http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(2): 128–133 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2013.872607

SPECIAL THEMED SECTION: HISTORICAL PERSPECTIVES

In and out of the curriculum: an historical case study in implementing interprofessional education Peter S. Cahn MGH Institute of Health Professions, Boston, MA, USA

Abstract

Keywords

Although international reports have called for making interprofessional education an integral part of health professions education, most interprofessional learning activities remain voluntary and occur a single time. Barriers to implementing comprehensive interprofessional education come from forces both internal and external to institutions. Understanding the historical context for how one graduate health professions school attempted to overcome these barriers will provide a longitudinal perspective that may assist other institutions with their interprofessional education efforts. The case of the Massachusetts General Hospital Institute of Health Professions shows that, despite being founded with a mission to educate students from different professions together, interprofessional education does not emerge naturally. An analysis of archival documents, academic catalogs and oral history interviews revealed that early attempts focused on requiring students to take common courses. Later, the faculty created voluntary interprofessional learning activities. Neither approach achieved its intended goals until the Institute developed deliberate strategies to counter the internal and external barriers to integrating interprofessional education. This historical case study suggests that sustainable interprofessional education initiatives require both an organizational home and a permanent place in the curriculum.

Historical case study, interprofessional curriculum development, interprofessional education, narrative methods

There has been a call for making interprofessional education (IPE) integrative rather than supplementary to the core curriculum for pre-licensure health professions students (Blue, Mitcham, Smith, Raymond, & Greenberg, 2010; Curran & Sharpe, 2007; Wilhelmsson et al., 2009). When voluntary and sporadic, IPE courses may draw fewer students representing a limited range of professions (Klocko, Krumwiede, Olivares-Urueta, & Williamson, 2012; Margalit et al., 2010). Only by making IPE a required and ongoing part of students’ experience will they be prepared to practice in a collaborative health care environment. Yet, in a comprehensive survey of 83 IPE programs across 14 countries, researchers found that close to 60% of the activities occurred just once, and fewer than 30% offered students course credit (Abu-Rish et al., 2012). To determine the barriers that might impede the implementation of an integrated IPE curriculum, researchers have conducted surveys of faculty members and reflected on completed educational initiatives. The most frequently cited obstacles to embedding IPE in health professions education fall into two categories: (1) forces internal to an institution that prevent coordination and (2) external forces that seek to maintain professional boundaries. On the institutional level, disparate schedules, skill levels and administrative support may militate against students from different professions learning together

Correspondence: Peter S. Cahn, MGH Institute of Health Professions, 36 1st Avenue, Boston, MA 02129-4557, USA. E-mail: [email protected]

Received 17 May 2013 Revised 10 September 2013 Accepted 3 December 2013 Published online 2 January 2014

(Bilodeau et al., 2010; Foreman, 2008; Gilbert, 2005). At the same time, the status imbalance between medicine and other health professions threatens to undermine the creation of interprofessional teams with equal participation (Gardner, Chamberlin, Heestand, & Stowe, 2002; Nancarrow & Borthwick, 2005; Reuben et al., 2004). In this article, I analyze one institution’s 35-year experience in confronting both internal and external obstacles to implementing an integrated IPE curriculum. Taking an historical perspective to IPE helps identify long-standing forces that may affect contemporary attempts to prepare students to deliver care in teams. The example of a graduate school founded with an explicit mission to advance interprofessional training is particularly instructive for those who believe that only by starting from scratch can an institution overcome the barriers to achieving IPE. Even in the case of a relatively young institution with a strong original commitment to interprofessionalism, success in integrating IPE across the curriculum has not been smooth. At its launch in 1977, the Massachusetts General Hospital (MGH) Institute of Health Professions (IHP) required students from different programs to take classes together. As its programs sought accreditation and its students entered into specialized tracks, the IHP came to treat IPE as frosting atop the primary curriculum – sweet-tasting but ultimately superfluous. Over time, faculty and administrators of the IHP recognized that the original commitment to interprofessionalism had been diluted and sought to return to an integrated approach to IPE. The history of how IPE moved in and out of the required curriculum at IHP offers lessons for all health professions educators seeking to make IPE part of the main course rather than simply dessert.

