RESEARCH REPORT
Long-Term Effect of a Short Interprofessional Education Interaction Between Medical and Physical Therapy Students Terin T. Sytsma,1 Elizabeth P. Haller,1 James W. Youdas,2 David A. Krause,2 Nathan J. Hellyer,2 Wojciech Pawlina,3 Nirusha Lachman3* 1 Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota 2 Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 3 Department of Anatomy, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
Medicine is increasingly focused on team-based practice as interprofessional cooperation leads to better patient care. Thus, it is necessary to teach teamwork and collaboration with other health care professionals in undergraduate medical education to ensure that trainees entering the workforce are prepared to work in teams. Gross anatomy provides an opportunity to expose students to interprofessional education (IPE) early in their training. The purpose of this study is to describe an IPE experience and report if the experience has lasting influence on the participating students. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire was administered to first year medical (MD) and physical therapy (PT) students at Mayo Medical School and Mayo School of Health Sciences. Results demonstrated an openness on the part of the students to IPE. Interprofessional education experiences were incorporated into gross anatomy courses in both medical and PT curricula. The IPE experiences included a social event, peerteaching, and collaborative clinical problem-solving sessions. These sessions enhanced gross anatomy education by reinforcing previous material and providing the opportunity to work on clinical cases from the perspective of two healthcare disciplines. After course completion, students again completed the RIPLS. Finally, one year after course completion, students were asked to provide feedback on their experience. The post-curricular RIPLS, similar to the pre-curricular RIPLS, illustrated openness to IPE from both MD and PT students. There were however, significant differences in MD and PT perceptions of roles and responsibilities. One-year follow-up indicated long-term retention of lessons learned during C 2015 American Association of Anatomists. IPE. Anat Sci Educ 8: 317–323. V Key words: gross anatomy education; medical education; physical therapy education; interprofessional education; IPE; interprofessional learning; interprofessional curriculum
INTRODUCTION Interprofessional collaboration in healthcare is crucial for delivery of high quality patient care. Along with mastering specific discipline-based requirements, providers from various *Correspondence to: Dr. Nirusha Lachman, Department of Anatomy, Mayo Clinic College of Medicine, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905, USA. E-mail: [email protected] Received 28 April 2015; Revised 4 May 2015; Accepted 5 May 2015. Published online 3 June 2015 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1546 C 2015 American Association of Anatomists V
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fields must understand each other’s professional roles and communicate effectively within the healthcare team. Interprofessional teamwork in healthcare has been said to foster better utilization of human resources, enhance workflow, promote economic sustainability and increase patient satisfaction (Frenk et al., 2010; McKinlay and Pullon, 2014). While it has also been underscored that working in teams is neither easy nor intuitive, studies have demonstrated that team skills can be learned in order to improve interactions between individual members of the team (Lerner et al., 2009; McKinlay and Pullon, 2014). By definition, interprofessional education (IPE) is said to occur “when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE, 2002). The Liaison
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Committee on Medical Education (LCMEV) recently published new standards and elements for accreditation of medical education programs (LCME, 2014), incorporating the requirement of interprofessional collaborative skills to ensure that a medical school prepares medical students to function collaboratively on health care teams (Standard 7; Element 7.9). While interprofessional collaboration continues to be an expected competency, many undergraduate healthcare educational programs lack adequate IPE experiences (Schmitt et al., 2011; Zorek and Raehl, 2013). Both standard medical school and allied health curricula however, may provide opportunities within their individual programs to initiate and foster these collaborative relationships early in training for health care professionals. In the clinical setting, IPE is often initiated successfully in the workplace for professionals who are already in practice. Such programs have been shown to improve collaborative team behavior such as increased operating room efficiency (Bender et al., 2015). Patient satisfaction and reduced clinical errors have also been reported, but greater understanding is needed regarding which components of IPE programs are responsible for such success (Reeves et al., 2008; McKinlay and Pullon, 2014). Barriers to instituting IPE in undergraduate training include difficulty in coordinating coursework, lack of an established framework and resistance to IPE by students and/or faculty (Gilbert, 2005; Hammick et al., 2007; IPEC Expert Panel, 2011). Medical education is traditionally centered on distinct professional roles, creating boundaries rather than collaboration in the professional development of health care providers (Hall, 2005; McNair, 2005). The benefit of conducting IPE later in training lies in its ability to allow students to become more confident in their specific professional roles and responsibilities. However, exposure to IPE early in training enables students to become familiar with and comfortable working within an interprofessional environment, better preparing them for future collaborations (Gilbert, 2005). McKinlay and Pullon (2014) argue that learning interprofessional teamwork skills in the workplace when clinical responsibility and patient care stakes are high is far from ideal. Learning of these skills is therefore better served within the medical school and allied health curricula as they provide a favorable platform for the initiation of interprofessional learning within the framework of basic science courses (Kirch and Ast, 2015). Previous models for IPE programs in undergraduate healthcare training have used a variety of teaching techniques, that include interdisciplinary didactic education sessions, service learning, clinical collaboration, social interactions, dissection collaboration, and simulation experiences (Hammick et al., 2007; Hamilton et al., 2008; Bridges et al., 2011; Krause et al., 2014; Fernandes et al., 2015; Herrmann et al., 2015). However, more data is needed in outlining models for pre-licensure IPE programs and evaluating their effectiveness, especially in the long term (Zwarenstein et al., 2005; Reeves, 2012; Thistlethwaite, 2015). Gross anatomy courses based on team learning and laboratory activities provide a suitable and useful platform for establishing IPE within the medical education framework (Kirch and Ast, 2015). Anatomy as a core subject forms the basis for almost all health care courses and is a topic that can be easily related between different professional tracks. The majority of healthcare professionals, including physicians, nurses, physical therapists, occupational therapists, and physician assistants study anatomy within their training, cre318
ating greater opportunity for students to learn together within a common set of objectives. When looking at the physical therapy (PT) and medical (MD) school anatomy curricula, the PT curriculum focus on musculoskeletal anatomy and the additional thoraco-abdominal organ based topics in the medical school curriculum allows for common learning activities that strengthen each group’s knowledge and enhances learning that may not be as easily achieved through uniprofessional learning (Thistlethwaite, 2012, 2015). In 2007, IPE activities were incorporated into the gross anatomy course for MD and PT students and additional IPE opportunities continue to be incorporated in both curricula (Hamilton et al., 2008; Krause et al., 2014). The two classes share a dissection laboratory and overlap time spent in class and in laboratory. The PT gross anatomy course occurs within the first semester of the students’ first year along with other classes, while the MD gross anatomy course is a seven week didactic block (120 hours) taken early in the first year (Hamilton et al., 2008; Krause et al., 2014). While prior studies on the effects of IPE have focused on attitudes preceding and immediately following IPE, the longer term impact or influence of these educational experiences has not been well documented (Thistlethwaite and Moran, 2010; Olson and Bialocerkowski, 2014; Thistlethwaite, 2015). The purpose of this study was to determine, using a survey tool, whether an IPE experience in a gross anatomy course has a lasting impact on MD and PT students.
MATERIAL AND METHODS The research plan and study methods were deemed exempt by the Institutional Review Board at Mayo Clinic (protocol ID:13-005227). One tool that has been developed by Parsell and Bligh (1999) and widely used to assess healthcare students’ attitudes and perceptions toward IPE is the “Readiness for Interprofessional Learning Scale” (RIPLS). This validated questionnaire assesses agreement with various statements about IPE on a five-point Likert scale and evaluates principle factors that students must appreciate for IPE curriculum success (Parsell and Bligh, 1999; McFadyen et al., 2006). The RIPLS can be divided into four subscales: Teamwork and Collaboration (items 1–9), Negative Professional Identity (items 10–12), Positive Professional Identity (items 13–16) and Roles and Responsibility (items 17–19) (McFadyen et al., 2006). Prior to initiating IPE interactions, the RIPLS questionnaire (Parsell and Bligh, 1999) was administered to first-year MD and PT students to evaluate attitudes toward IPE. The anonymous RIPLS questionnaire was optional and had no impact on the students’ final grade. Results from the questionnaire were analyzed with respect to composite responses of all students and the responses of the MD and PT groups separately. The responses were also evaluated with respect to the four subscales of the RIPLS questionnaire. Results were reported utilizing means and standard deviations (6SD) for each RIPLS item and subscale. A social lunch event was held prior to the start of the IPE curriculum to introduce students to their interprofessional colleagues. The students were organized into interdisciplinary teams that would serve as their working groups for the duration of the course. Five teams consisted of two four-member MD dissection groups and one four-member PT group (total students per team n 5 12), and two interdisciplinary teams Sytsma et al.
consisted of one MD and one PT dissection group (total students per team n 5 8). At the initial lunch event, students were given icebreaker questions and encouraged to discuss their interests and respective education programs (Krause et al., 2014). By initiating interprofessional relationships on a personal level, students were able to learn about each other’s training in an informal setting. The social event established a foundation of collaboration and teamwork that could be further developed during the course.
