The issue of doctor-nurse relations, as raised by Theresa Brown in her NY Times Op-Ed, Physician, Heel Thyself, has left many readers, both within and outside the medical community, in turmoil. In his piece in the The Atlantic, Ford Vox was astounded at Ms. Brown’s lack of professionalism in addressing workplace-issues and implores the physician in question to make a public response. At White Coat Notes, Ishani Ganguli shares her own experiences as a medical student with doctor-nurses relations. Finally, Dr. Kevin Pho, of KevinMD.com, also commented on the issue. In his recent post, he commends Ms. Brown’s efforts to bring the issue of bullying within the hospital to light, while acknowledging that her actions do little to fix the problem at its core.
Regardless of your stance on the piece, and as Dr. Pho and Ms. Ganguli point out, there is a need for and increased emphasis on interprofessional education (IPE) in medical schools. What does that mean? Well, just today, athe American Association of Medical Colleges released a report, Core Competencies for Interprofessional Collaborative Practice. The report states:
Core competencies are needed in order to:
1.) create a coordinated effort across the health professions to embed essential content in all health professions education curricula,
2.) guide professional and institutional curricular development of learning approaches and assessment strategies to achieve productive outcomes,
3.) provide the foundation for a learning continuum in interprofessional competency development across the professions and the lifelong learning trajectory,
4.) acknowledge that evaluation and research work will strengthen the scholarship in this area,
5.) prompt dialogue to evaluate the “fit” between educationally identified core competencies for interprofessional collaborative practice and practice needs/demands,
6.) find opportunities to integrate essential interprofessional education content consistent with current accreditation expectations for each health professions education program ( see University of Minnesota, Academic Health Center, Office of Education, 2009 ),
7.) offer information to accreditors of educational programs across the health professions that they can use to set common accreditation standards for interprofessional education, and to know where to look in institutional settings for examples of implementation of those standards (see Accreditation of Interprofessional Health Education: Principles and practices, 2009; and Accreditation of Interprofessional Health Education: National Forum, 2009 ), and
8.) inform professional licensing and credentialing bodies in defining potential testing content for interprofessional collaborative practice.
My medical school has its own IPE course, which I recently completed. It involved a collaboration of medical, nursing, pharmacy, and occupational and physical therapy students with one volunteer patient-mentor who had previously been diagnosed with a chronic medical condition. We worked to meet and explore the standards for collaborative practice established by the World Health Organization’s Framework for action on interprofessional education and collaborative practice (which can be downloaded, here). Specifically stated, “Collaborative practice in health-care occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings. Practice includes both clinical and non-clinical health-related work, such as diagnosis, treatment, surveillance, health communications, management and sanitation engineering.” In other words, these are the ideas that our course assignments were based upon.
We met as a group with our patient-mentor a total of four times – once each semester. We started out by learning how to obtain a comprehensive health history, which allowed us to explore how the various members of the interprofessional team think about and use the information obtained from a health history differently. We developed a comprehensive health plan, with emphasis on all aspects of patient care – social, psychological, and biological. We made home visits, and discussed medical errors, particularly in regard to those that occur during inpatient hospital stays. We discussed conflict resolution strategies when working as a team, and used social media to interact and complete assignments. We attended lectures that re-visted examples of the old stereotypes and treatment of non-physician health care workers and discussed appropriate and effective communication strategies for use in the hospitals. Most importantly, we learned that our IPE education would help make us better, patient-centered care-givers, cut down on the number of medical errors, and save money within the health care system.
So how is this a bad thing? Well, I, for one, found the lack of emphasis on primary care in my course to be grossly insufficient. Even Ms. Brown’s piece, by no fault of her own, addresses doctor-nurse relations that take place solely in the inpatient setting. This is especially notable, for those developing and implementing IPE courses, considering the degree to which previously- stated IPE objectives overlap with those of the Patient-Centered Medical Home (PCMH). The ACP website states,
A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.
Personally, I wonder why it is really so difficult to dedicate a session or so of what has been designated as “IPE time” to discussion of the Patient-Centered Medical Home? So many schools have already adopted IPE programs and courses and the overlap of objectives between the two provides a seamless framework for the integration of PCMH into the curriculum. Furthermore, based on the increasing number of medical students turning their backs on primary care practice, this seems like a relatively simple way to emphasize the innovative and exciting trends that will one day become the face of primary care (not to mention changes in PCP reimbursement and lifestyle, which are currently two major contributors to the primary care shortage — but that’s better left for another discussion). Finally, if a primary goal of IPE is to decrease medical errors and cut costs, then doesn’t it make sense to address these issues BEFORE the patient needs escalation of care to a more expensive hospital setting? It seems to me that the continued emphasis on health care in the inpatient setting just perpetuates the cycle of poor (or lack of) primary care, leading to unnecessary ER and hospital visits. Not to mention the fact that’s its pretty difficult for any health care practice – hospital, medical home, or otherwise – to be truly “patient-centered” if its staff are bickering all the time.
I would love to hear from other students about the handling of IPE by their institutions. Does your school have a program or a course? If it does, is there an emphasis on primary care? And, most importantly, are the methods they use to address these topics effective in creating a professional work environment between health care professionals of different backgrounds?