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Introduction

History

In and out of the curriculum

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Background

Analysis

The idea for a degree-granting entity within MGH emerged in the 1960s. Eleven different hospital departments ran their own training programs to meet workforce needs for health care providers. Some, like the MGH School of Nursing, led to a diploma, others to a certificate. Hospital leaders saw benefit in centralizing the disparate educational efforts and enhancing their academic legitimacy. From the start, they envisioned a school that would educate future health professionals together (Castleman, Crockett, & Sutton, 1983; Peirce & Ditomassi, 2011). Interprofessional education in the health professions was not a new idea when the IHP was founded. It was not even new to MGH. Baldwin (2007) dates some of the earliest efforts to promote collaborative health care in the United States to MGH’s Richard Cabot, who wrote about the ‘‘teamwork of the doctor, the educator, and the social worker’’ in 1915 (p. 24). What would be new about the IHP’s approach was that interprofessional education would be a required part of the curriculum. Although in the early development of the school, the leaders and faculty used the term ‘‘interdisciplinary’’ to describe their approach, I employ the term ‘‘interprofessional’’ to convey the contemporary meaning of different professions working and learning together. By requiring students in dietetics, nursing, physical therapy, social work and speech-language pathology to take core courses together, the planned graduate school aimed to foster interprofessional learning. Charles Sanders, the general director of the hospital during the IHP’s launch, defended the model, acknowledging that, ‘‘Team approaches to patient care can be developed better through a single faculty on a single campus with students from various areas of learning meeting together in basic, common courses, rather than in fragmented courses in different colleges’’ (Black, 1979, p. 25). Julian Haynes, the first provost, echoed this vision in telling the Boston Globe that ‘‘We’re going in the direction of a non-departmental structure, a unitary faculty, and an interdisciplinary curriculum’’ (Pave, 1981, p. C1). In September 1980, the IHP opened with 26 faculty members, 16 students and 19 courses in its catalog designated as interprofessional.

I divided notes from the archives and quotes from the interviews into discrete segments and arranged them in chronological order. Then, I coded the segments based on keywords to reveal recurring themes. To ensure validity, I shared initial findings with the interview subjects as well as other IHP faculty members and incorporated their suggested corrections.

Methods This article is based on an historical analysis of data (documents and oral histories) gathered from the MGH to learn how IHP leaders attempted to create a graduate school with IPE infused across its curriculum and how the vision changed over time. Data collection Several historical sources were searched. First, the MGH archives provided me access to files from the IHP Board of Trustees from 1978 to 1990. These documents contain correspondence, agendas and reports related to the early governance of the Institute. Second, the former MGH School of Nursing maintains a separate archive. In those files, I consulted brochures, newspaper clippings and plans for the transition into a degree-granting institution. Finally, the IHP, where I am employed, allowed me to review minutes from trustee committee meetings, course catalogs and annual reports from the 1980s to the 2000s. In addition to printed sources, I conducted my own oral history interviews with four faculty members who have been involved with the IHP since its inception. I selected these leaders because their involvement with key IPE initiatives would give nuance to the written materials. Interviews lasted one hour and occurred both in person and over the telephone. In all cases, I asked a set of standardized questions about obstacles and facilitators to IPE and typed responses simultaneously on a computer.

