The case for educating health care students in professionalism as the core content of interprofessional education

BACKGROUND: Professional teams are becoming more central to health care as evidence emerges that effective teamwork enhances the quality of patient care. Currently, health care professionals are poorly prepared by their education for their roles on the team. In parallel, there are increasing demands from consumers for health care professionals to serve the interests of society and patients through engaging in effective professional partnerships. Professionalism for health care providers is now being defined as a commitment to standards of excellence in the practice of the profession that are designed primarily to serve the interests of the patient and to be responsive to the health needs of society. Yet, there are multiple barriers impeding the development of professionalism beyond a uni-professional frame of reference. METHOD: Incorporating teamwork and professionalism into health care professional curricula at pre-registration level is proving to be challenging. These 2 areas of learning are brought together in this paper through a discussion of the role of interprofessional education in preparing all health care professional students for the workforce. CONCLUSION: Interprofessionalism is presented as a pre-registration curriculum framework that includes values shared by all health care professionals, which should be learned in order to more adequately prepare students for working in health care teams. It will be argued that interprofessional education provides appropriate methods by which to learn interprofessionalism, and that this will ultimately contribute to overcoming uni-professional exclusivity.     

''I found myself to be a down to earth Dutch girl'': a qualitative study into learning outcomes from international traineeships

OBJECTIVE: To explore learning outcomes from international traineeships for undergraduate medical students. METHODS: In-depth interviews were conducted with 24 undergraduate medical students at Maastricht University Medical School, The Netherlands. The 24 subjects were selected by purposeful sampling. RESULTS: Students reported meaningful learning outcomes in 6 domains: medical knowledge; skills; international health care organisation; international medical education; society and culture, and personal growth. DISCUSSION: International traineeships appear to provide good opportunities for students to meet the requirements of globalisation as well as some of the generic objectives of undergraduate medical education. The tentative findings of this study need to be confirmed by further studies.     

Comparing clinical and lay accounts of the diagnosis and treatment of back pain

This paper builds on the body of knowledge concerning clinician-patient relationships, patient-centred care and concordance. It extends the analysis to directly comparing patient and professional accounts of diagnosis, treatment and outcomes over time. Comparisons will be made between lay and clinical perspectives, but also between different professional approaches and patients' assessment of those differences. The paper is based upon an in-depth qualitative analysis of two case studies: first, one patient who established concordant relationships with the health professionals who treated her back pain; second, one patient who had both concordant and discordant relationships with health professionals. The issues explored centre on the determinants of concordant/discordant therapeutic relationships and whether greater attention given to the meaning of illness leads to improved care.     

Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning

OBJECTIVES: The belief that the effectiveness of patient care will improve through collaboration and teamwork within and between health care teams is providing a focus internationally for 'shared learning' in health professional education. While it may be hard to overcome structural and organizational obstacles to implementing interprofessional learning, negative student attitudes may be most difficult to change. This study has sought to quantify the attitudes of first-year medical, nursing and pharmacy students' towards interprofessional learning, at course commencement. DESIGN: The Readiness for Interprofessional Learning Scale (RIPLS) (University of Liverpool, Department of Health Care Education), was administered to first-year medical, nursing and pharmacy students at the University of Auckland. Differences between the three groups were analysed. SETTING: The Faculty of Medical and Health Sciences, University of Auckland. RESULTS: The majority of students reported positive attitudes towards shared learning. The benefits of shared learning, including the acquisition of teamworking skills, were seen to be beneficial to patient care and likely to enhance professional working relationships. However professional groups differed: nursing and pharmacy students indicated more strongly that an outcome of learning together would be more effective teamworking. Medical students were the least sure of their professional role, and considered that they required the acquisition of more knowledge and skills than nursing or pharmacy students. CONCLUSION: Developing effective teamworking skills is an appropriate focus for first-year health professional students. The timing of learning about the roles of different professionals is yet to be resolved.     

