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Doctors and Nurses, Not Learning Together

07/28/2016 09:50AM | 7569 views

There are few group projects in medical school — which is strange when you considerthat there are few solo practitioners in the real world.


During medical school, I spent countless evenings in a library, half-asleep, poring over textbooks and talking through cases with other medical students. What I did not do, ever, was take a class with anyone studying to be a nurse, physician assistant, pharmacist or social worker. Nor did I collaborate with any of these health professionals to complete a project, participate in a simulation or design a treatment plan. It wasn’t until residency that I first began to understand just how many professions come together to take care of a single patient — what exactly they do, how they do it, and how what I do makes their jobs easier or harder.

As a first-year resident, you finally learn to put into practice the theory of medicine you have been nurturing since fumbling around with organic chemistry models in college. You learn in a safe and hierarchical environment — with senior residents, fellows, consultants and attending physicians each demonstrating, with increasing degrees of nuance and sophistication, how much clinical medicine you have yet to learn and how far you have left to go.

But, in all that time, there is surprisingly little education on what it means to be a leader of a medical team, with its nurses, physician assistants, pharmacists, respiratory therapists, physical therapists, dieticians and case managers. There is even less discussion of how to understand one another’s roles, perspectives, frustrations and limitations.

Instead, traditional education emphasizes separate training for each health professional, which inadequately prepares students and residents for new models of health care delivery that emphasize team-based care and shared responsibility for patients.

The push toward more collaborative care has been underway for years. In 2001, the Institute of Medicine issued a report recommending that all health professionals receive training in interdisciplinary teams. Since then, the Accreditation Council for Graduate Medical Education has integrated interprofessional learning into its competency milestones. A central goal of health care overhaul — beyond improving access to care — is transforming a fragmented health system into a more unified one through better team-based care models. As Ezekiel Emanuel, a health policy expert, notes, medical care is evolving “away from the traditional physician-patient relationship toward a much more effective but complex health care team-patient-caregiver relationship.”

This idea is now more clinically and financially important than ever before. Recently, the Department of Health and Human Services announced that by 2018 it aims to have half of all Medicare payments under alternative payment models, including bundled payments, primary care medical homes, and accountable care organizations — all of which require greater degrees of integration and cooperation among health care providers to overcome the limitations of a fragmented and inefficient system.

And yet, despite near-universal recognition that better care means more collaborative care, changes to health professional school curricula have been slow coming.

There are, however, pockets of promise across the country. The Robert Wood Johnson Foundation and three other leading foundations recently helped start the National Center for Interprofessional Practice and Education to improve teamwork and break down siloed training approaches. Another initiative, Retooling for Quality and Safety, led by the Josiah Macy Jr. Foundation and Institute for Healthcare Improvement, awarded grants to six universities to support interprofessional activities aimed at integrating patient safety into medical and nursing school curricula. Participating schools designed a variety of creative learning models to bring students together, such as interprofessional Grand Rounds conferences and web-based learning modules; small-group exercises to develop care plans or break bad news; quality improvement projects to improve hand hygiene or prevent falls; and clinical simulations with debriefing sessions during which all team members had the opportunity to describe what went well and what could have been improved.

Data evaluating whether interprofessional training improves teamwork, communication and leadership is still preliminary, but promising. A study of over 600 medical, nursing, physiotherapy and occupational therapy students enrolled in an interprofessional training course found that all student groups gained knowledge of other professions’ work, but also developed a deeper understanding of their own professional role. Other research suggests that joint clinical simulation and facilitated debriefing sessions can improve confidence by providing collaborative care for a rapidly deteriorating patient and enhance communication by increasing providers’ ability to identify various professional roles, “close the loop on patient care,” and correct others in a constructive manner. Similar results have been found for medical and nurse anesthetist students in operating room simulations. At the resident level, the use of multidisciplinary rounds — in which doctors-in-training discuss diagnoses and patient care issues with case managers, nursing coordinators and others — has been shown to improve hospital performance on quality metrics for heart failure and pneumonia and decrease how long patients stay in the hospital.

Research suggests that it is important to start this process early, as student willingness to engage in interprofessional training seems to decline over time, except, interestingly, for nursing students. Research also suggests that doctors — expected to lead health teams — might stand to benefit most from such training. One study found that while three-quarters of physicians rated their collaboration and communication with nurses as high or very high, only about a third of nurses felt the same way.

Team-based care forms the foundation of novel payment models and a higher-value health care system — and the training of new health professionals must reflect the evolving practice environment in which they find themselves. Thus far, our recognition that today’s patients need teams has outstripped our recognition that today’s teams need training. It’s time to fix that — together.

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