Since the mid-1970s, there has been heightened awareness of the need for physicians to collaborate with other health professionals to ensure the delivery of quality health care. Physicians, historically seen as the primary deliverers of health care, are encouraged to participate in health care teams because “the contemporary world of health care requires that doctors see themselves as only one voice in a societal conversation about health and health care, and that when they fail to see themselves as situated in this way, they are failing to understand the world they inhabit.” 1, p.916 In To Err is Human, Kohn and colleagues recommend that interdisciplinary team training programs can significantly improve patient safety.2 The Institute of Medicine cites the creation and maintenance of interdisciplinary teams as necessary to support change in both the organization and delivery of health care to ensure that “all Americans receive care that is safe, effective, patient-centered, timely, efficient, and equitable.”3, p.6 To promote moving to a patient-centered health care delivery system, the World Health Organization developed an International Classification of Functioning Model to promote a more holistic understanding of a patient's health conditions, functional state, environmental and personal factors.4
Clearly, if physicians are expected to function as members of interdisciplinary teams, medical school curricula must provide students with opportunities to develop skills in working as part of a team and to learn about the diverse roles of members of the health professions team in delivering patient-centered health care. In its January 1998 Report I: Learning Objectives for Medical Student Education-Guidelines for Medical Schools, the Association of American Medical Colleges urges medical schools to ensure that their graduates demonstrate “An understanding of, and respect for, the roles of other health care professionals, and of the need to collaborate with others in caring for individual patients and in promoting the health of defined populations.”5, p.5 Cooper and colleagues' 2001 review of evidence for interdisciplinary education states that the most significant influences of those programs were in the areas of students' knowledge, attitudes, skills and beliefs related to understanding of professional roles and working as a team. In addition, they found that early learning experiences result in the evolution of positive attitudes toward working as part of an interdisciplinary team.6 However, Baldwin and Baldwin have cautioned that the location of multiple health profession schools on the same campus has not ensured that “students will share interdisciplinary learning experiences which will more effectively prepare them for the team practice of comprehensive health care.”7, p.190 In terms of residency education, the Outcome Project of the Accreditation Council for Graduate Medical Education (ACGME), approved in 1999, includes four specific competencies that highlight the value of working in interdisciplinary teams and the ability to communicate with other health professionals.8 Some medical schools, including the University of North Carolina at Chapel Hill, adopted the ACGME outcomes as outcomes for their medical curricula, creating a seamless continuum from preprofessional through graduate medical education.
Institutions cannot assume that routine interactions among medical students and other health professionals within a medical setting will result in medical students' understanding of the benefits of interdisciplinary health care delivery. Therefore, medical schools must identify effective educational activities that provide knowledge of how interdisciplinary teams function, practice in developing those skills, and information about the role of various health professionals in providing patient-centered care.
The University of North Carolina is fortunate to have its Schools of Medicine and Allied Health Sciences, Dentistry, Pharmacy, Public Health, Nursing, and Social Work located on a single campus, but the physical proximity of these schools and programs has not resulted in systematic, shared learning experiences among medical and other health professions students. In 1999, an interdisciplinary planning committee, comprising faculty from medicine, nursing, occupational therapy, pharmacy, physical therapy, social work, speech-language pathology, and medical education designed an interdisciplinary case conference as a learning strategy to enable health professions students to understand and appreciate the professional knowledge and roles of various health care professionals, effectively share responsibility for interdisciplinary team health care, and describe a rationale for an interdisciplinary team approach to patient care. In the spring of 2000, a pilot activity was conducted with 439 student participants. Feedback from both participating students and faculty informed the design of the subsequent health affairs interdisciplinary case conferences that were administered during the spring semesters of 2001, 2002, 2003, and 2004. During some of these years, the project was expanded to include dentistry, audiology, and rehabilitation counseling students.
This study had two purposes. First, we examined the effectiveness of the health affairs interdisciplinary case conference as a learning strategy by assessing medical students' attitudes about interdisciplinary care. Second, we assessed their knowledge about other health professionals' roles in health care delivery both before and after they participated in the health affairs interdisciplinary case conference.
Program goals and outcomes
The interdisciplinary learning program had three goals for the students, each with its respective outcomes.
Goal 1, for the students to understand and appreciate the professional knowledge and roles of various health professionals, had two outcomes: For students
- to accurately identify the appropriate health care professionals to address particular problems for a patient with multiple health care needs; and
- to describe the specific contributions of their disciplines and three other disciplines in the evaluation of this patient.
Goal 2, for students to learn to effectively share responsibility for interdisciplinary team health care delivery, had three outcomes: For students
- to demonstrate the ability to use interdisciplinary team management principles to ensure quality health care provision to a given patient;
- to describe how they would collaborate to effectively share responsibility for health care; and
- to identify three challenges, including increased cost, to interdisciplinary team health care delivery and describe strategies to address the challenges.