Advancing practice: Using nutrition information and technology to improve health—the nutrition informatics global challenge

Aims: The unique combination of technology, information and nutrition has been utilised in health care for decades. As technology and effective use of health data evolve, the field of ‘nutrition informatics’ is positioned to advance best practices of nutrition care delivered by registered dietitians and dietetic technicians registered. The present paper reviews the opportunities. Methods: A narrative review was constructed with reference to the literature. Results: Evolution of the use of digital health care in the USA is on an aggressive timeline because of regulations, which provide financial incentives to eligible professionals and hospitals who can prove ‘meaningful use’ of certified health‐care technology. While adoption and use of electronic health records has occurred at the international level for decades, only recently have American adoption rates increased. Health‐care providers are adjusting to rapid cultural changes, which support the interoperability of health data. The dietetics profession must move in tandem with this transition to digital care. This requires implementation and development of nutrition standards, vocabularies and quality measures, which support exchange of pertinent nutrition data critical to patient care and wellbeing. All dietetic professionals need to appreciate the paradigm shift in health care. Conclusions: Dietitians who are involved with informatics will help with this transition through their work with systems implementations, understanding competencies necessary for successful integration of digital nutrition and using electronic nutrition data for research.     

A review of evaluation outcomes of web-based continuing medical education

INTRODUCTION: The Internet and worldwide web have expanded opportunities for the provision of a flexible, convenient and interactive form of continuing medical education (CME). Larger numbers of doctors are accessing and using the Internet to locate and seek medical information. It has been suggested that a significant proportion of this usage is directly related to questions that arise from patient care. A variety of Internet technologies are being used to provide both asynchronous and synchronous forms of web-based CME. Various models for designing and facilitating web-based CME learning have also been reported. The purpose of this study was to examine the nature and characteristics of the web-based CME evaluative outcomes reported in the peer-reviewed literature. METHODS: A search of Medline was undertaken and the level of evaluative outcomes reported was categorised using Kirkpatrick's model for levels of summative evaluation. RESULTS: The results of this analysis revealed that the majority of evaluative research on web-based CME is based on participant satisfaction data. There was limited research demonstrating performance change in clinical practices and there were no studies reported in the literature that demonstrated that web-based CME was effective in influencing patient or health outcomes. DISCUSSION: The findings suggest an important need to examine in greater detail the nature and characteristics of those web-based learning technologies, environments and systems which are most effective in enhancing practice change and ultimately impacting patient and health outcomes. This is particularly important as the Internet grows in popularity as a medium for knowledge transfer.     

Digital technologies in primary care: Implications for patient care and future research

Digital health is the convergence of digital technologies with health, healthcare, living, and society. Contrasting with the slow trend during the last decades, in the last few years, we have observed an expansion and widespread adoption and implementation. In this paper, we revisit the potential that digital health presents for the delivery of higher quality, safer and more equitable care. Focussing on three examples – patient access to health records, big data analytics, and virtual care – we discuss the emerging opportunities and challenges of digital health, and how they can change primary care. We also reflect on the implications for research to evaluate digital interventions: the need to evaluate clear outcomes in light of the six dimensions of quality of care (patient-centredness, efficiency, effectiveness, safety, timeliness, and equity); to define clear populations to understand what works and for which patients; and to involve different stakeholders in the formulation and evaluation of the research questions. Finally, we share five wishes for the future of digital care in General Practice: the involvement of primary healthcare professionals and patients in the design and maintenance of digital solutions; improving infrastructure, support, and training; development of clear regulations and best practice standards; ensuring patient safety and privacy; and working towards more equitable digital solutions, that leave no one behind.     

Using simulation-based training to improve patient safety: what does it take?