The Medical and Physical Therapy Interprofessional Curriculum The IPE curriculum was designed to incorporate elements of peer-teaching, near-peer teaching and teaching and learning innovations through use of new technology. Activities were primarily laboratory based since dissection and hands-on learning in the practical sessions best fostered interprofessional interaction. Interactions were designed to encourage teamwork and promote understanding of anatomical principles by capitalizing on the expertise of each program. The curriculum included two laboratory sessions where students from one program were responsible for teaching a dissection they had already completed to the other half of their interprofessional team. Since the courses were designed on different schedules, each group of students had a point in their curriculum where they had learned an area before the other students had been introduced to it, either in the classroom or dissection laboratory. During the first session, PT students taught MD students upper limb anatomy, whereas in the second session, MD students took the lead in teaching PT students heart and lung anatomy. Dissection checklists (Hofer et al., 2011) of pertinent structures were provided prior to the teaching session to give the students a chance to review anatomical structures that they would be responsible for identifying. In conjunction with checklists, both MD and PT students used their respective core concept objectives to provide a more clinically relevant understanding of the learning goals for anatomy. During the sessions, both programs’ faculty and teaching assistants encouraged collaboration by demonstrating team teaching approaches through shared expertise between groups. By removing physical boundaries between the dissection stations, students were encouraged to visit each other’s dissection tables during commonly scheduled times and appreciate the differences in focus of core anatomical concepts between the programs. In addition to dissection, the introduction and use of hand held ultrasound devices in the medical curriculum as a tool to appreciate living anatomy provided unique learning experiences for PT students. The use of cadaver CT imaging in the anatomy curriculum was also a novel tool for PT students to explore. Through these learning modalities, MD students were able to reinforce their own understanding and improve skills simply by teaching technique and interpretation of anatomical imaging to PT students. A third component of the IPE curriculum included clinical problem-solving sessions. The objective of these team-based sessions was to promote interdisciplinary problem solving in order to understand and analyze clinical cases by simulating the future collaborative approach in clinical practice. In a classroom setting, students worked in their IPE teams to discuss clinical scenarios requiring application of their anatomical knowlAnatomical Sciences Education
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edge. With faculty guidance, the cases were constructed by teaching assistants to correspond with learning objectives addressed in the laboratory and to highlight the knowledge base of each program. Students were required to utilize knowledge of anatomy to formulate a differential diagnoses, discuss anatomy-based questions within their IPE teams, and present their conclusions as a team. At the conclusion of the IPE curriculum the RIPLS questionnaire was re-administered to assess for any changes in student responses. Responses were evaluated in the same way as for the pre-curriculum questionnaire. Statistical analysis of pre- and post-curriculum RIPLS questionnaire responses were analyzed and evaluated using the Wilcoxon Signed-Rank Test provided in the Statistical Package for Social Scientists (SPSS), version 22 for Windows (IBM Corp., Armonk, NY). Both MD and PT students’ responses were analyzed and evaluated together. Finally, one year after completion of the course, an anonymous online survey was conducted to assess students’ perspectives on the IPE curriculum. The survey consisted of four open ended questions: (1) What did you like about the anatomy interprofessional education curriculum?; (2) What didn’t you like about the anatomy interprofessional curriculum?; (3) What would you change about the anatomy interprofessional curriculum?; (4) Are you a medical student or physical therapy student? Results of the one-year follow-up survey were analyzed qualitatively, using thematic analysis as a base for coding and identifying recurrent themes from the students’ responses (Braun and Clarke, 2006, 2014).
RESULTS Quantitative Analysis Thirty-five MD students (72.91%) and 18 PT students (64.28%) responded to the RIPLS questionnaire prior to the start of the IPE curriculum (Table 1). Overall, students showed positive attitudes towards IPE. They agreed that “For small group learning to work, students need to trust and respect each other” (mean MD 5 4.54, SD 6 0.56 and mean PT 5 4.72, SD 6 0.60). Students disagreed that learning with other healthcare students “is a waste of time or unnecessary” (mean MD 5 1.97, SD 6 0.89 and mean PT 5 1.78, SD 6 0.55). Subscale analysis also demonstrated results that were favorable towards readiness for IPE. Average response for the Teamwork and Collaboration subscale were the highest (mean MD 5 4.30, SD 6 0.81 and mean PT 5 4.35, SD 60.63) and the lowest in Negative Professional Identity subscale (mean MD 5 1.90, SD 6 0.85 and mean PT 5 1.74, SD 60.68), which negatively correlates with readiness for IPE (Figure 1). There was a significant difference between MD and PT students in the Roles and Responsibility subscale (items 17-19) for both pre- and post-IPE curriculum questionnaire results (Table 1). Thirty-six MD students (75%) and 18 PT students (64.28%) completed the follow-up RIPLS questionnaire. No significant change was found between student readiness for IPE before and after the IPE curriculum. There was also no significant change in subscale scores for either of the groups (Figure 1). However, differences were observed between MD and PT students in the “Roles and Responsibility” subscale with average responses of 2.82 (SD 6 0.93) and 1.92 (SD 6 0.61) respectively (P < 0.001). Two other trends emerged in post-IPE curriculum analysis: MD students 319
Figure 1. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire subscale analysis of responses from medical (MD) and physical therapy (PT) students before (Pre-IPE) and after (Post-IPE) interprofessional education experience in the gross anatomy course.
developed more clarity in their professional role after the experience, and PT students were less convinced that shared learning experiences with other healthcare students would help them communicate better with patients and other professionals (Table 1).
Qualitative Analysis A total of 41 students responded to the free response survey one year following completion of the IPE curriculum. Twenty eight MD students (59.6%) and 13 PT students (46.4%) submitted feedback on the curriculum. Assessment of the one-year survey responses on the impact of the IPE curriculum resulted in two main themes regarding student experiences and reactions to working with students from another healthcare profession. The first theme highlighted the “appreciation for the opportunity to meet and work with students from another program”. Many students responded to the first question, “what did you like about the anatomy interprofessional education curriculum?” with comments about social aspects of the curriculum and the value working together on the clinical problem-solving cases. One PT student reflected “I think the most learning occurred out of the case study days and seeing how the med students worked through them. It was fun to see where the expertise areas were and how we were able to work together as a team.” The second main theme from the follow-up survey highlighted “increased understanding of the other group’s professional roles.” Many students remarked that they had a better understanding of the educational content of other program after the peer-teaching sessions in dissection lab and problemsolving sessions in the classroom. For example, one PT student remarked, “We were able to learn material that the med students were more knowledgeable about such as internal organs. In return we were able to share and teach them about parts of the musculoskeletal system that they had spent less time on.” An MD student commented that the problemsolving sessions “made us think about how other members of the healthcare team might approach a condition.” 320
There were also many suggestions for improvement in the IPE curriculum. When asked what they would change about the program, the desire for more time working together was a common suggestion. There were also requests for more structure to the curriculum. Some students recommended completing the clinical cases in small groups rather than having all interdisciplinary teams in the same room. An MD student suggested having the PT students teach “basic physical examination skills. . . especially since the cadavers are available to us, so we can see exactly what each maneuver is testing.” Faculty of both programs noted that there was excellent participation in the IPE curriculum amongst most PT and MD students. The students actively engaged in the different components of the program, and faculty commented that the IPE curriculum supplemented the syllabus of both programs well. Students continued to interact outside of the designated IPE sessions. After the peer-teaching sessions, they continued to share interesting dissection findings with members of the other training program and were open to asking questions of each other and faculty of both programs.
DISCUSSION This study set out to determine whether the implementation of a formal IPE curriculum in the MD and PT gross anatomy course would have any longer term effect on the perceptions of IPE and professional collaboration among students enrolled in these programs. Results suggest that despite a brief experience in an anatomy course, all students agreed that formalizing IPE activities in a commonly required basic science course can result in lasting positive attitudes towards IPE and a perceived value in collaborative learning. Themes from the one-year survey suggest an appreciation for learning with other health care professionals and a greater understanding of the role of other professionals. It was interesting, but not inconceivable to note that a percentage of PT students were less convinced than their MD counterparts that learning with others would help them communicate better with other professionals. It is not unusual for students in the early stages of their careers, to lack the Sytsma et al.
