Wednesday, May 6, 2015

I have not posted to my blog in over a year.    Today, I was inspired to compose some thoughts after reading an article that a colleague sent me from the New York Times.  It feels good to be blogging again.   I look forward to hearing your thoughts.   


In the May 1 issue of the New York Times it was enlightening to see a discussion of interprofessional education (IPE) highlighted in a column (unfortunately) titled “Doctors and Nurses Not Learning Together” by Dr. Dhruv Khullar ( a resident at Mass General).    Dr. Khullar is a frequent contributor to the column and has produced several op-ed pieces on health care.   In the article under discussion, the writer discusses the lack of exposure in medical school to mutual education opportunities with nurses, physician assistants, social workers, or pharmacists.  He indicates that in his residency he began to understand and appreciate the roles that these others play in the care of the patient.  He also notes that his education has provided no particular focus on the role of the physician as the leader of the health care team, a role he suggests as essential. He praises the work of the Josiah Macy Foundation, Robert Wood Johnson Foundation and others in driving the discussion toward team based care as better care.    While there a number of key points that I found missing from the discussion, it is important that consideration of IPE advance to the public forum and what better place for this to occur than the New York Times?  Congratulations to Dr. Khullar for using this important forum to raise these issues.  While clearly from a learner/trainee perspective, he brings a valued and valid viewpoint to the discussion.
                In response to the NYT article, a lengthy discussion is posted online.  The responses were almost all from physicians and nurses debating (with heat) the relationship issues that have infected some segments of the conversation between these two critically important groups for a very long time.     One respondent, a student from the MGH Institute cited her positive IPE experience, and a few others commented positively on their learning experiences elsewhere.  Most respondents, however, raised political, financial, power differential issues as obstacles to collaboration.   Very few respondents, other than a few students noted above, spoke to critical issues of patient care, outcomes, safety, health, and economics as the drivers for educating groups of health care professionals together.   These are the central issues, not politeness and politics, that need to serve as a rationale for delivering the best care collaboratively.  Debate about leadership and power need to take a backseat to patients, families and communities.  These structural and political issues, while important, are historical hot buttons that will not be resolved easily.  In the meantime, putting the patient at the center, making it safe for all members of the team to speak up, expecting everyone to work at the “top of their license,” and using evidence based approaches to communication and problem solving are all more likely to affect outcomes and health than the “captain of the ship” argument.  
                Another piece to this story that is at the center of the discussion so important to the IHP is the role of non-nurse and non-physician providers in healthcare safety and outcomes.  One could argue that the best providers of rehabilitation, psychological and behavioral health, health navigation, and nutrition services have done their work so well, that they are often invisible to physician and nurse colleagues.   These “other” professionals (I avoided the term allied deliberately)  are evaluating, assessing, interpreting, prescribing and carrying out interventions, measuring impact of care, communicating with families, patients, and making important connections across the individual’s life experience.     One could argue that for most patients with chronic or disabling conditions, that their contacts with these providers are far more frequent than they are with primary care of medical specialists.   The role of these other specialists is only beginning to emerge in the literature as to their impact on primary care, their role in outcomes, and their importance as teachers of physician and nurse colleagues.  
I hope that you will take time to read Dr. Dhuvar’s article, as it provides an important context that nicely explains why we are doing IPE at the Institute.  More important, I hope that you will find time to advance the debate beyond arguments of salary and power.  Instead, take some time to debate the impact that competent interprofessional care can bring to your patients.  


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