BACKGROUND: Through simulations health care workers can learn by practicing skills taught and experiencing mistakes before interacting with an actual patient. A number of areas within the health care industry are currently using simulation-based training to help individuals and teams improve patient safety. WHAT IS SIMULATION-BASED TRAINING? The key components of simulation-based training are as follows: performance history/skill inventory, tasks/competencies, training objectives, events/exercises, measures/metrics, performance diagnosis, and feedback and debrief. WHAT DOES IT TAKE FOR SIMULATION-BASED TRAINING TO BE EFFECTIVE? To be effective, simulation-based training must be implemented appropriately. The guidelines are as follows: understand the training needs and requirements; instructional features, such as performance measurement and feedback, must be embedded within the simulation; craft scenarios based on guidance from the learning outcomes; create opportunities for assessing and diagnosing individual and/or team performance within the simulation; guide the learning; focus on cognitive/psychological simulation fidelity; form a mutual partnership between subject matter experts and learning experts; and ensure that the training program worked. CONCLUSION: The health care community can gain significantly from using simulation-based training to reduce errors and improve patient safety when it is designed and delivered appropriately.     

Blurring the boundaries: scenario-based simulation in a clinical setting

CONTEXT: The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi-clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the 'patient' and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the 'Virtual Chaperone') is evaluated for use in clinical settings. METHODS: A qualitative design (observation and interview studies) investigated volunteer medical students undertaking 2 procedure scenarios (insertion of urinary catheter and wound closure with sutures) within the accident unit of a large London hospital. All procedures were observed in real time and recorded digitally (using the Virtual Chaperone). A protocol was used for structured feedback. Observational and interview data was analysed using standard qualitative techniques. RESULTS: Seven sessions with 22 undergraduate medical students took place over 9 months within 1 centre. Data confirmed the feasibility of using a moveable, self-contained training scenario within an authentic clinical setting. Overall, the response from participants was positive. CONCLUSION: Scenario-based teaching within an authentic clinical environment is feasible and perceived by participants to be educationally useful. This approach blurs traditional boundaries between skills laboratory teaching and clinical practice and may offer considerable advantages in training for clinical procedures.     

Doctor-patient communication in the e-health era

ABSTRACT: The digital revolution will have a profound impact on how physicians and health care delivery organizations interact with patients and the community at-large. Over the coming decades, face-to-face patient/doctor contacts will become less common and exchanges between consumers and providers will increasingly be mediated by electronic devices.In highly developed health care systems like those in Israel, the United States, and Europe, most aspects of the health care and consumer health experience are becoming supported by a wide array of technology such as electronic and personal health records (EHRs and PHRs), biometric & telemedicine devices, and consumer-focused wireless and wired Internet applications.In an article in this issue, Peleg and Nazarenko report on a survey they fielded within Israel's largest integrated delivery system regarding patient views on the use of electronic communication with their doctors via direct-access mobile phones and e-mail. A previous complementary paper describes the parallel perspectives of the physician staff at the same organization. These two surveys offer useful insights to clinicians, managers, researchers, and policymakers on how best to integrate e-mail and direct-to-doctor mobile phones into their practice settings. These papers, along with several other recent Israeli studies on e-health, also provide an opportunity to step back and take stock of the dramatic impact that information & communication technology (ICT) and health information technology (HIT) will have on clinician/patient communication moving forward.The main goals of this commentary are to describe the scope of this issue and to offer a framework for understanding the potential impact that e-health tools will have on provider/patient communication. It will be essential that clinicians, managers, policymakers, and researchers gain an increased understanding of this trend so that health care systems around the globe can adapt, adopt, and embrace these rapidly evolving digital technologies.     

A model for merging residency programmes during health care consolidations: a course for success

INTRODUCTION: As health care delivery systems experience economic and competitive challenges, institutional mergers have become a means for economic survival. Academic hospital mergers are well chronicled, yet little has been written about postgraduate, or residency, training programme mergers and their human and programmatic consequences. Mergers present opportunities to strengthen and redesign residency programmes, but risks include programme disruption, resident and faculty morale, and housestaff and faculty recruitment and retention. Mergers can cause a sense of disequilibrium, influencing resident and staff perceptions of job security, commitment to teaching, and even the viability of the residency programme. OBJECTIVE: We describe a process for the survival and successful merging of existing residency training programmes in the context of larger health care mergers. People, management, and communication skills are critical for leaders of the change process. We offer approaches and guidelines for leaders and others who are involved health care and residency training programme mergers. Awareness and understanding of systems issues and human factors improve the likelihood of success. Although our guidelines are intended primarily for residency programme mergers, they are equally applicable to mergers of health care institutions. CONCLUSION: Successful residency training programme mergers require a carefully planned and executed series of actions that minimise disruptions. Effective communication on all levels is key. Success is associated with effective leadership, good communication skills, an open process with physician input, attention to institutional cultures, and a relatively short timetable. Most important is the continuous involvement, input, and creation of the programme by those most affected.     