Table 1. Pre- and Post-IPE Curriculum Mean Responses to the Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire Pre-IPE responses mean (6SD)
Survey item
MD
PT
Post-IPE responses mean (6SD) MD
PT
1.
Learning with other students will help me become a more effective member of a health care team
4.17 (60.95)
4.39 (60.61)
4.17 (60.7)
4.22 (60.43)
2.
Patients would ultimately benefit if health-care students worked together to solve patient problems
4.46 (60.66)
4.44 (60.70)
4.50 (60.88)
4.67 (60.49)
3.
Shared learning with other health-care students will increase my ability to understand clinical problems
4.26 (60.82)
4.22 (60.65)
4.11 (60.85)
4.33 (60.59)
4.
Learning with health-care students before qualification would improve relationships after qualification
4.11 (60.96)
4.39 (60.61)
4.14 (60.93)
4.06 (60.80)
5.
Communication skills should be learned with other health-care students
4.4 (60.74)
4.22 (60.55)
4.42 (60.84)
4.22 (60.65)
6.
Shared learning will help me to think positively about other professionals
4.11 (60.90)
4.17 (60.62)
4.11 (60.85)
4.11 (60.83)
7.
For small group learning to work, students need to trust and respect each other
4.54 (60.56)
4.72 (60.46)
4.47 (60.77)
4.44 (60.51)
8.
Team-working skills are essential for all health care students to learn
4.46 (60.85)
4.5 (60.99)
4.44 (60.84)
4.39 (60.61)
9.
Shared learning will help me to understand my own limitations
4.23 (60.81)
4.11 (60.47)
4.08 (60.94)
4.22 (60.55)
10. I don’t want to waste my time learning with other health-care students
1.97 (60.89)
1.78 (60.55)
1.86 (60.99)
1.78 (60.55)
11. It is not necessary for undergraduate health-care students to learn together
1.97 (60.86)
2.00 (60.97)
2.11 (60.98)
2.06 (60.54)
12. Clinical problem-solving skills can only be learned with students from my own department
1.77 (60.81)
1.44 (60.51)
1.81 (60.82)
1.67 (60.97)
13. Shared learning with other health-care students will help me to communicate better with patients and other professionals
4.29 (60.71)
4.44 (60.51)
4.11 (60.78)
3.83 (60.71)
14. I would welcome the opportunity to work on small-group projects with 3.83 (60.95) other health-care students
3.78 (60.73)
3.83 (60.97)
3.94 (60.73)
15. Shared learning will help to clarify the nature of patient problems
3.94 (60.84)
3.89 (60.90)
3.75 (60.97)
4.22 (60.43)
16. Shared learning before qualification will help me become a better team worker
4.17 (60.79)
4.28 (60.57)
4.00 (60.86)
4.00 (60.59)
17. The function of nurses and therapists is mainly to provide support for doctors
2.17 (60.98)a 1.44 (60.51)a 2.39 (60.87)b 1.50 (60.51)b
18. I am not sure what my professional role will be
3.03 (61.04)b 1.67 (60.59)b 2.64 (60.93)a 1.94 (60.73)a
19. I have to acquire much more knowledge and skills than other healthcare students
3.29 (60.89)b 2.39 (60.50)b 3.44 (61.00)b 2.33 (60.59)b
a
P < 0.05; bP < 0.001; RIPLS subscale breakdown: 1. Teamwork and Collaboration (Items 1-9); 2. Negative Professional Identity (Items 10-12); 3. Positive Professional Identity (Items 13-16); 4. Roles and Responsibility (Items 17-19); Five-point Likert scale: 1 5 strongly disagree and 5 5 strongly agree.
professional maturity that enables them to project benefits of their early learning experiences in the long-term setting. On the other hand, one cannot completely overlook the fact that true change in mindset and perception among professions
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that have for so long operated independently takes time in establishing a culture of team-based practice. Indeed, additional IPE experiences throughout training programs may lead to reduced anxiety in future professional collaboration.
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In the current healthcare environment, interprofessional collaboration is both expected and valued. Teaching interprofessional collaboration early on in the medical curriculum allows students to develop teamwork and collaboration skills required to provide high quality patient care. Studies have reinforced IPE as an important driver in leading to positive outcomes in patient care and reduced clinical error rates (Reeves et al., 2008; Herrmann et al., 2015). The ability to work as part of a team with other healthcare professionals is an expected competency of medical training programs with an increased focus on team-based practice and IPE (IPEC Expert Panel, 2011; Schmitt et al., 2011; Reeves, 2012; Clark, 2013). Support from faculty is key to achieving IPE success (Gilbert, 2005; Hall, 2005), but learner openness to IPE is also important for interprofessional initiatives to succeed (Hammick et al., 2007). Initial student responses to the RIPLS tool demonstrated that first year PT and MD students clearly desired IPE experiences and were open to working with students in other training programs. Exposure to IPE early in training prepares learners for integration of interprofessional collaboration later on in their careers (Gilbert, 2005). Gross anatomy is a course common to many healthcare professions and is offered early in training when students have similar knowledge bases and less defined professional identities. This ensures that all parties involved have something to contribute and to gain by working together. The social activity preceding this IPE curriculum allowed students to meet in an informal setting and learn about each other’s personal and professional interests prior to beginning the more formal IPE curriculum. To ensure continuity of the learning experience interprofessional student groups were maintained for the full duration of the course. Upon the one-year follow-up, many students considered the meet-and-greet to be a curricular highlight. In the dissection laboratory, students developed teaching skills through peer-teaching (Salom€aki et al., 2014; Shields et al., 2015). Along with offering the opportunity to revisit material, these sessions also allowed students from the MD and PT programs to better understand the emphasis and level of training of the other professional group and appreciate differences between the two disciplines while working toward a common goal. The interprofessional problem-solving sessions encouraged application of anatomic concepts in clinical scenarios. Successful teams integrated both PT and MD perspectives when diagnosing and treating patients. This further allowed students to learn about the training perspective of each program and consider how they might work together in their future careers (Seif et al., 2014, Shields et al., 2015). While many studies have investigated the short-term impact of IPE curricula on student learning and readiness for interprofessional learning, there is a great need for longterm follow-up regarding the impact of IPE in undergraduate medical education (Olson and Bialocerkowski, 2014) Obtaining one-year post-curricular student feedback provides novel understanding of long-term retention of IPE lessons. Short-term follow-up with the RIPLS tool showed little change in either group of students. However, results of the qualitative follow-up survey one year after the curriculum suggest a long-lasting impact of early IPE on students in undergraduate healthcare programs. Themes that emerged from thematic survey analysis included: appreciation of the social interactions, improved understanding of professional 322
training in the opposite program and a desire for more time working together. There were also many thoughtful suggestions for curriculum improvement, suggesting a desire among the students for quality IPE interactions. Overall, students were positive about the experience and suggestions for improvement included more regular interactions, increased structure to the curriculum and additional clinical applications. These recommendations are consistent with previous suggestions for improvement in IPE curriculums (Clark, 2013; Olson and Bialocerkowski, 2014; Herrmann et al., 2015).
Limitations Although the RIPLS questionnaire has been used by many to evaluate IPE programs in various settings, there have been calls for evaluation tools that better assess the competencies that IPE strives to instill (Reeves, 2012). Despite positive experiences with this IPE curriculum, there was little change in the responses on the RIPLS questionnaire after program completion. This could be due to the small sample size and high readiness for interprofessional learning on initial surveys. There was a difference between PT and MD students in the “Roles and Responsibilities” subscale that remained consistent after the course. Perhaps the difference between the two groups reflects a difference between MD and PT students in clarity of future roles and career goals. Of note, the validity of this particular subscale of the RIPLS tool has been questioned for undergraduate students early in their training (McFadyen et al., 2006). Another limitation of this study is related to brief exposure including only a few sessions of formal IPE within the respective MD and PT anatomy courses. It is not known what student perceptions would be with a more robust experience or multiple experiences throughout training. Lastly, the return rate of surveys could have a bias on study results.
