At the Intersection of Health, Health Care and Policy Cite this article as: George E. Thibault Reforming Health Professions Education Will Require Culture Change And Closer Ties Between Classroom And Practice Health Affairs, 32, no.11 (2013):1928-1932 doi: 10.1377/hlthaff.2013.0827

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Interprofessional Education By George E. Thibault 10.1377/hlthaff.2013.0827 HEALTH AFFAIRS 32, NO. 11 (2013): 1928–1932 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.

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George E. Thibault (gthibault@macyfoundation .org) is president of the Josiah Macy Jr. Foundation, in New York City.

VIEWPOINT

Reforming Health Professions Education Will Require Culture Change And Closer Ties Between Classroom And Practice The size, composition, distribution, and skills of the health care workforce will determine the success of health care reform in the United States. Whatever the size of the workforce that will be required in the future to meet society’s needs, how health professionals are educated merits additional attention. Reform of health professions education is needed in the following six critical areas: interprofessional education, new models for clinical education, new content to complement the biological sciences, new educational models based on competency, new educational technologies, and faculty development for teaching and educational innovation. Institutional and public policies need to support these innovations and the closer integration of education reform and health care delivery reform. ABSTRACT

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he fact that Health Affairs is devoting an issue to the health care workforce is a testimonial to the growing realization that the success of health care reform in this country is inextricably linked to the size, composition, distribution, and skills of that workforce. Workforce issues were not a central part of the health care reform discussions initially, perhaps because it was thought that these issues would be taken care of by the marketplace or the professions, that they were too complex, or that they did not really amount to a serious problem. However, many policy makers and health care leaders are now coming to the conclusion that there is a problem.1 Although workforce issues are complex, they are solvable. Finding the solutions is a responsibility shared by the public, the professions (including educators), and those who pay for health care. Discussions about the workforce often focus on the number of each kind of health profession1928

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al that will be needed and the policy implications of those numbers. These are important debates, and those engaged in them should exercise a certain amount of humility. Predictions about the numbers of providers required to meet societal needs have frequently been inaccurate.2 This is not surprising, since such predictions are based on plotting historical utilization and practice patterns onto expected population and economic growth. Workforce predictions have not been able to anticipate important changes in practice patterns, new roles for health professionals, or altered utilization patterns resulting from new information or incentives. The United States is in the midst of the most dramatic changes in decades in all three of these areas, and thus it is advisable to be cautious about the accuracy of workforce projections. In addition, it is important to strive to get better workforce data (regionally, nationally, and across all of the professions) and to create better and more accurate predictive models. The

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Affordable Care Act established a National Health Care Workforce Commission and charged it with identifying improved workforce predictive models, but the commission has not yet been funded. At the same time, there is a need to focus more energy on the content and pedagogy of health professions education. Regardless of the number of health professionals required in the future, all health professionals must be trained differently if they are to meet the needs of a changing patient population and to lead and thrive in a changed health care delivery system. All health professionals should be educated so that they can contribute to meeting the societal goals of better care, better health, and lower cost for all— the Triple Aim.3 Many innovations will be necessary, and many examples of educational innovations can already be identified in health professions prelicensure, graduate, and continuing education programs across the country. Some of these innovations are specific to one profession or site, but they may be potential models for others. In this article I highlight six areas of innovation, described in detail below, that I believe are applicable to all of the health professions and that could lead to new national norms for health professions education if programs and policies were developed to support them.

Interprofessional Education There is an increasing body of evidence4 that health care delivered by well-functioning multiprofessional teams leads to better outcomes than more traditional care. However, the historical— and still predominant—educational model is to keep members of different health professions separate until they are fully trained and only then attempt to get them to work together in teams. Much experience shows that this strategy often fails because of attitudinal biases, lack of understanding of others’ professional roles and expertise, and an absence of the competencies needed for effective teamwork and collaborative practice.4 The World Health Organization defines interprofessional education as what happens “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”5 For the past five years the Josiah Macy Jr. Foundation has been supporting interprofessional education programs at more than twenty institutions across the United States. These programs have all involved medical students and nursing students, and many have also involved students from other health professions