Findings The history of IPE at the IHP divides into three phases, wending in and out of the required curriculum in response to the balance of internal and external forces. Required courses 1980–1995 As a new educational institution, IHP benefited from a blank slate on which to integrate interprofessional concepts throughout the curricula. The founders, clinicians themselves, believed wholeheartedly in the importance of teamwork in patient care. In an interview, an early faculty member described the atmosphere at the founding: ‘‘It seemed so obvious that you should be educated together because we worked that way in clinic.’’ The bedrock commitment to interprofessionalism kept the concept prominent in the IHP’s mission, but conflicting internal forces hindered its smooth implementation. Students arrived with different levels of preparation and different intended learning outcomes. As one of the original faculty members recalled, ‘‘I don’t think there is anybody in this place that is not committed to interdisciplinary work, but it turns out that we have different ideas about how to do that and what it means’’ (quoted in Betters-Reed, 1982, p. 172). In 1983, a team from the New England Association of Schools and Colleges visited the nascent IHP to evaluate its application for accreditation. The team’s report noted that steps had already been put in place to fulfill the goal of preparing students for interprofessional practice. Students in all degree programs took common courses in ethics and research methods. Still, the evaluators indicated the need for more work in this area: ‘‘The relationship of discipline-specific and interdisciplinary courses needs to be defined for the graduate. Distinctions between awareness and appreciation for other disciplines must be addressed in the implementation of the goal’’. The Institute’s own self-study for accreditation, written in 1985, celebrated early efforts in fostering IPE through an increase in ‘‘conjoint’’ courses. Faculty from different departments co-taught courses like ‘‘Living with Death, Living with Grief’’ and ‘‘Integrated Approaches to Pain Management’’ for students from multiple professions. Despite these successes, more than half the faculty surveyed felt that progress toward meeting IPE objectives was slow. In particular, they felt the pressures to launch new programs undermined the incentive to teach interprofessional courses. The self-study concluded that once the departments stabilized curriculum development, the internal forces hindering IPE would abate and faculty would have more time to devote to creating interprofessional courses. Even after completing the program requirements and receiving accreditation, however, the IHP still struggled with creating a balance between profession-specific and interprofessional courses. Some of the clearest signs of internal forces working against IPE appear as absences in the archival documents. For instance, IHP administrators produced a statement of long-range goals at a meeting in January 1987. Prominent on the list of goals was ‘‘Progress will be made in building models of interdisciplinary education.’’ Yet, in the same session, the administration considered requests for the coming year’s budget. Not surprisingly, each program asked for additional faculty and

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administrative staff to support courses in their professions. No unit advocated for interprofessional education, so the leaders could not allocate resources specifically for that purpose. They had to hope that individual programs would coordinate on their own. External forces to enhance the status of health professions also undermined the approach of delivering IPE through required classes. In the 1980s, faculty developed an innovative seminar on leadership styles that convened students from across the professions to reflect on scenarios from their clinical experiences. As popular as the leadership class was among students, it succumbed to the encroachment of specialized curricula imposed by national professional associations, which left little room for electives. Bette Ann Harris, a longtime faculty member, described the erosion of the IHP’s original mission in an address to the American Physical Therapy Association. ‘‘With reluctance we dropped the requirement that students, in order to graduate, must take at least two interdisciplinary courses.’’ At the faculty meeting where the decision was made, a colleague requested that the minutes reflect that they made the decision ‘‘with great sadness’’ (Harris, 2006, p. 3). Changes in the physical therapy curriculum make visible the shift from interprofessional classes to profession-specific ones. From the program pages in IHP course catalogs, I tallied the total number of credits required and recorded how many fell under the designation ‘‘HP,’’ the IHP code for an interprofessional course. The first graduate degree offered at IHP was a master’s in physical therapy for advanced practitioners, which required a student to earn 36 credits of coursework, of which roughly 20% came in explicitly interprofessional courses. In 1995, the IHP introduced an entry-level master’s in physical therapy. The required credits for this program totaled 85, but the proportion of interprofessional courses remained similar to the curriculum for the advanced master’s. When the faculty proposed replacing the entry-level master’s degree with a Doctor of Physical Therapy, one of the rationales was to ‘‘incorporate stronger interdisciplinary objectives through the program’’. Yet, when the new curriculum debuted in 2000– 2001, the overall credits required more than doubled from the advanced master’s program while the interprofessional course requirements fell. In the first year of the DPT curriculum, students took courses in pharmacology, health policy and ethics together with other professions. By the next year of the program, the required pharmacology and health policy courses had been rebranded as exclusively for physical therapists. Only a 2-credit interprofessional ethics course remained (Table I). A former department chair explained that she approached other programs about coordinating courses, but when they could not agree on common learning goals, she opted to create classes just for physical therapy students. Internal and external forces combined to incentivize program building over interprofessional learning opportunities during the first decade of the IHP.

