop and operationalize IPE competencies.  So much of IPE involves group dynamics.  A key question for organizations to confront is to answer “What are the barriers that keep us from working together?”  Instead of their being the physician tribe, the nursing tribe, and social work and pharmacy tribes, can we start looking at each other as one tribe caring for people?

Bonnie Miller: There will be tension. Much of the tension I believe involves redefining what the professions are, and what the workforce of the future needs to look like, and how each of the various professions will contribute.

 

Peter Buerhaus: What advice would you offer to those considering developing IPE?

Linda Norman: People will need to figure out what will work in their own organization.  They’ll need to assess their resources and be wary of thinking that they can take a model of IPE being done in another institution and simply adopt it.

Heather Davidson:  If the organizational goal is to place students together in a clinic, they need to anticipate the need for faculty representing the different professions that will help navigate IPE education for the students. VPIL uses rotating faculty who are not billing clinicians and are not part of the clinic staff but are part of the educational program. These professionals help the students, as a team, navigate their learning experiences, keep the IPE focus on task, ask questions, debrief students and work with clinical preceptors.  We believe the program’s rotating faculty is a very important part of our VPIL success. You cannot just place an IPE student team in a clinical environment, no matter how excited they are to have them, and then walk away.

Bonnie Miller:  We’re starting to see that as the students and clinic become comfortable with each other, the student team begins to “own the clinic”, and they need less guidance from the VPIL rotating faculty.  IPE champions are really important at every level; you need the champions at the institution leadership level all the way to those at the implementation level.  Identify the model that you think will work for your setting, and then identify who your champions will be. Do not make it too hard for them. And, of course, there is the resource issue:  It is very frustrating for people on the ground floor trying to implement IPE when they do not have the resources needed to be successful.

Linda Norman: While creating IPE is a complex process, the outcomes for the students, faculty, and clinical area are well worth the effort. Organizations that embark on IPE need to devote the time and resources to have meaningful programs. IPE is an area within healthcare that is still in its infancy and we can only anticipate that the types of IPE programs and related initiatives will grow exponentially in the next decade. There is a groundswell of support for IPE within health professions education that has not been present previously.

 

Peter Buerhaus:  Thank you Linda, Bonnie, and Heather.

 

 

References

  1. Miller, Bonnie M., Moore, Donald E., Stead, William W., Balser, Jeffery R.  (2010). Beyond Flexner: A new model of continuous learning in the health professions.  Academic Medicine 2010; 85(2): 266-272.