such as pharmacy, public health, dentistry, and social work. The programs have provided evidence that the logistical and cultural barriers often given as reasons for not including interprofessional education in the curriculum can be overcome, even in very traditional settings. My review of these programs reveals that interprofessional education is very popular with students in all of the professions and can produce measurable changes in students’ attitudes about their professional colleagues, as well as documented improvements in teamwork and team-based competencies.6 Some themes have emerged from this work that will be helpful to institutions as they initiate interprofessional education programs. First, leadership from the top is essential. The deans of all participating health professions schools must make interprofessional education a priority; on a health science campus, the president, provost, or chancellor must make it a campuswide initiative. Second, extensive planning is necessary to accomplish the scheduling changes, curriculum development, and assessment tools that are required for rigorous interprofessional educational experiences. Third, students must be involved in real work that has meaning for their professional development. Interprofessional education is not an end in itself. Instead, it is a tool for accomplishing important educational goals, such as teaching students how to assess and improve the quality of care.7 Finally, much attention must be paid to faculty development, since most faculty have had little or no experience with interprofessional education. Compared to the faculty, students are often initially more comfortable with the idea and enthusiastic about it. However, most faculty also become strong proponents of interprofessional education once they are given the experience and tools to succeed. Many national8 and international9,10 reports on health professions education have identified interprofessional education as an important innovation for aligning health professions education with societal needs. There is still much to be learned about the optimal timing and amount of interprofessional education in the educational trajectory of each of the health professions, how best to integrate it with the unique educational goals of each profession, and how to develop an interprofessional faculty. But a consensus is emerging that the health care professionals of the future must have the competency to work in teams to provide collaborative care and that their educational experiN ov e m b e r 201 3

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New Models For Clinical Education Most health care is delivered outside of the hospital, and patients with chronic disease have the greatest need for health care. However, a large amount of health professions education remains hospital based, with short rotations and a focus on acute episodes of care. This is particularly true of medical education, but it applies to education in the other health professions as well. Even those professions that are less hospital based continue to rely heavily on a model of frequent rotation for clinical education. There are many advantages to a more longitudinal, integrated model for clinical education.11 Students in all of the health professions should have the opportunity to form relationships with patients and families over time. This is the only way in which students can develop a full understanding of the impact and management of chronic disease, and it is the best way to appreciate the importance of context and social factors in health. In addition to facilitating learning about patients, families, communities, and chronic disease, longitudinal clinical experiences allow for continuity in student-teacher relationships. That in turn makes it more likely that students will have role models for professional development and more likely that teachers can give constructive and meaningful feedback and evaluation. Finally, students can learn more efficiently if there is continuity in the site of learning, so they do not need to spend time and energy at the beginning of each new rotation to learn new computer systems, institutional logistics, and local rules. A student embedded in one site is more likely to be able to participate meaningfully in improving care at that site. Longitudinal, integrated educational experiences also are more likely to facilitate opportunities for meaningful interprofessional learning and collaboration. There are many important learning opportunities for each of the health professions in the hospital and other acute care settings, and some skills and knowledge can be taught only in those settings. But the preparation of a health care workforce that meets contemporary and future needs will require more clinical experiences that are longitudinal, integrated, immersive, and community based.

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New Content To Complement The Biological Sciences The Flexner Report of 191012 revolutionized the education of medical students in the United States and Canada by establishing that a rigorous grounding in the biological sciences is the proper base for medical education. That revolution spread to other health professions, and for a century the two countries have benefited from the high standards that each of the professions has established for teaching the scientific underpinnings of medical practice. Flexner realized that the biological sciences were not the entirety of medicine, but his report appropriately addressed what was the most critical issue of his time. As the complexity of the practice of medicine has increased and the society in which medicine is embedded has changed, however, it has become increasingly apparent that understanding the scientific basis of diseases, diagnoses, and treatments is necessary but not sufficient to prepare effective practitioners and leaders in the health professions. Members of the health care workforce of today and tomorrow also must understand systems of care, the principles of quality improvement and patient safety, health economics, ethics, population health, and the social determinants of disease.13,14 And they must have a clear understanding of their roles and responsibilities as health professionals. To accomplish these goals, health professions educators will need to carefully integrate this content throughout students’ educational experiences. They also will need to call on the expertise of educators in other professions. Many of these new content areas are not specific to any one of the health professions, and as a result they can be the platform for exemplary interprofessional educational experiences.