Goal 3, for students to describe a rationale for an interdisciplinary team approach to patient care, had three outcomes: For students
- to articulate two professional benefits of working with an interdisciplinary team;
- to articulate two benefits for patients when services are provided through an interdisciplinary team; and
- to describe the role of the interdisciplinary team in addressing ethical dilemmas.
The challenges that most often hinder implementation of interdisciplinary learning activities are lack of time for planning, scarce financial resources, assignments specific to each professional group, varying educational schedules, and discipline-specific requirements for registration.7 Not surprisingly, the planning committee faced these same challenges. We overcame these challenges by identifying faculty willing to do the necessary planning, acquiring institutional support for the actual activity, incorporating activities that required involvement from all participating professions, and scheduling the required activity in the evening outside the routine classroom hours. In developing plans for an educational activity, the planning committee was guided by three characteristics that Kolb states must be present for experiential learning to occur: the learner must deduce concepts from experience and continue to revise these concepts through subsequent experiences, learning must be based on the learner's needs and interests, and the learning process must be adaptive, always grounded in a specific context.9
A total of 2,005 health profession students, representing ten health professions, participated in the health affairs interdisciplinary case conference over the four-year period, spring 2001 through spring 2004. Six hundred fifteen of these participants (31%) were second-year medical students enrolled in the Introduction to Medicine Course. All students participated in the three-hour conference as part of their respective courses whose directors served on the planning committee.
Health affairs interdisciplinary case conference
With the principles of experiential learning in mind, the planning committee determined that a health affairs interdisciplinary case conference, conducted in small groups of seven to nine students from the participating disciplines, would provide an opportunity for students to debunk myths about their respective professions; share information about their respective professions' roles in health care delivery; and, as a team, interview a standardized patient (SP) and develop a patient-centered management plan using a World Health Organization International Classification Model.4 Each small group comprised students from a minimum of four different health professions, with at least one medical student in each group. The two-stage encounter with an SP was based on one of three patient scenarios. Each group was assigned the appropriate scenario that included a unique medical and social history that warranted the involvement of a specific combination of health professionals. The protocol for preparing the SPs was the protocol routinely used by the School of Medicine's SP Program and ensured a standardized clinical presentation, medical history, social history, patient affect and appearance, as well as a consistent opening statement. This protocol for training the SPs and assigning cases to each group are described in detail in Joyner and colleagues' article describing the participation of pharmacy students in the health affairs interdisciplinary case conference.10 The World Health Organization's International Classification of Function and Disability focuses on three related dimensions—body structure, function, and impairments; individual activities and limitations on activities; and participation in society and limitations on participation in society—and provided a context in which the students could discuss and organize the information elicited from the SP and, then, develop their groups' patient-centered management plan.4
We developed preconference and postconference instruments to assess medical students' knowledge about the skills and expertise possessed by ten health professionals, and to assess their attitudes regarding the role of those same ten professionals in the delivery of health care. In order to assess preconference to postconference change in these two areas, identical items appeared on both instruments. The first ten items on the preconference instrument (related to program Goal 1) asked students to rate their knowledge about each of the participating health professions on a five-point scale (1 = none, 5 = comprehensive). These items had an internal consistency of .90 (Cronbach's alpha). Items 11 to 14 (related to program Goal 3) asked students to rate their level of agreement about the value of interdisciplinary teams in the delivery of health care on a five-point scale (l = strongly disagree, 5 = strongly agree). These items had an internal consistency of .33 (Cronbach's alpha). Items 15 to 24 (related to program Goals 1 and 2) asked students to rate on a five-point scale how often each participating health professional might lead an interdisciplinary health care team (1 = never, 5 = always). These items had a Cronbach's alpha of .83. Items 25 to 34 (related to program Goals 1, 2, and 3) asked students to rate on a six-point scale the importance of the role of each participating health professional in the care of a patient described in a case scenario (l = not at all, 5 = extremely, 6 = not applicable). These items had a Cronbach's alpha of .76. Students' responses on these scales served as the dependent variable in our analyses. Items 35 through 38 (related to program Goal 3) asked students to rate on a five-point scale the importance of specific activities relative to how an interdisciplinary team functions (1 = not at all, 5 = definitely). These items had a Cronbach's alpha of .71.
Prior to starting their case conferences, students were asked to complete the preconference instrument. Following completion of the three-hour small-group activity, students completed a postconference instrument. We analyzed data from these instruments to produce the study results.
We performed repeated-measures analyses using SAS Proc GLM (SAS Institute Inc., Cary, NC) to assess how medical students' knowledge about the training and skills of participating health professions changed as a result of their participation in the interdisciplinary case (alpha = .05). We used similar analyses to compare how medical students' attitudes about the value of interdisciplinary teams changed as a result of their participation in the interdisciplinary case. This study was approved by the University of North Carolina at Chapel Hill's IRB Committee based on 45 CFR Part 46, Section 101.