Voluntary activities 1995–2007 By the mid-1990s, The Long Range Planning Committee, a joint body of faculty and trustees, recognized the difficulty of promoting interprofessional education through required courses. At a meeting in December 1994, the Committee concluded that, ‘‘IHP core courses are a way to approach interdisciplinary education, but have not been achievable so far.’’ The members identified internal constraints like decentralized budgets and tightly structured curricula as barriers to implementing IPE, echoing the same hindering factors that faculty had identified in the 1985 accreditation self-study. The committee’s proposed solution, however, did not address the lack of infrastructure to support IPE directly. According to the meeting minutes, they recommended working with a facilitator to ‘‘define what we mean by ‘interdisciplinary’ and the resources needed to achieve the goal.’’ I found no record of whether the committee engaged a facilitator, but their subsequent actions indicated that their attention shifted away from IPE. In 1996, the Long Range Planning Committee began a process to define the Institute’s 5-year strategic plan. They generated a list of 20 possible goals and circulated a ballot to all faculty, staff and trustees with instructions to rate the importance of each item from 1 (least important) to 5 (most important). The different constituencies reached consensus on their top and bottom-scoring choices (Table II). Their rankings reveal a decided preference for developing academically strong programs and less interest in creating an interprofessional core of required foundational courses. With internal priorities focusing on strengthening individual academic programs and no external pressure to pursue IPE through required courses, the IHP explored other ways to fulfill its commitment to interprofessionalism. A tangible sign of this shift appeared in the minutes of a 1998 meeting of the Board of Trustees’ Research, Academic Planning and Student Affairs Committee. The group decided to change the phrase ‘‘core curriculum’’ in a report to ‘‘interdisciplinary learning activities’’ to better reflect the loose collaboration they envisioned among departments. One of the most visible interprofessional learning activities launched in 2000. Interdisciplinary Seminars presented a hypothetical clinical case and then grouped students into teams to Table II. Rating of priorities for MGH Institute of Health Professions strategic plan in 1996.

Goal Offer programs that are responsive to needs within the health care system and are distinguished for their academic excellence. Establish a core of courses that include concepts, theories, and practices that are shared by all health professionals

Board rating

Faculty rating

Staff rating

4.9

4.6

4.5

3.1

3.2

3.7

Table I. Proportion of interprofessional courses in physical therapy degree programs at MGH Institute of Health Professions.

Year 1984–1985 1995–1996 2000–2001 2001–2002 2007–2008

Physical therapy degree program

Total coursework credits

Minimum interprofessional course credits

Percent of credits that are IP (%)

Advanced Masters Entry-level Masters Entry-level Doctorate Entry-level Doctorate Entry-level Doctorate

36 85 99 98 100

7 7 5 2 2

19 8 5 2 2

In and out of the curriculum

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develop an integrated plan of care. Three faculty members representing the primary programs (nursing, physical therapy and communication sciences and disorders) facilitated the discussions. Comments from some faculty facilitators revealed that without a common foundation of coursework, students from different professions could not easily communicate with each other. One faculty member wrote in a debriefing, ‘‘Many of the students did not know much about each other’s disciplines. When they broke down in small groups they were asking questions like, ‘What type of education do you need to practice in your field? What settings do you practice in?’ Questions like these suggest that, in some cases, they do not know basic information that eventually leads to other complex questions like, ‘How can your input help me in caring for my patient?’’’ A long-time faculty member recalled, ‘‘We had a noble goal of being interprofessional, but for a long time we thought it was just sticking students in the same room. There was a total mismatch of maturity, professional identity and content information.’’ Another attempt to engage students in the entry-level programs in interprofessional education never continued past the pilot phase. In 2003, a faculty member at Harvard Medical School who coordinated the Patient–Doctor curriculum contacted the School of Nursing at IHP to propose a joint course with third-year medical students and third-year nurse practitioner students. The 6-week course would bring students together in interprofessional teams to identify a quality improvement problem, propose solutions and present their findings. A faculty member from the medical school and one from the nursing program jointly facilitated weekly seminars. Twelve nursing students volunteered to participate, and nursing faculty volunteered to serve as team mentors. Although participants indicated that the venture met some of its learning objectives, competing demands prevented future collaboration. Harvard Medical School geared up to introduce a new curriculum, and the faculty member who had championed the partnership with nursing students moved to a different administrative position. As the director of the graduate program in nursing at the time explained in an interview, ‘‘Our person wasn’t there at the medical school.’’ At the same time, she was ‘‘focused on getting our programs accredited,’’ so no one could devote the attention necessary to nurture the relationship. The seminars failed to foster meaningful interprofessional learning because simply convening students from different professions in the same room did nothing to create a common language. On the other hand, the team-based approach with medical students did achieve its desired outcomes but lacked sufficient administrative resources to sustain it. Recognizing the weakness in the voluntary approach to IPE, in 2007, a faculty task force recommended ‘‘sunsetting’’ the clinical case seminars and replacing them with a Department of Interdisciplinary Studies. Each department would have to release one faculty member to teach an interprofessional course each semester. In a sense, they called for a return to achieving IPE through required courses, but this time with explicit attention to introducing team-building skills and providing a concrete and well-resourced structure to oversee it. Integrated required course 2008–2013 The IHP administration did not adopt the faculty recommendations immediately, but it moved to enact their spirit. They decided that, in the absence of strong external pressure from national associations to emphasize IPE, the institution would have to create its own internal structure to facilitate an integrated IPE curriculum. Halfway through its ten-year accreditation, the IHP submitted a self-assessment report to the New England