CONCLUSION An IPE curriculum for first year MD and PT students within existing gross anatomy curricula that includes a social event, peer-teaching, near-peer teaching, use of innovative learning technology and interprofessional problem-solving sessions can have both an immediate and lasting effect on student perceptions. Results from this study suggest that healthcare students are ready for IPE experiences at the beginning of their training sessions. IPE within gross anatomy encourages interprofessional collaboration and reinforces concepts that students learn in the single disciplinary classroom. It also teaches valuable non-technical skills such as teamwork, communication and peer-teaching, which are essential competencies for health care professionals. The impact of IPE extends beyond the anatomy classroom, students expressed a long-term retention of appreciation for and understanding of each other’s professions. They also expressed a desire for increased time to participate in more IPE-based activities across the curriculum. Future research is needed to describe the structure and impact of IPE programs across the various healthcare disciplines. Future studies could utilize alternative evaluations to broaden the scope of IPE attitudes (Arthur et al., 2012; Reeves, 2012). Furthermore, the IPE curriculum could be expanded to include collaboration between MD and PT students as they progress in their training and acquire more clinical knowledge.
Sytsma et al.
NOTES ON CONTRIBUTORS TERIN T. SYTSMA, B.A., is a fourth-year medical student at Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She was a teaching assistant in the 2013 Gross Anatomy course and worked on design team for developing interprofessional learning activities for first-year medical and physical therapy students. She will start her residency in Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minnesota this summer. ELIZABETH P. HALLER, B.A., is a fourth-year medical student at Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She was a teaching assistant in the 2013 Gross Anatomy course and worked on design team for developing interprofessional learning activities for first-year medical and physical therapy students. She will start her residency in Internal Medicine at the University of South Dakota, Sanford School of Medicine in Sioux Falls, South Dakota this summer. JAMES W. YOUDAS, P.T., M.S., is an associate professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is the coordinator and instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. DAVID A. KRAUSE, P.T., M.B.A., D.Sc.P.T., O.C.S., is an associate professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is an instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. NATHAN J. HELLYER, P.T., Ph.D., is an assistant professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is an instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. WOJCIECH PAWLINA, M.D., is a professor of anatomy and medical education and Chair of the Department of Anatomy at Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. He teaches anatomy and histology to first-year medical students and serves as Director of the Procedural Skills Laboratory. His research interest is in medical education. NIRUSHA LACHMAN, Ph.D., is an associate professor in the Department of Anatomy at Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She teaches anatomy and histology to first-year medical students, residents, graduate students and allied health students. Her research interest is in translational anatomical research and medical education. LITERATURE CITED Arthur N, Deutschlander S, Law R, Lait J, McCarthy P, Pallaveshi L, Roots R, Suter E, Weaver L. 2012. An Inventory of Quantitative Tools Measuring Interprofessional Education and Collaborative Practice Outcomes: A Report by the Canadian Interprofessional Health Collaborative (CIHC). 1st Ed. Vancouver, BC, Canada: University of British Columbia, Canadian Interprofessional Health Collaborative. 68 p. Bender JS, Nicolescu TO, Hollingsworth SB, Murer K, Wallace KR, Ertl WJ. 2015. Improving operating room efficiency via an interprofessional approach. Am J Surg 209:447–450. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. 2011. Interprofessional collaboration: Three best practice models of interprofessional education. Med Educ Online 16:2011. Braun V, Clarke V. 2006. Using thematic analysis in psychology. Qual Res Psych 3:77–101. Braun V, Clarke V. 2014. What can "thematic analysis" offer health and wellbeing researchers? Int J Qual Stud Health Well-Being 9:26152 CAIPE. 2002. Centre for the Advancement of Interprofessional Education. Defining IPE. Fareham, UK: Centre for the Advancement of Interprofessional Education. URL: http://caipe.org.uk/about-us/defining-ipe/ [accessed 11 February 2015]. Clark PG. 2013. Toward a transtheoretical model of interprofessional education: Stages, processes and forces supporting institutional change. J Interprof Care 27:43–49.
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Fernandes AR, Palombella A, Salfi J, Wainman B. 2015. Dissecting through barriers: A mixed-methods study on the effect of interprofessional education in a dissection course with health care professional students. Anat Sci Educ 8: 305–316. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376:1923–1958. Gilbert JH. 2005. Interprofessional learning and higher education structural barriers. J Interprof Care 19:S87–S106. Hall P. 2005. Interprofessional teamwork: Professional cultures as barriers. J Interprof Care 19:S188–S196. Hamilton SS, Yuan BJ, Lachman N, Hellyer NJ, Krause DA, Hollman JH, Youdas JW, Pawlina W. 2008. Interprofessional education in gross anatomy: Experience with first-year medical and physical therapy students at Mayo Clinic. Anat Sci Educ 1:258–263. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. 2007. A best evidence systematic review of interprofessional education: BEME guide no. 9. Med Teach 29: 735–751. Herrmann G, Woermann U, Schlegel C. 2015. Interprofessional education in anatomy: Learning together in medical and nursing training. Anat Sci Educ 8: 324–330. Hofer RE, Nikolaus OB, Pawlina W. 2011. Using checklists in a gross anatomy laboratory improves learning outcomes and dissection quality. Anat Sci Educ 4:249–255. IPEC Expert Panel. 2011. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 1st Ed. Washington, DC: Interprofessional Education Collaborative. 47 p. URL: http:// www.aacn.nche.edu/education-resources/ipecreport.pdf [accessed 12 February 2015]. Kirch DG, Ast C. 2015. Interprofessionalism: Educating to meet patient needs. Anat Sci Educ 8:296–298. Krause DA, Hollman JH, Pawlina W, Newcomer KL. 2014. Interprofessional education: Collaboration or competition? A tale of two experiences. Curr Sports Med Rep 13:291–292. LCME. 2014. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Standards and Elements Effective July 1, 2015. 1st Ed. Washington DC: Liaison Committee on Medical Education V (LCME ). 36 p. Lerner S, Magrane D, Friedman E. 2009. Teaching teamwork in medical education. Mt Sinai J Med 76:318–329. McFadyen AK, Webster VS, Maclaren WM. 2006. The test-retest reliability of a revised version of the readiness for interprofessional learning scale (RIPLS). J Interprof Care 20:633–639. McKinlay E, Pullon S. 2014. Having interprofessional education during the undergraduate years is essential for building teamwork skills in general practice: Yes. J Prim Health Care 6:331–333. McNair RP. 2005. The case for educating health care students in professionalism as the core content of interprofessional education. Med Educ 39:456–464. Olson R, Bialocerkowski A. 2014. Interprofessional education in allied health: A systematic review. Med Educ 48:236–246. Parsell G, Bligh J. 1999. The development of a questionnaire to assess the readiness of health care students for interprofessional learning (RIPLS). Med Educ 33:95–100. Reeves S. 2012. The rise and rise of interprofessional competence. J Interprof Care 26:253–255. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. 2008. Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2008:CD002213. Salom€ aki T, Laakkonen J, Ruohoniemi M. 2014. Students as teachers in an anatomy dissection course. J Vet Med Educ 41:60–67. Schmitt M, Blue A, Aschenbrener CA, Viggiano TR. 2011. Core competencies for interprofessional collaborative practice: Reforming health care by transforming health professionals’ education. Acad Med 86:1351. Seif G, Coker-Bolt P, Kraft S, Gonsalves W, Simpson K, Johnson E. 2014. The development of clinical reasoning and interprofessional behaviors: Servicelearning at a student-run free clinic. J Interprof Care 28:559–564. Shields RK, Pizzimenti MA, Dudley-Javoroski S, Schwinn DA. 2015. Fostering interprofessional teamwork in an academic medical center: Near-peer education for students during gross medical anatomy. Anat Sci Educ 8:331–337. Thistlethwaite J. 2012. Interprofessional education: A review of context, learning and the research agenda. Med Educ 46:58–70. Thistlethwaite JE. 2015. Interprofessional education and the basic sciences: Rationale and outcomes. Anat Sci Educ 8:299–304. Thistlethwaite JE, Moran M. 2010. Learning outcomes for interprofessional education (IPE): Literature review and synthesis. J Interprof Care 24:503–513. Zorek J, Raehl C. 2013. Interprofessional education accreditation standards in the USA: A comparative analysis. J Interprof Care 27:123–130. Zwarenstein M, Reeves S, Perrier L. 2005. Effectiveness of pre-licensure interprofessional education and post-licensure collaborative interventions. J Interprof Care 19:S148–S165. R
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Long-Term Effect of a Short Interprofessional Education Interaction Between Medical and Physical Therapy Students Terin T. Sytsma,1 Elizabeth P. Haller,1 James W. Youdas,2 David A. Krause,2 Nathan J. Hellyer,2 Wojciech Pawlina,3 Nirusha Lachman3* 1 Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota 2 Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 3 Department of Anatomy, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