We based our analyses on responses from 605 medical students (98.5%). Table 1 shows the results of the preconference and postconference survey instruments. After participating in the health affairs interdisciplinary case conference, medical students significantly increased their ratings of knowledge about the training and skills of all health professions participating in the health affairs interdisciplinary case conference. Medical students' attitudes toward the value of interdisciplinary teams became significantly more positive on three of four items: the team approach improves patients' quality of care, patients receiving interdisciplinary team care are more likely than other patients to be treated as a whole person, and working on a team keeps most health professionals enthusiastic and interested in their jobs. However, medical students' attitudes about whether working in teams complicates things did not change significantly. Following participation in the health affairs interdisciplinary case conference, medical students' attitudes toward team leadership by various health professionals' significantly improved for all professions except audiology. Audiology students did not participate in every year of the study so fewer small groups contained an audiology student. It is possible that medical students' limited interactions with audiology students resulted in decreased ratings. Medical students' ability to assess the importance of patient care involvement in specific health care situations by various health professionals both increased and decreased after participating in the health affairs interdisciplinary case conference. While medical students' assessments of the importance of care provided by audiologists and pharmacists in the context of a specific clinical scenario increased, their assessment of the importance of occupational therapists, physical therapists, registered nurses, and social workers decreased. Given the high precase conference ratings medical students gave professions other than audiology within the context of the clinical scenario, significant decreases in postcase conference ratings may be due to natural regression. After participating in the health affairs interdisciplinary case conference, medical students rated specific attributes of working in teams, such as the importance to the quality of care of the patient, treating the patient as a whole person, and promoting enthusiasm among participating professionals, more highly.
Participation in the health affairs interdisciplinary case conference appears to have increased medical students' ratings of their knowledge regarding the training and roles of each of the ten health professions included in the study. Medical students' average gains in knowledge were significant for all professions. However, their increase in knowledge was somewhat less for three professions: dentists, registered nurses, and physicians. This is probably due to the inherent familiarity medical students have with their own career choices and the fact that, traditionally, physicians, dentists, and nurses are more frequently encountered and are more familiar than other health care professionals. Clearly medical students are familiar with the knowledge and training affiliated with their chosen profession, but the significant increase in medical students' postconference knowledge scores regarding physicians may reflect new perspectives on the role of the physician within the context of an interdisciplinary team.
Interestingly, medical students' postconference ratings regarding their attitudes about whether “working in teams complicates things” did not change significantly. This may be due to the fact that the students were not accustomed to sharing the development of a management plan with so many other health professionals and had not seen team management as frequently. However, medical students' ratings of their attitudes toward the value of interdisciplinary teams in keeping professionals' enthusiasm and interest in their work at a high level significantly increased following the conference. Participation in a SP management activity appeared to be a stimulating endeavor for these medical students.
While our study is for a single institution, it is based on an impressive—and unusually high—response rate, 605 students (98.5%). Mangione, in his book Mail Surveys: Improving the Quality, states that “a response rate in excess of 85% is viewed as an excellent rate of return.”11, p.5 A limitation of our study is that we were evaluating a program at the preliminary level of reaction. According to Kirkpatrick's logical steps that define how a program or intervention is being evaluated, this is only the first of four steps that begin with reaction and end with results.12 We acknowledge that our data do not ensure changes in the long-term professional behaviors of these medical students, but it appears that an interactive model such as a health affairs interdisciplinary case conference can serve as an initial means to increase students' recognition of the benefits of interdisciplinary health care delivery.
Despite the growing need for interdisciplinary health care, health professions education remains largely segregated by profession, with little opportunity for students to learn about and with students and faculty from other professions or to learn an interdisciplinary approach to practice. At our institution, using a simulated health affairs interdisciplinary case conference approach provides one effective vehicle for beginning to address this problem. Students teach one another about their respective professions and learn more about their own as well by seeing their professions in relationship to others. Further, this case-based, interactive approach embodies principles derived from contemporary research on teaching and learning as described by Bransford and colleagues.13 They suggest that an effective learning environment should be learner-centered, allowing students to examine their preconceptions; knowledge centered, providing a well-structured foundation; assessment centered, permitting students to test their thinking; and community centered, giving students opportunities to explore ideas collaboratively. The health affairs interdisciplinary case conference may serve as a catalyst for more extensive interdisciplinary courses and activities and as a foundation for further skill development and achievement in residency training.
The Health Affairs Interdisciplinary Case Conference is funded by the Office of the Executive Vice Chancellor and Provost, University of North Carolina at Chapel Hill. The authors acknowledge the members of the Health Affairs Interdisciplinary Case Conference Group that planned and executed the program described here. Finally, the authors thank Ms. Linda Fisher-Neenan for editing the manuscript.
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