‘The unknown becomes the known’: collective learning and change in primary care teams

Context The growing emphasis on teamwork within the National Health Service (NHS) has made it a priority to understand how health care teams learn together and cope with change. Objectives This study aimed to explore how collective learning and change happen in primary care teams and how the process varies across the disciplines of general medical practice, pharmacy and dentistry. Methods This study reports on qualitative data gathered from 10 primary care teams over 1 year, by means of observational visits and 38 semi‐structured interviews. Results Informal collective learning is a powerful team coping mechanism that develops through experiential, evolving and implicit learning processes. These processes are predominantly relational in that they rely on the extent to which team members know and understand one another as people. This makes shared learning an effective but ‘messy’ dynamic, the motivation for which is internally generated by the team itself. Teams report that if they cannot learn together, they cannot meet patient needs. Conclusions These findings demonstrate that teams share their knowledge because they believe it has value, not because they are driven by external incentives or are monitored. This challenges the prevailing assumption that, to be effective, interprofessional learning should be externally managed. As health care develops, it will become increasingly important to consider how to support the internal learning processes of care teams as they navigate complex organisational changes and the shared learning experiences that characterise those changes. Those who support learning and development within the NHS should therefore focus on how relational processes, as well as educational content, contribute to a team’s collective learning capability and the quality of care its members provide.     

Using geographic information systems to understand health care access

BACKGROUND: Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts. OBJECTIVE: To combine the patient data of a community health center (CHC) with health care survey data to display the CHC service area, the community's health care access needs, and relationships among access, poverty, and political boundaries. DESIGN: Georeferencing, analyzing, and mapping information from 2 databases. SETTING: Boone County, Missouri. PARTICIPANTS: Community health center patients and survey respondents. MAIN OUTCOME MEASURES: Maps that define the CHC service area and patient demographics and show poor health care access in relation to the CHC service area, CHC utilization in relation to poverty, and rates of health care access by geopolitical region. RESULTS: The CHC serves a distinctly different area than originally targeted. Subpopulations with unmet health care access needs and poverty were identified by census tract. These underserved populations fell within geopolitical boundaries that were easily linked to their elected officials. CONCLUSIONS: Geographic information systems are powerful tools for combining disparate data in a visual format to illustrate complex relationships that affect health care access. These systems can help evaluate interventions, inform health services research, and guide health care policy. Arch Fam Med. 2000;9:971-978     

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities

BACKGROUND: Racial and ethnic disparities in health care have been consistently documented in the diagnosis, treatment, and outcomes of many common clinical conditions. There has been an acceleration of health information technology (HIT) implementation in the United States, with health care reform legislation including multiple provisions for collecting and using health information to improve and monitor quality and efficiency in health care. Despite an uneven and generally low level of implementation, research has demonstrated that HIT has the potential to improve quality of care and patient safety. If carefully designed and implemented, HIT also has the potential to eliminate disparities. HIT AND DISPARITIES: Several root causes for disparities are amenable to interventions using HIT, particularly innovations in electronic health records, as well as strategies for chronic disease management. Recommendations regardinghealth care system, provider, and patient factors can help health care organizations address disparities as they adopt, expand, and tailor their HIT systems. In terms of health care system factors, organizations should (1) automate and standardize the collection of race/ethnicity and language data, (2) prioritize the use of the data for identifying disparities and tailoring improvement efforts, (3) focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients, (4) develop focused computerized clinical decision support systems for clinical areas with significant disparities, and (5) include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools to address the digital divide. CONCLUSIONS: As investments are made in HIT, consideration must be given to the impact that these innovations have on the quality and cost of health care for all patients, including those who experience disparities.     

Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions

BACKGROUND: Preventable adverse events represent learning opportunities. Indeed, understanding and learning from preventable adverse events are the new organizational imperatives in health care. However, health services researchers note that there is a dearth of research on learning from failure in health care and, in industry, a limited capacity to learn from incidents and failure. PURPOSE: We address the gap between awareness of preventable adverse events and knowledge that relates to how to respond to them effectively. We develop a multilevel model of learning and theorize factors that influence learning from preventable adverse events. METHODOLOGY: Drawing upon theories of organizational learning and organizational behavior, we develop a multilevel model of learning from failure, where perceived characteristics of the events, group composition and dynamics, and the behavioral and structural arrangements of health care organizations are proposed to play important roles. PRACTICAL IMPLICATIONS: Our model highlights factors that facilitate learning from failure and others that impede it. Awareness and attention to these factors can help health care managers extract learning from failures, like preventable adverse events, and may ultimately contribute to reducing the occurrence of preventable adverse events and improving quality of care.     

Patients' perceptions of primary health care in an inner-city practice

BACKGROUND: The 1978 Alma Ata declaration by the World Health Organization emphasized the importance of primary health care, which includes social services and participation, as well as primary medical care. In the UK, primary medical care is based on general practice, increasingly working from purpose-built premises with primary care teams. However, this does not usually include social services or involve patient participation. Both general practice and social services are undergoing reorganization as separate entities, with little emphasis on intersectoral collaboration. OBJECTIVES: We aimed to assess patients' perceptions of primary health care in an inner-city practice in terms of primary medical care, social services and participation. METHODS: Perceptions of medical and social services, together with levels of satisfaction and patient participation, were assessed by self-completed questionnaires for 248 patients attending an inner-city health centre and by 74 home interviews for those who had requested house calls. RESULTS: Patients were more satisfied with primary medical care than with other aspects of primary health care, such as housing. Older patients at home were less satisfied with primary medical care and more satisfied with social services than younger patients attending the health centre. Physiotherapy, chiropody and pharmacy were the services most requested at the health centre. A domiciliary pharmacy, help with hearing aids and a social worker at the health centre were the main requests by older patients at home. CONCLUSIONS: Medical and social services at primary care level should have coterminous boundaries based on general practice populations, ideally with access through multipurpose health centres.      

Behaviour of medical students in seeking mental and physical health care: exploration and comparison with psychology students

CONTEXT: Doctors are often reluctant to seek health care through the usual channels and tend to self-diagnose and prescribe. Medical students learn attitudes and values from clinician role models and may also adopt behaviour patterns that lead them to seek help for physical and mental health problems from informal sources. OBJECTIVES: This study aimed to explore the behaviour of students in seeking health care for physical and mental health problems, comparing medical with psychology students, and to understand what barriers to conventional routes of seeking health care may affect this. METHODS: We administered a questionnaire asking for demographic details and responses to 2 vignettes in which a student from the respondent's discipline was experiencing firstly symptoms of a mental health problem and secondly symptoms of a physical health problem. Data were analysed with spss and univariate anovas to examine differences between respondents. RESULTS: A total of 172 students at the psychology and medical schools at James Cook University in Australia participated. We identified a number of barriers affecting student behaviour in seeking help, which included worries about knowing the doctor they could consult at the university health centre or having future dealings with him or her, and cost of treatment. There were differences between the 2 groups of students. DISCUSSION: There are several barriers for both psychology and medical students to accessing appropriate professional mental health care. Medical students also experience barriers to attaining appropriate physical health care when needed. Psychology and medical students were more likely to seek advice informally from friends and/or family with regard to mental health care.     

Explanations in consultations: the combined effectiveness of doctors' and nurses' communication with patients

BACKGROUND: Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied. SETTING: This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care. METHODS: Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis. FINDINGS: Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement. CONCLUSION: Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education.