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Association of Schools and Colleges. The document described how academic leaders have identified interprofessional efforts as a key goal and devoted time in retreats to developing relevant metrics. It includes the summary statement, ‘‘Since its inception, the Institute has valued the interdisciplinary environment; it is time to walk the talk.’’ Walking the talk has translated to a more structured, visible organization for IPE. Voluntary activities have continued, but under the supervision of the provost-appointed members of the Interdisciplinary Activities Committee. Beginning in the 2009– 2010 academic year, the Committee was charged with providing high-level oversight to coordinate the Interdisciplinary Seminar and the Schwartz Center Educational Rounds, which encourage compassionate care (Corless et al., 2009). The Committee also helped to evaluate the effectiveness of the events and produced an annual report of IPE across the departments. At the same time, the IHP took steps to create an organizational home for interprofessional studies. In November 2009, the academic leaders approved the concept for a center for interprofessional studies. The proposed center would bring together areas of study that cross all the IHP professions such as health informatics, ethics, statistics and research methods. Some of these initiatives impact entry-level students, while others represent expansion into post-professional graduate degrees. Educating students who have already received professional licensure frees curriculum developers from meeting professionspecific competencies, allowing them to focus on interprofessional learning. Just as the IHP altered its internal dynamics by establishing an organizational home for IPE, voices from across the globe amplified the call for reforming health professions education. George E. Thibault, President of the Josiah Macy, Jr. Foundation and Chair of the IHP Board of Trustees participated in a landmark international forum dedicated to promoting ‘‘interdependence’’ in education (Frenk et al., 2010). A second, high-profile report commissioned by several associations of health professionals in the United States defined core competencies of interprofessional collaborative practice with the goal of spurring their integration into curricula (Interprofessional Education Collaborative Expert Panel, 2011). Conveners of both groups admitted that the push for interprofessionalism echoed earlier calls, but recent debates over increasing access to health care renewed the urgency of reforming health professions education. The 5-year strategic map starting in 2011 included as a goal for the IHP to ‘‘lead in the development of interprofessional education.’’ Tellingly, the metrics designed to track progress toward that goal focused on creating mandatory interprofessional learning opportunities. Under the aegis of the newly created Center for Interprofessional Studies and Innovation (CIPSI), a task force of faculty members representing all the departments proposed a required course for all entry-level students. Following courses at academic medical centers like the University of Florida (Davidson & Waddell, 2005), the IHP agreed to assign first-year students in entry-level programs to interprofessional teams, which will complete a hybrid course structured around the four core competencies identified by the Interprofessional Education Collaborative. The first cohorts enrolled in the required course in fall 2013.