New Educational Models Based On Competency The time it takes to prepare a competent health professional is determined by the standards of the relevant profession. These standards have historically been based on time (years or months of experiences of a certain type) rather than competency. For many of the professions (and specialties within them) the time required for licensure and certification has increased because new content, specializations, or degree requirements have been added. The professions have a responsibility to the public to make sure that the length of time a student spends in training is adequate to ensure his or her competence as a professional. But training that is unnecessarily long can have ad-

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verse societal effects by incurring more public or private costs, creating disincentives for some people to pursue careers in the health professions, and delaying the entry of health professionals into the workforce. Ezekiel Emanuel and Victor Fuchs have suggested that the total time for education and training of physicians (which is the longest in the health professions) could be shortened by as much as 30 percent without compromising quality.15 Instead of establishing an arbitrary length of time for training, the goal should be to establish each profession’s desired competencies and the means of assessing whether a student has mastered them. This could result in a more efficient process, enabling some people to finish training sooner (although others may need longer) than is currently the case. And it would assure the public that the certification process is based on measured outcomes rather than arbitrary time intervals. The milestone initiative of the Accreditation Council for Graduate Medical Education for the graduate education of physicians16 is a step in this direction. It also should be recognized that providing a competent and up-to-date workforce goes beyond the initial education and training for licensure and certification. More attention needs to be paid to the continuing professional development for all health professionals to ensure lifelong learning that is interprofessional, team based, and relevant to their practice.17

New Educational Technologies The health professions have been quick to embrace new diagnostic and therapeutic technologies but slower to embrace new educational and health informatics technologies. Simulated clinical experiences—using standardized patients (trained participants who portray specific kinds of patients), simple mannequins, or complex mannequins that can be used to simulate complicated clinical scenarios—are an increasingly important part of all health professions education. Not only are these tools important for the acquisition of critical skills in each of the professions, but they can also be a powerful means for teaching and assessing team-based competencies interprofessionally.18 All health professionals also will need to learn how to use electronic health records and other informatics systems that will be crucial for their communication with patients and colleagues and for their own continuing education. This is a rapidly changing area, and it is very important that health professions education programs evolve with these changes. Finally, the “classroom” for the health profes-

sions will be changing, as it is in other educational arenas, along the lines recommended by provocative educators such as Salman Khan, the developer of the online Khan Academy.19 All of the health professions will be less dependent on lectures for the transmission of information. More reliance on innovative online teaching methods will free up classroom time for team building, competency assessment, and the honing of analytical skills. Innovative online teaching also will support other educational goals, such as a competency-based educational plan and interprofessional education. All of these technological changes, properly used and blended with personal experiences with patients and faculty, can help prepare students in the health professions for the changing world they are entering and for their own lifelong learning.

Faculty Development For Teaching And Educational Innovation Many health professions faculty are more directly involved in the work of their profession (that is, patient care) and in research than is the case with faculty in other professions. This model has many positive features, such as helping ensure that faculty are teaching relevant and up-todate content and practices. But it can be a disadvantage if faculty devote too little time to developing teaching skills or if there is a lack of support for the careers of the subset of faculty who will be educational leaders and innovators. To accomplish the educational reform outlined in this article, all teaching faculty will need to learn content and skills in areas unfamiliar to them, such as interprofessional education, new models of clinical education, new subject areas, assessment of competencies, and the use of new educational and information technologies. In some instances, new, nontraditional faculty (such as health professionals based in the community or at a health center) will need to be recruited. There is a need across the health professions to devote more time to developing faculty as teachers and to recognize the scholarly contributions of teachers and educators through appropriate promotion criteria and other recognition. There also is a need to have more faculty with the skills and creativity to lead these educational innovations—and additional incentives for those faculty to do just that. Educational leadership and innovation need to be recognized as a legitimate and highly regarded career pathway. The Macy Foundation has created the Macy Faculty Scholars Program20 to identify and nurture a cadre of nursing and medical faculty as November 2013

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Shorter training time The total time for educating and training physicians could be shortened by as much as 30 percent without compromising quality, according to Ezekiel Emanuel and Victor Fuchs.

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Interprofessional Education educational innovators and to develop a national network of educational leaders. More public and private support for faculty is required to make sure the health professions workforce can meet society’s needs.

