Learning together to work together

I have always liked this view of, and rationale for, teamwork and a wider collaboration within health professions education and clinical practice. It has seemed intuitive to me for many years that health professionals who have common goals in terms of providing excellent patient-centred (or client-centred) care need to learn ‘with, from and about’ each other for some proportion of their education.2 Interprofessional education (IPE) is a way of achieving this. When I advocate for IPE I am often asked where, and what, is the evidence that it works? I have several answers to this question: if we don't do it, we won't be able to provide the evidence; where was the evidence for many educational innovations of the last decades when they were introduced (for example, problem-based learning, early patient contact and intern shadowing); and there is certainly emerging evidence that we need to manage teamwork and interprofessional communication better. In June I attended a conference in Vancouver devoted to IPE and collaborative practice: Collaborating Across Borders IV. The borders here refer not only to that between Canada and the USA (from where the majority of the participants originated), but also to the borders and barriers that often exist between professionals, and those between academics and practitioners. For myself, and many others, the most powerful session of the three days was delivered on the first morning by Regina Holliday, an artist and carer.3 Regina performed her story: a story of her interactions with the health service through the diagnosis, illness and death of her husband. Although her husband's diagnosis and deterioration from renal cancer had taken place in the USA, the themes of poor communication and lack of compassion are common in all health services, globally. Regina spoke of the fight her family had to gain access to his health records, and the pressing need for all health education, and associated conferences, to include the ‘patient's voice’. The audience was visibly moved by her presentation, her eloquence and her request for participatory health care. A particularly poignant moment was when she spoke about her young son asking why they had to pay for car parking at the hospital where his Daddy was dying. Regina now paints patients’ stories, and many of these pictures are displayed on the jackets of 200 volunteer walkers in the USA, which prompt a discussion and debate about how health professionals, both pre- and post-qualification, may learn to interact more empathically with their clients. Regina reminded me that as clinical teachers we are the role models for our learners: we need to show them that we are listening and responding to patient feedback. Although IPE may appear innovative and newfangled to some, in certain formats it actually dates from the 1940s, when an IPE seminar in public health was delivered in the USA. In the 1970s there were pockets of interprofessional learning in Australia, the USA and the UK. Yet students and new graduates still feedback that they do not understand their (future) colleagues’ roles and responsibilities. One interesting slide from Professor DeWitt Baldwin's presentation at the conference showed that although the number of medical doctors per 100 000 head of population has not increased much in the USA between 1850 and 2010, the numbers of other health professionals have grown markedly. We need to learn to work together. Professor Baldwin, a paediatrician, family doctor and psychiatrist, has been involved in IPE for over 50 years. In his ‘retirement’ he is working on the huge data set that is the American Association of Medical Colleges (AAMC) medical graduate survey. Since 2011 this survey, which all medical students in the USA complete, has included the question: ‘Have you participated in any required curricular activities where you had experience of or interaction with other health professional students?’ The answers indicate that about 66 per cent of students have had such participation, with the other students predominantly coming from the disciplines of pharmacy and nursing. Most of the interaction involves active patient engagement. This is heartening, but doesn't tell us much about the effects or impact of such interaction; however, further data from surveys of residents (registrars) show that those who received interprofessional training at least once a month reported that they were more satisfied with their learning experiences, made fewer errors and were less likely to be depressed or anxious.4 These are interesting findings that will hopefully be published soon. While we wait for further evidence as educators and clinicians we do need to be aware that accreditation bodies in many countries now mandate interprofessional learning outcomes for the health professions. These not only focus on teamwork but also on working with others in looser collaborations, and include: communication around handover (hand-off); showing respect for the roles of others; referral processes; negotiation and conflict resolution; and leadership, including the ability to accept leadership by others. In the UK the General Medical Council stipulates that graduating doctors should be able to ‘learn and work effectively within a multi-professional team’.5 In Canada the CanMeds framework states that doctors should ‘participate effectively and appropriately in an interprofessional health care team and work effectively work with other health professionals to prevent, negotiate, and resolve interprofessional conflict’.6 Similarly, the Australian Medical Council includes in its accreditation standards that graduates should be able to ‘describe and respect the roles and expertise of other health care professionals, and demonstrate ability to learn and work effectively as a member of an interprofessional team or other professional group’.7 There are similar outcomes but with much diversity of wording for nurses, midwives, pharmacists, physiotherapists and occupational therapists, etc. There is a lot to consider in the planning, delivery and evaluation of IPE, and the assessment of student learning.8 There are numerous sources of guidance, scholarship and practical tips. In this edition of The Clinical Teacher Richard Hays ponders on this topic, and there are other reflections about the nature and scope of inter-professionalism. I will finish with another reflection on Regina's narrative. All health professionals should be capable of providing excellent care, and all sometimes fail to do this. Open disclosure, learning from our mistakes, and being collaborative with our colleagues and patients are key elements that we as teachers need to demonstrate to our students.

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