Discussion In some structural ways, the MGH Institute of Health Professions does not resemble other institutions that prepare future health professionals. The IHP is part of a health care system, not a university. It does not educate physicians, and it is focused exclusively on post-baccalaureate students. Yet, in the

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J Interprof Care, 2014; 28(2): 128–133

Factors favoring integrated IPE

Figure 1. Model for countering external and internal barriers to integrated IPE.

fundamental pressures that impact the IHP, its history mirrors the experience of any health professions institution. In fact, I found resonance between a longitudinal view of the IHP and the conclusions of a survey of interprofessional education initiatives in the United Kingdom. There, researchers concluded that both internal and external factors inhibited the implementation of collaborative learning across the health professions (Pirrie, Wilson, Harden, & Elsegood, 1998). The case of the IHP confirms these limiting factors while suggesting how positive influences may also contribute to the success of infusing IPE throughout the curriculum. At times in the history of the IHP, forces favored integration of IPE; at other times they incentivized increased specialization (Figure 1). In 2006, when the academic dean retired, she reflected on the record of interprofessional education during her time at the IHP, ‘‘There has always been a push-and-pull between the needs of individual academic programs and the development of interdisciplinary offerings’’ (Carey, 2007, p. 22). At the outset, the IHP founders envisioned a mandatory core curriculum with a unitary faculty. Their boundaryless model responded directly to external forces like reports from professional associations and hospital demand for collaborative clinicians, which encouraged greater integration of the professions. However, once the new school began accepting students, a different set of forces came to predominate. Seeking accreditation from national bodies meant demonstrating profession-specific competencies. Faculty quickly departmentalized and assigned their teaching responsibilities to academic units. The external forces that inspired the creation of the IHP receded as the exigencies of setting up new programs grew, while no countervailing champion of IPE arose within the organization, a factor identified elsewhere as crucial in building support for IPE (Kelley & Aston, 2011). Faculty and administrators still endorsed the goals of IPE even as the space for required conjoint courses shrank. They assured themselves that IPE would receive more sustained attention once the professional curricula stabilized. The mistake they made was to assume that IPE would strengthen in time without any structural changes to balance the forces pushing for specialization. Even when academic programs reach sufficient maturity, the pressures to erect boundaries between professions is deep-rooted (Reeves, MacMillan, & van Soeren, 2010). Nor will faculty members welcome the task of creating interprofessional content

for their courses without a guarantee that sufficient students will enroll and their departments will reward their effort. In the absence of a strong local champion for IPE, the IHP shifted from achieving its interprofessional goals through required courses to creating a set of voluntary activities. This arrangement bypassed some of the daunting challenges of harmonizing student schedules and finding open spaces in required curricula. Similarly, an example of extracurricular IPE from the University of Minnesota shows the potential vitality of student-organized activities (Johnson et al., 2006). Yet, at the University of Minnesota as at the IHP, without an organizational home and permanent place in the curriculum, voluntary IPE becomes difficult to sustain. Students lack a common vocabulary to understand the roles of health care team members, and faculty members may also feel the burden of uncompensated work. At the IHP, when evaluations showed student dissatisfaction with some activities, no one claimed the authority to revamp the offerings. In the 2000s, the IHP faculty and administrators returned to the idea of achieving IPE through a required course. The difference this time was that new forces – both internal and external – had solidified to offer support for IPE. Creating an integrated, interprofessional course could not have happened until both outside and inside voices merged in a chorus of advocacy for IPE. The new, credit-bearing course launched in fall 2013 with participation from all entry-level graduate programs. Extracurricular IPE activities will continue, but now, with the possibility for incorporation in a structured learning experience, students will be able to reflect on the experience and receive formal feedback. The lesson that other institutions interested in integrating IPE into their curricula may take from the history of the MGH Institute of Health Professions is to counter barriers with their own supportive forces. In most cases, affecting external influences like health care policy and accrediting standards require long-term lobbying. In contrast, developing forces internal to each institution is easier to achieve. The IHP was fortunate in that it did not have to convince most faculty members of the benefits of IPE. By placing interprofessionalism in its mission statement, the IHP ensured that it attracted faculty committed to the same principles. Erecting internal structures to operationalize IPE took more investment of resources. With a dedicated center for interprofessional studies, the institution assigns accountability for IPE and measures outcomes. In this way, IPE becomes a staple and not simply a luxury.

Acknowledgements Thank you to Bette Ann Harris, Ruth Purtilo, Leslie Portney, Margery Chisholm and the members of the MGH IHP Faculty Writing Group for their perspectives and suggestions.

Declaration of interest The author reports no declarations of interest. The author alone is responsible for the writing and content of this paper.

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In and out of the curriculum: an historical case study in implementing interprofessional education.

Although international reports have called for making interprofessional education an integral part of health professions education, most interprofessi...
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