Medicine is increasingly focused on team-based practice as interprofessional cooperation leads to better patient care. Thus, it is necessary to teach teamwork and collaboration with other health care professionals in undergraduate medical education to ensure that trainees entering the workforce are prepared to work in teams. Gross anatomy provides an opportunity to expose students to interprofessional education (IPE) early in their training. The purpose of this study is to describe an IPE experience and report if the experience has lasting influence on the participating students. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire was administered to first year medical (MD) and physical therapy (PT) students at Mayo Medical School and Mayo School of Health Sciences. Results demonstrated an openness on the part of the students to IPE. Interprofessional education experiences were incorporated into gross anatomy courses in both medical and PT curricula. The IPE experiences included a social event, peerteaching, and collaborative clinical problem-solving sessions. These sessions enhanced gross anatomy education by reinforcing previous material and providing the opportunity to work on clinical cases from the perspective of two healthcare disciplines. After course completion, students again completed the RIPLS. Finally, one year after course completion, students were asked to provide feedback on their experience. The post-curricular RIPLS, similar to the pre-curricular RIPLS, illustrated openness to IPE from both MD and PT students. There were however, significant differences in MD and PT perceptions of roles and responsibilities. One-year follow-up indicated long-term retention of lessons learned during C 2015 American Association of Anatomists. IPE. Anat Sci Educ 8: 317–323. V Key words: gross anatomy education; medical education; physical therapy education; interprofessional education; IPE; interprofessional learning; interprofessional curriculum
INTRODUCTION Interprofessional collaboration in healthcare is crucial for delivery of high quality patient care. Along with mastering specific discipline-based requirements, providers from various *Correspondence to: Dr. Nirusha Lachman, Department of Anatomy, Mayo Clinic College of Medicine, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905, USA. E-mail: [email protected] Received 28 April 2015; Revised 4 May 2015; Accepted 5 May 2015. Published online 3 June 2015 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1546 C 2015 American Association of Anatomists V
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fields must understand each other’s professional roles and communicate effectively within the healthcare team. Interprofessional teamwork in healthcare has been said to foster better utilization of human resources, enhance workflow, promote economic sustainability and increase patient satisfaction (Frenk et al., 2010; McKinlay and Pullon, 2014). While it has also been underscored that working in teams is neither easy nor intuitive, studies have demonstrated that team skills can be learned in order to improve interactions between individual members of the team (Lerner et al., 2009; McKinlay and Pullon, 2014). By definition, interprofessional education (IPE) is said to occur “when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE, 2002). The Liaison
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Committee on Medical Education (LCMEV) recently published new standards and elements for accreditation of medical education programs (LCME, 2014), incorporating the requirement of interprofessional collaborative skills to ensure that a medical school prepares medical students to function collaboratively on health care teams (Standard 7; Element 7.9). While interprofessional collaboration continues to be an expected competency, many undergraduate healthcare educational programs lack adequate IPE experiences (Schmitt et al., 2011; Zorek and Raehl, 2013). Both standard medical school and allied health curricula however, may provide opportunities within their individual programs to initiate and foster these collaborative relationships early in training for health care professionals. In the clinical setting, IPE is often initiated successfully in the workplace for professionals who are already in practice. Such programs have been shown to improve collaborative team behavior such as increased operating room efficiency (Bender et al., 2015). Patient satisfaction and reduced clinical errors have also been reported, but greater understanding is needed regarding which components of IPE programs are responsible for such success (Reeves et al., 2008; McKinlay and Pullon, 2014). Barriers to instituting IPE in undergraduate training include difficulty in coordinating coursework, lack of an established framework and resistance to IPE by students and/or faculty (Gilbert, 2005; Hammick et al., 2007; IPEC Expert Panel, 2011). Medical education is traditionally centered on distinct professional roles, creating boundaries rather than collaboration in the professional development of health care providers (Hall, 2005; McNair, 2005). The benefit of conducting IPE later in training lies in its ability to allow students to become more confident in their specific professional roles and responsibilities. However, exposure to IPE early in training enables students to become familiar with and comfortable working within an interprofessional environment, better preparing them for future collaborations (Gilbert, 2005). McKinlay and Pullon (2014) argue that learning interprofessional teamwork skills in the workplace when clinical responsibility and patient care stakes are high is far from ideal. Learning of these skills is therefore better served within the medical school and allied health curricula as they provide a favorable platform for the initiation of interprofessional learning within the framework of basic science courses (Kirch and Ast, 2015). Previous models for IPE programs in undergraduate healthcare training have used a variety of teaching techniques, that include interdisciplinary didactic education sessions, service learning, clinical collaboration, social interactions, dissection collaboration, and simulation experiences (Hammick et al., 2007; Hamilton et al., 2008; Bridges et al., 2011; Krause et al., 2014; Fernandes et al., 2015; Herrmann et al., 2015). However, more data is needed in outlining models for pre-licensure IPE programs and evaluating their effectiveness, especially in the long term (Zwarenstein et al., 2005; Reeves, 2012; Thistlethwaite, 2015). Gross anatomy courses based on team learning and laboratory activities provide a suitable and useful platform for establishing IPE within the medical education framework (Kirch and Ast, 2015). Anatomy as a core subject forms the basis for almost all health care courses and is a topic that can be easily related between different professional tracks. The majority of healthcare professionals, including physicians, nurses, physical therapists, occupational therapists, and physician assistants study anatomy within their training, cre318
ating greater opportunity for students to learn together within a common set of objectives. When looking at the physical therapy (PT) and medical (MD) school anatomy curricula, the PT curriculum focus on musculoskeletal anatomy and the additional thoraco-abdominal organ based topics in the medical school curriculum allows for common learning activities that strengthen each group’s knowledge and enhances learning that may not be as easily achieved through uniprofessional learning (Thistlethwaite, 2012, 2015). In 2007, IPE activities were incorporated into the gross anatomy course for MD and PT students and additional IPE opportunities continue to be incorporated in both curricula (Hamilton et al., 2008; Krause et al., 2014). The two classes share a dissection laboratory and overlap time spent in class and in laboratory. The PT gross anatomy course occurs within the first semester of the students’ first year along with other classes, while the MD gross anatomy course is a seven week didactic block (120 hours) taken early in the first year (Hamilton et al., 2008; Krause et al., 2014). While prior studies on the effects of IPE have focused on attitudes preceding and immediately following IPE, the longer term impact or influence of these educational experiences has not been well documented (Thistlethwaite and Moran, 2010; Olson and Bialocerkowski, 2014; Thistlethwaite, 2015). The purpose of this study was to determine, using a survey tool, whether an IPE experience in a gross anatomy course has a lasting impact on MD and PT students.
MATERIAL AND METHODS The research plan and study methods were deemed exempt by the Institutional Review Board at Mayo Clinic (protocol ID:13-005227). One tool that has been developed by Parsell and Bligh (1999) and widely used to assess healthcare students’ attitudes and perceptions toward IPE is the “Readiness for Interprofessional Learning Scale” (RIPLS). This validated questionnaire assesses agreement with various statements about IPE on a five-point Likert scale and evaluates principle factors that students must appreciate for IPE curriculum success (Parsell and Bligh, 1999; McFadyen et al., 2006). The RIPLS can be divided into four subscales: Teamwork and Collaboration (items 1–9), Negative Professional Identity (items 10–12), Positive Professional Identity (items 13–16) and Roles and Responsibility (items 17–19) (McFadyen et al., 2006). Prior to initiating IPE interactions, the RIPLS questionnaire (Parsell and Bligh, 1999) was administered to first-year MD and PT students to evaluate attitudes toward IPE. The anonymous RIPLS questionnaire was optional and had no impact on the students’ final grade. Results from the questionnaire were analyzed with respect to composite responses of all students and the responses of the MD and PT groups separately. The responses were also evaluated with respect to the four subscales of the RIPLS questionnaire. Results were reported utilizing means and standard deviations (6SD) for each RIPLS item and subscale. A social lunch event was held prior to the start of the IPE curriculum to introduce students to their interprofessional colleagues. The students were organized into interdisciplinary teams that would serve as their working groups for the duration of the course. Five teams consisted of two four-member MD dissection groups and one four-member PT group (total students per team n 5 12), and two interdisciplinary teams Sytsma et al.
consisted of one MD and one PT dissection group (total students per team n 5 8). At the initial lunch event, students were given icebreaker questions and encouraged to discuss their interests and respective education programs (Krause et al., 2014). By initiating interprofessional relationships on a personal level, students were able to learn about each other’s training in an informal setting. The social event established a foundation of collaboration and teamwork that could be further developed during the course.
