IPE ... or interprofessional education ... has become a popular buzzword among educators preparing the next generation of providers. An interprofessional, team-based curriculum has been lauded as the best way to prepare healthcare professionals to work collaboratively in a value-based system where efficiency and quality are rewarded.
But does it work? Do the lessons learned in the classroom effectively translate into the clinical setting? And does this model of delivery actually have an impact on patient outcomes and the healthcare system itself?
Those were some of the questions posed by the Institute of Medicine's Global Forum on Innovation in Health Professions Education. In late April, a six-member committee, chaired by Malcolm Cox, MD, published their findings in the IOM report "Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes."
The short answer to a long list of questions is that while the empirical evidence suggests this is a desirable way to train future providers, there simply isn't enough scientific research to validate that opinion.
Asking the Question
Cox, who is an adjunct professor of Medicine at the University of Pennsylvania Perelman School of Medicine and the former Chief Academic Affiliations Officer of the U.S. Department of Veterans Affairs, noted IPE became a common topic of discussion and debate among members of the Global Forum.
"One of the things that came up early on was that health professions education was 'faith-based' when it came to outcomes ... that is we believed, without much data, that interprofessional education would be helpful, if not essential, to producing the kind of clinical workforce that the U.S. and world need in the future," he said.
Cox noted a common sentiment among many educators is 'the era of the Lone Ranger' is over. He added, "I think that's true ... no one doubts that. Moreover, no one doubts that the U.S. health system is rapidly moving in that direction." And in fact, Cox pointed out, data exists showing teams can provide safer, more effective, efficient care ... but that isn't the same as proving the best route to get there.
"How do we prepare health professionals to hit the ground running when they reach the clinical workforce so they are ready to work in teams rather than as individuals?" he asked. "What we discovered is that while teams are known to be effective, how to create great teams is unclear," Cox continued.
No 'I' in Team
"The leaders of healthcare systems are not pleased with the graduates we are sending them," Cox stated. While these new professionals might be well versed in disease recognition and the medical sciences, they aren't well trained in working together, noted the physician-educator, who previously served as dean for Medical Education at Harvard Medical School
Even when professionals from multiple disciplines are grouped together, Cox said it's often more a matter proximity than actual teamwork. "Team leadership should be expertise- and situation-based rather than hierarchically based," he pointed out. "Physicians are still giving orders and nurses are taking orders, which is fine if the physician has the most knowledge on a subject, but there are times when the nurse or physical therapist or pharmacist should lead. The most effective team is where the expertise of professionals overlap so that the whole is greater than the sum of the parts."
While a lot of emphasis is placed on leadership, Cox said the concept of 'followership' is equally important. "Physicians are great leaders but poor followers ... I'm allowed to say this because I'm one of them," he added with a chuckle.
In his experience, he added, "The only way you can really learn to work together as a team ... is to work together as a team."
IPE & Outcomes
Cox said the committee studied the available research and literature for both the intermediate and final outcomes of IPE. The intermediate outcomes side of the equation is tied to learning outcomes and whether or not students understood, gained knowledge and developed new skills. "There's pretty good information that interprofessional education begins to promote collaborative behavior within students," he said.
"But," he continued, "we haven't taken it to the final endpoint, which is do those learning outcomes lead to enhanced patient health and health system outcomes?" Cox said, "The conclusion was there is no data that links the learning outcomes to health and system outcomes ... that's where the gap is."
While this committee was focused specifically on measuring IPE, Cox said he personally believes that all health education innovations should be held to the same evidence-based standard. "We keep changing the way we educate, and there's little solid data that any of these changes lead to measurable changes in health or system outcomes," he said. "Belief is one thing, but data is another."
Filling the Gap
Cox pointed out IOM studies are not geared to go beyond the question at hand ... in this case, a question of measurement. However, the report included recommendations on how to move forward to produce more data to assess the real world outcomes of IPE on patients, populations and healthcare systems.
The committee highlighted four areas that should be addressed in order to truly evaluate the impact of IPE on collaborative practice - 1) more closely align the education and healthcare delivery systems, 2) develop a conceptual framework for measuring the impact of IPE (see graphic), 3) strengthen the evidence base for linking IPE to health and system outcomes, and 4) better link IPE with changes in collaborative behavior. Furthermore, the committee made two recommendations:
- Interprofessional stakeholders, funders and policymakers should commit resources to a coordinated series of well-designed studies of the association between interprofessional education and collaborative behavior, including teamwork and performance in practice. These studies should be focused on developing broad consensus on how to measure interprofessional collaboration effectively across a range of learning environments, patient populations and practice settings.
- Health professions educators and academic and health system leaders should adopt a mixed-methods research approach for evaluating the impact of IPE on health and system outcomes. When possible, such studies should include an economic analysis and be carried out by teams of experts that include educational evaluators, health services researchers, and economists, along with educators and others engaged in IPE.
Cox said the first recommendation is focused on collaborative learning outcomes. The second, which he said is "the real crème de la crème" of the report, looks at linking IPE to health and system outcomes by using 'mixed methods' ... incorporating both qualitative and quantitative research designs. "We need to know the how and why, as well as the what," he stated, adding that without the qualitative piece, it's difficult to generalize the quantitative results and apply findings to the larger population.
The IPE Study Team
Not surprisingly, Cox pointed out the report on interprofessional education took teamwork and was a collaborative effort of the six-member committee. In addition to Cox, the team consisted of Barbara Brandt, EdM, PhD, director, National Center for Interprofessional Practice and Education at the University of Minnesota; Janice Palaganas, PhDc, RN, MSN, director of Educational Innovation and Development, Center for Medical Simulation, Massachusetts General Hospital, Harvard Medical School; Scott Reeves, PhD, MSc, professor of Interprofessional Research, Centre for Health and Social Care Research, Kingston University and St. George's, University of London; Albert Wu, MD, professor and director, Center for Health Services and Outcomes Research at John Hopkins Bloomberg School of Public Health; and Brenda Zierler, PhD, RN, FAAN, co-director of the Center for Health Sciences Interprofessional Education, Practice and Research at the University of Washington.
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Global Forum on Innovation in Health Profession Education