Conclusion The ultimate test for all of these proposed reforms of health professions education is whether the result produces a health care workforce that leads to better care, better health, and lower costs.3 Better metrics will be required to assess the relationship between educational interventions and patient outcomes—a task that is always difficult because there are so many intervening variables. Success will be achieved when health professions education and the health care delivery system are more closely linked.21 Educational reform must be informed by changes in the de-

livery system, and delivery system reform must include the educational mission. Bringing about all of these changes will not be easy, but I am encouraged by the amount of positive change that has already taken place both in health professions education and in the health care delivery system. The culture change that is needed to achieve a closer linkage between education and practice in a collaborative, interprofessional environment will require leadership, careful planning, innovative uses of technology, new partnerships, and faculty development. The health care workforce for tomorrow needs to be educated and trained in settings that are models for the efficient, reliable, collaborative practice that leads to the best patient outcomes. It is important that health care policies support these educational innovations, which must be embedded in a reformed health care system. ▪

NOTES 1 Iglehart JK. Reform and the health care workforce—current capacity, future demand. N Engl J Med. 2009;361(19):e38. 2 Blumenthal D. New steam from an old cauldron—the physician-supply debate. N Engl J Med. 2004;350(17): 1780–7. 3 Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008; 27(3):759–69. 4 Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: report of an expert panel. Washington (DC): Interprofessional Education Collaborative; 2011. 5 World Health Organization. Framework for action on interprofessional education and collaborative practice [Internet]. Geneva: WHO; 2010 [cited 2013 Sep 23]. Available from: http://whqlibdoc .who.int/hq/2010/WHO_HRH_ HPN_10.3_eng.pdf 6 Josiah Macy Jr. Foundation. Conference on Interprofessional Education: April 1–3, 2012 [Internet]. New York (NY): The Foundation; 2012 [cited 2013 Sep 23]. Available from: http://macy foundation.org/docs/macy_pubs/ JMF_IPE_book_web.pdf 7 Headrick LA, Barton AJ, Ogrinc G, Strang C, Aboumatar HJ, Aud MA, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Aff (Millwood). 2012;31(12):2669–80. 8 Greiner AC, Knebel E, editors. Health professions education: a

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bridge to quality. Washington (DC): National Academies Press; 2003. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756): 1923–58. Institute of Medicine. Interprofessional education for collaboration: learning how to improve health from interprofessional models across the continuum of education to practice: workshop summary. Washington (DC): National Academies Press; 2013. Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356(8): 858–66. Flexner A. Medical education in the United States and Canada, bulletin number four (the Flexner report). Stanford (CA): Carnegie Foundation for the Advancement of Teaching; 1910. Berwick DM, Finkelstein JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new “public interest.” Acad Med. 2010;85(9 Suppl):S56–65. Josiah Macy Jr. Foundation. Ensuring an effective physician workforce for the United States: recommendations for reforming graduate medical education to meet the needs of the public [Internet]. New York (NY): The Foundation; 2011 Nov [cited 2013 Oct 2]. Available from: http://macy foundation.org/docs/macy_pubs/

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JMF_GME_Conference2_ Monograph(2).pdf Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA. 2012;301(11):1143–4. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051–6. Institute of Medicine. Redesigning continuing education in the health professions. Washington (DC): National Academies Press; 2010. Wilhaus J, Palaganas J, Manos J, Anderson J, Cooper A, Jeffries P, et al. Interprofessional education and healthcare simulation symposium [Internet]. Wheaton (IL): Society for Simulation in Healthcare; 2013 Jan [cited 2013 Sep 24]. Available from: http://ssih.org/ uploads/static_pages/ipe-final_ compressed_1.pdf Khan S. The one world schoolhouse: education reimagined. London: Hodder and Stoughton Ltd.; 2012. Josiah Macy Jr. Foundation. Macy Faculty Scholars: about the program [Internet]. New York (NY): The Foundation. c2013 [cited 2013 Sep 24]. Available from: http://macy foundation.org/macy-scholars Cox M, Naylor M. Transforming patient care: aligning interprofessional education with clinical practice redesign [Internet]. New York (NY): Josiah Macy Jr. Foundation; 2013 [cited 2013 Sep 24]. Available from: http://macyfoundation.org/ docs/macy_pubs/JMF_ TransformingPatientCare_Jan2013Conference_fin_Web.pdf

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Reforming health professions education will require culture change and closer ties between classroom and practice.

The size, composition, distribution, and skills of the health care workforce will determine the success of health care reform in the United States. Wh...
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