The Medical and Physical Therapy Interprofessional Curriculum The IPE curriculum was designed to incorporate elements of peer-teaching, near-peer teaching and teaching and learning innovations through use of new technology. Activities were primarily laboratory based since dissection and hands-on learning in the practical sessions best fostered interprofessional interaction. Interactions were designed to encourage teamwork and promote understanding of anatomical principles by capitalizing on the expertise of each program. The curriculum included two laboratory sessions where students from one program were responsible for teaching a dissection they had already completed to the other half of their interprofessional team. Since the courses were designed on different schedules, each group of students had a point in their curriculum where they had learned an area before the other students had been introduced to it, either in the classroom or dissection laboratory. During the first session, PT students taught MD students upper limb anatomy, whereas in the second session, MD students took the lead in teaching PT students heart and lung anatomy. Dissection checklists (Hofer et al., 2011) of pertinent structures were provided prior to the teaching session to give the students a chance to review anatomical structures that they would be responsible for identifying. In conjunction with checklists, both MD and PT students used their respective core concept objectives to provide a more clinically relevant understanding of the learning goals for anatomy. During the sessions, both programs’ faculty and teaching assistants encouraged collaboration by demonstrating team teaching approaches through shared expertise between groups. By removing physical boundaries between the dissection stations, students were encouraged to visit each other’s dissection tables during commonly scheduled times and appreciate the differences in focus of core anatomical concepts between the programs. In addition to dissection, the introduction and use of hand held ultrasound devices in the medical curriculum as a tool to appreciate living anatomy provided unique learning experiences for PT students. The use of cadaver CT imaging in the anatomy curriculum was also a novel tool for PT students to explore. Through these learning modalities, MD students were able to reinforce their own understanding and improve skills simply by teaching technique and interpretation of anatomical imaging to PT students. A third component of the IPE curriculum included clinical problem-solving sessions. The objective of these team-based sessions was to promote interdisciplinary problem solving in order to understand and analyze clinical cases by simulating the future collaborative approach in clinical practice. In a classroom setting, students worked in their IPE teams to discuss clinical scenarios requiring application of their anatomical knowlAnatomical Sciences Education
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edge. With faculty guidance, the cases were constructed by teaching assistants to correspond with learning objectives addressed in the laboratory and to highlight the knowledge base of each program. Students were required to utilize knowledge of anatomy to formulate a differential diagnoses, discuss anatomy-based questions within their IPE teams, and present their conclusions as a team. At the conclusion of the IPE curriculum the RIPLS questionnaire was re-administered to assess for any changes in student responses. Responses were evaluated in the same way as for the pre-curriculum questionnaire. Statistical analysis of pre- and post-curriculum RIPLS questionnaire responses were analyzed and evaluated using the Wilcoxon Signed-Rank Test provided in the Statistical Package for Social Scientists (SPSS), version 22 for Windows (IBM Corp., Armonk, NY). Both MD and PT students’ responses were analyzed and evaluated together. Finally, one year after completion of the course, an anonymous online survey was conducted to assess students’ perspectives on the IPE curriculum. The survey consisted of four open ended questions: (1) What did you like about the anatomy interprofessional education curriculum?; (2) What didn’t you like about the anatomy interprofessional curriculum?; (3) What would you change about the anatomy interprofessional curriculum?; (4) Are you a medical student or physical therapy student? Results of the one-year follow-up survey were analyzed qualitatively, using thematic analysis as a base for coding and identifying recurrent themes from the students’ responses (Braun and Clarke, 2006, 2014).
RESULTS Quantitative Analysis Thirty-five MD students (72.91%) and 18 PT students (64.28%) responded to the RIPLS questionnaire prior to the start of the IPE curriculum (Table 1). Overall, students showed positive attitudes towards IPE. They agreed that “For small group learning to work, students need to trust and respect each other” (mean MD 5 4.54, SD 6 0.56 and mean PT 5 4.72, SD 6 0.60). Students disagreed that learning with other healthcare students “is a waste of time or unnecessary” (mean MD 5 1.97, SD 6 0.89 and mean PT 5 1.78, SD 6 0.55). Subscale analysis also demonstrated results that were favorable towards readiness for IPE. Average response for the Teamwork and Collaboration subscale were the highest (mean MD 5 4.30, SD 6 0.81 and mean PT 5 4.35, SD 60.63) and the lowest in Negative Professional Identity subscale (mean MD 5 1.90, SD 6 0.85 and mean PT 5 1.74, SD 60.68), which negatively correlates with readiness for IPE (Figure 1). There was a significant difference between MD and PT students in the Roles and Responsibility subscale (items 17-19) for both pre- and post-IPE curriculum questionnaire results (Table 1). Thirty-six MD students (75%) and 18 PT students (64.28%) completed the follow-up RIPLS questionnaire. No significant change was found between student readiness for IPE before and after the IPE curriculum. There was also no significant change in subscale scores for either of the groups (Figure 1). However, differences were observed between MD and PT students in the “Roles and Responsibility” subscale with average responses of 2.82 (SD 6 0.93) and 1.92 (SD 6 0.61) respectively (P < 0.001). Two other trends emerged in post-IPE curriculum analysis: MD students 319
Figure 1. The Readiness for Interprofessional Learning Scale (RIPLS) questionnaire subscale analysis of responses from medical (MD) and physical therapy (PT) students before (Pre-IPE) and after (Post-IPE) interprofessional education experience in the gross anatomy course.
developed more clarity in their professional role after the experience, and PT students were less convinced that shared learning experiences with other healthcare students would help them communicate better with patients and other professionals (Table 1).
Qualitative Analysis A total of 41 students responded to the free response survey one year following completion of the IPE curriculum. Twenty eight MD students (59.6%) and 13 PT students (46.4%) submitted feedback on the curriculum. Assessment of the one-year survey responses on the impact of the IPE curriculum resulted in two main themes regarding student experiences and reactions to working with students from another healthcare profession. The first theme highlighted the “appreciation for the opportunity to meet and work with students from another program”. Many students responded to the first question, “what did you like about the anatomy interprofessional education curriculum?” with comments about social aspects of the curriculum and the value working together on the clinical problem-solving cases. One PT student reflected “I think the most learning occurred out of the case study days and seeing how the med students worked through them. It was fun to see where the expertise areas were and how we were able to work together as a team.” The second main theme from the follow-up survey highlighted “increased understanding of the other group’s professional roles.” Many students remarked that they had a better understanding of the educational content of other program after the peer-teaching sessions in dissection lab and problemsolving sessions in the classroom. For example, one PT student remarked, “We were able to learn material that the med students were more knowledgeable about such as internal organs. In return we were able to share and teach them about parts of the musculoskeletal system that they had spent less time on.” An MD student commented that the problemsolving sessions “made us think about how other members of the healthcare team might approach a condition.” 320
There were also many suggestions for improvement in the IPE curriculum. When asked what they would change about the program, the desire for more time working together was a common suggestion. There were also requests for more structure to the curriculum. Some students recommended completing the clinical cases in small groups rather than having all interdisciplinary teams in the same room. An MD student suggested having the PT students teach “basic physical examination skills. . . especially since the cadavers are available to us, so we can see exactly what each maneuver is testing.” Faculty of both programs noted that there was excellent participation in the IPE curriculum amongst most PT and MD students. The students actively engaged in the different components of the program, and faculty commented that the IPE curriculum supplemented the syllabus of both programs well. Students continued to interact outside of the designated IPE sessions. After the peer-teaching sessions, they continued to share interesting dissection findings with members of the other training program and were open to asking questions of each other and faculty of both programs.
DISCUSSION This study set out to determine whether the implementation of a formal IPE curriculum in the MD and PT gross anatomy course would have any longer term effect on the perceptions of IPE and professional collaboration among students enrolled in these programs. Results suggest that despite a brief experience in an anatomy course, all students agreed that formalizing IPE activities in a commonly required basic science course can result in lasting positive attitudes towards IPE and a perceived value in collaborative learning. Themes from the one-year survey suggest an appreciation for learning with other health care professionals and a greater understanding of the role of other professionals. It was interesting, but not inconceivable to note that a percentage of PT students were less convinced than their MD counterparts that learning with others would help them communicate better with other professionals. It is not unusual for students in the early stages of their careers, to lack the Sytsma et al.
Table 1. Pre- and Post-IPE Curriculum Mean Responses to the Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire Pre-IPE responses mean (6SD)
Survey item
MD
PT
Post-IPE responses mean (6SD) MD
PT
1.
Learning with other students will help me become a more effective member of a health care team
4.17 (60.95)
4.39 (60.61)
4.17 (60.7)
4.22 (60.43)
2.
Patients would ultimately benefit if health-care students worked together to solve patient problems
4.46 (60.66)
4.44 (60.70)
4.50 (60.88)
4.67 (60.49)
3.
Shared learning with other health-care students will increase my ability to understand clinical problems
4.26 (60.82)
4.22 (60.65)
4.11 (60.85)
4.33 (60.59)
4.
Learning with health-care students before qualification would improve relationships after qualification
4.11 (60.96)
4.39 (60.61)
4.14 (60.93)
4.06 (60.80)
5.
Communication skills should be learned with other health-care students
4.4 (60.74)
4.22 (60.55)
4.42 (60.84)
4.22 (60.65)
6.
Shared learning will help me to think positively about other professionals
4.11 (60.90)
4.17 (60.62)
4.11 (60.85)
4.11 (60.83)
7.
For small group learning to work, students need to trust and respect each other
4.54 (60.56)
4.72 (60.46)
4.47 (60.77)
4.44 (60.51)
8.
Team-working skills are essential for all health care students to learn
4.46 (60.85)
4.5 (60.99)
4.44 (60.84)
4.39 (60.61)
9.
Shared learning will help me to understand my own limitations
4.23 (60.81)
4.11 (60.47)
4.08 (60.94)
4.22 (60.55)
10. I don’t want to waste my time learning with other health-care students
1.97 (60.89)
1.78 (60.55)
1.86 (60.99)
1.78 (60.55)
11. It is not necessary for undergraduate health-care students to learn together
1.97 (60.86)
2.00 (60.97)
2.11 (60.98)
2.06 (60.54)
12. Clinical problem-solving skills can only be learned with students from my own department
1.77 (60.81)
1.44 (60.51)
1.81 (60.82)
1.67 (60.97)
13. Shared learning with other health-care students will help me to communicate better with patients and other professionals
4.29 (60.71)
4.44 (60.51)
4.11 (60.78)
3.83 (60.71)
14. I would welcome the opportunity to work on small-group projects with 3.83 (60.95) other health-care students
3.78 (60.73)
3.83 (60.97)
3.94 (60.73)
15. Shared learning will help to clarify the nature of patient problems
3.94 (60.84)
3.89 (60.90)
3.75 (60.97)
4.22 (60.43)
16. Shared learning before qualification will help me become a better team worker
4.17 (60.79)
4.28 (60.57)
4.00 (60.86)
4.00 (60.59)
17. The function of nurses and therapists is mainly to provide support for doctors
2.17 (60.98)a 1.44 (60.51)a 2.39 (60.87)b 1.50 (60.51)b
18. I am not sure what my professional role will be
3.03 (61.04)b 1.67 (60.59)b 2.64 (60.93)a 1.94 (60.73)a
19. I have to acquire much more knowledge and skills than other healthcare students
3.29 (60.89)b 2.39 (60.50)b 3.44 (61.00)b 2.33 (60.59)b
a
P < 0.05; bP < 0.001; RIPLS subscale breakdown: 1. Teamwork and Collaboration (Items 1-9); 2. Negative Professional Identity (Items 10-12); 3. Positive Professional Identity (Items 13-16); 4. Roles and Responsibility (Items 17-19); Five-point Likert scale: 1 5 strongly disagree and 5 5 strongly agree.
professional maturity that enables them to project benefits of their early learning experiences in the long-term setting. On the other hand, one cannot completely overlook the fact that true change in mindset and perception among professions
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that have for so long operated independently takes time in establishing a culture of team-based practice. Indeed, additional IPE experiences throughout training programs may lead to reduced anxiety in future professional collaboration.
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In the current healthcare environment, interprofessional collaboration is both expected and valued. Teaching interprofessional collaboration early on in the medical curriculum allows students to develop teamwork and collaboration skills required to provide high quality patient care. Studies have reinforced IPE as an important driver in leading to positive outcomes in patient care and reduced clinical error rates (Reeves et al., 2008; Herrmann et al., 2015). The ability to work as part of a team with other healthcare professionals is an expected competency of medical training programs with an increased focus on team-based practice and IPE (IPEC Expert Panel, 2011; Schmitt et al., 2011; Reeves, 2012; Clark, 2013). Support from faculty is key to achieving IPE success (Gilbert, 2005; Hall, 2005), but learner openness to IPE is also important for interprofessional initiatives to succeed (Hammick et al., 2007). Initial student responses to the RIPLS tool demonstrated that first year PT and MD students clearly desired IPE experiences and were open to working with students in other training programs. Exposure to IPE early in training prepares learners for integration of interprofessional collaboration later on in their careers (Gilbert, 2005). Gross anatomy is a course common to many healthcare professions and is offered early in training when students have similar knowledge bases and less defined professional identities. This ensures that all parties involved have something to contribute and to gain by working together. The social activity preceding this IPE curriculum allowed students to meet in an informal setting and learn about each other’s personal and professional interests prior to beginning the more formal IPE curriculum. To ensure continuity of the learning experience interprofessional student groups were maintained for the full duration of the course. Upon the one-year follow-up, many students considered the meet-and-greet to be a curricular highlight. In the dissection laboratory, students developed teaching skills through peer-teaching (Salom€aki et al., 2014; Shields et al., 2015). Along with offering the opportunity to revisit material, these sessions also allowed students from the MD and PT programs to better understand the emphasis and level of training of the other professional group and appreciate differences between the two disciplines while working toward a common goal. The interprofessional problem-solving sessions encouraged application of anatomic concepts in clinical scenarios. Successful teams integrated both PT and MD perspectives when diagnosing and treating patients. This further allowed students to learn about the training perspective of each program and consider how they might work together in their future careers (Seif et al., 2014, Shields et al., 2015). While many studies have investigated the short-term impact of IPE curricula on student learning and readiness for interprofessional learning, there is a great need for longterm follow-up regarding the impact of IPE in undergraduate medical education (Olson and Bialocerkowski, 2014) Obtaining one-year post-curricular student feedback provides novel understanding of long-term retention of IPE lessons. Short-term follow-up with the RIPLS tool showed little change in either group of students. However, results of the qualitative follow-up survey one year after the curriculum suggest a long-lasting impact of early IPE on students in undergraduate healthcare programs. Themes that emerged from thematic survey analysis included: appreciation of the social interactions, improved understanding of professional 322
training in the opposite program and a desire for more time working together. There were also many thoughtful suggestions for curriculum improvement, suggesting a desire among the students for quality IPE interactions. Overall, students were positive about the experience and suggestions for improvement included more regular interactions, increased structure to the curriculum and additional clinical applications. These recommendations are consistent with previous suggestions for improvement in IPE curriculums (Clark, 2013; Olson and Bialocerkowski, 2014; Herrmann et al., 2015).
Limitations Although the RIPLS questionnaire has been used by many to evaluate IPE programs in various settings, there have been calls for evaluation tools that better assess the competencies that IPE strives to instill (Reeves, 2012). Despite positive experiences with this IPE curriculum, there was little change in the responses on the RIPLS questionnaire after program completion. This could be due to the small sample size and high readiness for interprofessional learning on initial surveys. There was a difference between PT and MD students in the “Roles and Responsibilities” subscale that remained consistent after the course. Perhaps the difference between the two groups reflects a difference between MD and PT students in clarity of future roles and career goals. Of note, the validity of this particular subscale of the RIPLS tool has been questioned for undergraduate students early in their training (McFadyen et al., 2006). Another limitation of this study is related to brief exposure including only a few sessions of formal IPE within the respective MD and PT anatomy courses. It is not known what student perceptions would be with a more robust experience or multiple experiences throughout training. Lastly, the return rate of surveys could have a bias on study results.
CONCLUSION An IPE curriculum for first year MD and PT students within existing gross anatomy curricula that includes a social event, peer-teaching, near-peer teaching, use of innovative learning technology and interprofessional problem-solving sessions can have both an immediate and lasting effect on student perceptions. Results from this study suggest that healthcare students are ready for IPE experiences at the beginning of their training sessions. IPE within gross anatomy encourages interprofessional collaboration and reinforces concepts that students learn in the single disciplinary classroom. It also teaches valuable non-technical skills such as teamwork, communication and peer-teaching, which are essential competencies for health care professionals. The impact of IPE extends beyond the anatomy classroom, students expressed a long-term retention of appreciation for and understanding of each other’s professions. They also expressed a desire for increased time to participate in more IPE-based activities across the curriculum. Future research is needed to describe the structure and impact of IPE programs across the various healthcare disciplines. Future studies could utilize alternative evaluations to broaden the scope of IPE attitudes (Arthur et al., 2012; Reeves, 2012). Furthermore, the IPE curriculum could be expanded to include collaboration between MD and PT students as they progress in their training and acquire more clinical knowledge.
Sytsma et al.
NOTES ON CONTRIBUTORS TERIN T. SYTSMA, B.A., is a fourth-year medical student at Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She was a teaching assistant in the 2013 Gross Anatomy course and worked on design team for developing interprofessional learning activities for first-year medical and physical therapy students. She will start her residency in Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minnesota this summer. ELIZABETH P. HALLER, B.A., is a fourth-year medical student at Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She was a teaching assistant in the 2013 Gross Anatomy course and worked on design team for developing interprofessional learning activities for first-year medical and physical therapy students. She will start her residency in Internal Medicine at the University of South Dakota, Sanford School of Medicine in Sioux Falls, South Dakota this summer. JAMES W. YOUDAS, P.T., M.S., is an associate professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is the coordinator and instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. DAVID A. KRAUSE, P.T., M.B.A., D.Sc.P.T., O.C.S., is an associate professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is an instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. NATHAN J. HELLYER, P.T., Ph.D., is an assistant professor in the Program in Physical Therapy at the Mayo Clinic College of Medicine, Mayo Clinic in Rochester, Minnesota. He is an instructor in the Anatomy for Physical Therapists Course for the first-year Doctor of Physical Therapy students. WOJCIECH PAWLINA, M.D., is a professor of anatomy and medical education and Chair of the Department of Anatomy at Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. He teaches anatomy and histology to first-year medical students and serves as Director of the Procedural Skills Laboratory. His research interest is in medical education. NIRUSHA LACHMAN, Ph.D., is an associate professor in the Department of Anatomy at Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota. She teaches anatomy and histology to first-year medical students, residents, graduate students and allied health students. Her research interest is in translational anatomical research and medical education. LITERATURE CITED Arthur N, Deutschlander S, Law R, Lait J, McCarthy P, Pallaveshi L, Roots R, Suter E, Weaver L. 2012. An Inventory of Quantitative Tools Measuring Interprofessional Education and Collaborative Practice Outcomes: A Report by the Canadian Interprofessional Health Collaborative (CIHC). 1st Ed. Vancouver, BC, Canada: University of British Columbia, Canadian Interprofessional Health Collaborative. 68 p. Bender JS, Nicolescu TO, Hollingsworth SB, Murer K, Wallace KR, Ertl WJ. 2015. Improving operating room efficiency via an interprofessional approach. Am J Surg 209:447–450. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. 2011. Interprofessional collaboration: Three best practice models of interprofessional education. Med Educ Online 16:2011. Braun V, Clarke V. 2006. Using thematic analysis in psychology. Qual Res Psych 3:77–101. Braun V, Clarke V. 2014. What can "thematic analysis" offer health and wellbeing researchers? Int J Qual Stud Health Well-Being 9:26152 CAIPE. 2002. Centre for the Advancement of Interprofessional Education. Defining IPE. Fareham, UK: Centre for the Advancement of Interprofessional Education. URL: http://caipe.org.uk/about-us/defining-ipe/ [accessed 11 February 2015]. Clark PG. 2013. Toward a transtheoretical model of interprofessional education: Stages, processes and forces supporting institutional change. J Interprof Care 27:43–49.
Anatomical Sciences Education
JULY/AUGUST 2015
Fernandes AR, Palombella A, Salfi J, Wainman B. 2015. Dissecting through barriers: A mixed-methods study on the effect of interprofessional education in a dissection course with health care professional students. Anat Sci Educ 8: 305–316. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376:1923–1958. Gilbert JH. 2005. Interprofessional learning and higher education structural barriers. J Interprof Care 19:S87–S106. Hall P. 2005. Interprofessional teamwork: Professional cultures as barriers. J Interprof Care 19:S188–S196. Hamilton SS, Yuan BJ, Lachman N, Hellyer NJ, Krause DA, Hollman JH, Youdas JW, Pawlina W. 2008. Interprofessional education in gross anatomy: Experience with first-year medical and physical therapy students at Mayo Clinic. Anat Sci Educ 1:258–263. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. 2007. A best evidence systematic review of interprofessional education: BEME guide no. 9. Med Teach 29: 735–751. Herrmann G, Woermann U, Schlegel C. 2015. Interprofessional education in anatomy: Learning together in medical and nursing training. Anat Sci Educ 8: 324–330. Hofer RE, Nikolaus OB, Pawlina W. 2011. Using checklists in a gross anatomy laboratory improves learning outcomes and dissection quality. Anat Sci Educ 4:249–255. IPEC Expert Panel. 2011. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 1st Ed. Washington, DC: Interprofessional Education Collaborative. 47 p. URL: http:// www.aacn.nche.edu/education-resources/ipecreport.pdf [accessed 12 February 2015]. Kirch DG, Ast C. 2015. Interprofessionalism: Educating to meet patient needs. Anat Sci Educ 8:296–298. Krause DA, Hollman JH, Pawlina W, Newcomer KL. 2014. Interprofessional education: Collaboration or competition? A tale of two experiences. Curr Sports Med Rep 13:291–292. LCME. 2014. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Standards and Elements Effective July 1, 2015. 1st Ed. Washington DC: Liaison Committee on Medical Education V (LCME ). 36 p. Lerner S, Magrane D, Friedman E. 2009. Teaching teamwork in medical education. Mt Sinai J Med 76:318–329. McFadyen AK, Webster VS, Maclaren WM. 2006. The test-retest reliability of a revised version of the readiness for interprofessional learning scale (RIPLS). J Interprof Care 20:633–639. McKinlay E, Pullon S. 2014. Having interprofessional education during the undergraduate years is essential for building teamwork skills in general practice: Yes. J Prim Health Care 6:331–333. McNair RP. 2005. The case for educating health care students in professionalism as the core content of interprofessional education. Med Educ 39:456–464. Olson R, Bialocerkowski A. 2014. Interprofessional education in allied health: A systematic review. Med Educ 48:236–246. Parsell G, Bligh J. 1999. The development of a questionnaire to assess the readiness of health care students for interprofessional learning (RIPLS). Med Educ 33:95–100. Reeves S. 2012. The rise and rise of interprofessional competence. J Interprof Care 26:253–255. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. 2008. Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2008:CD002213. Salom€ aki T, Laakkonen J, Ruohoniemi M. 2014. Students as teachers in an anatomy dissection course. J Vet Med Educ 41:60–67. Schmitt M, Blue A, Aschenbrener CA, Viggiano TR. 2011. Core competencies for interprofessional collaborative practice: Reforming health care by transforming health professionals’ education. Acad Med 86:1351. Seif G, Coker-Bolt P, Kraft S, Gonsalves W, Simpson K, Johnson E. 2014. The development of clinical reasoning and interprofessional behaviors: Servicelearning at a student-run free clinic. J Interprof Care 28:559–564. Shields RK, Pizzimenti MA, Dudley-Javoroski S, Schwinn DA. 2015. Fostering interprofessional teamwork in an academic medical center: Near-peer education for students during gross medical anatomy. Anat Sci Educ 8:331–337. Thistlethwaite J. 2012. Interprofessional education: A review of context, learning and the research agenda. Med Educ 46:58–70. Thistlethwaite JE. 2015. Interprofessional education and the basic sciences: Rationale and outcomes. Anat Sci Educ 8:299–304. Thistlethwaite JE, Moran M. 2010. Learning outcomes for interprofessional education (IPE): Literature review and synthesis. J Interprof Care 24:503–513. Zorek J, Raehl C. 2013. Interprofessional education accreditation standards in the USA: A comparative analysis. J Interprof Care 27:123–130. Zwarenstein M, Reeves S, Perrier L. 2005. Effectiveness of pre-licensure interprofessional education and post-licensure collaborative interventions. J Interprof Care 19:S148–S165. R
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