Interprofessional Education: The More, the Healthier
Jane Martinsons, AAHPM senior writer
Nowhere is enthusiasm surrounding palliative care interprofessional education (IPE) programs more palpable than at the Interactive Educational Exchange at the AAHPM & HPNA Annual Assembly, which every year features six innovations in education, including IPE programs. The Exchange features interprofessional collaboration on several fronts, including its faculty, attendees, submission reviewers, and the presentations. Attendees consistently laud the event and ask for more time to engage with and learn from presenters according to Laura J. Morrison, MD FAAHPM, of the Yale Palliative Care Program and director of palliative medicine education at Yale School of Medicine, who created and led the Exchange for the first 4 years.
The popularity of both the Exchange and IPE programs in general is driven largely by accreditation requirements, a rapidly changing healthcare environment, and efforts nationwide to improve healthcare safety and quality. Leaders in IPE say that healthcare organizations are not asking whether to start an IPE program—they have heard about the benefits of a multidisciplinary team approach to patient care and medical education for years—but how to do it.
IPE experts who recently spoke to AAHPM Quarterly are eager to share their hard-learned lessons in developing these IPE models, and they invite Academy members to contact them for information about their programs, which enroll an average of 40 trainees or fellows per year. Together, they convey a message of “the more, the healthier” in educating and involving professionals from any discipline, beyond medicine and nursing, whose daily work touches on palliative and hospice care.
But “the more” of what? In addition to wanting more funding, which is a perennial request, these sources say that palliative care patients, providers, and even the field need more of the following resources.
To sustain a knowledgeable workforce, medical and nursing education must mirror the rapidly changing interdisciplinary nature of today’s healthcare environment.
Mark P. Pfeifer, MD, of the Interdisciplinary Curriculum for Oncology Palliative Education (iCOPE), University of Louisville, Louisville, KY, noted that oncology patients in need of palliative care are well aware of interdisciplinary care because they are “tossed around among oncologists, surgeons, primary care physicians, and hospice and palliative care people.”
“We have to look at each other, hear everyone’s perspective, and honor the pride that people have in their own disciplines.”
—Mark P. Pfeifer, MD, Interdisciplinary Curriculum for Oncology Palliative Education (iCOPE)
As such, providers must be comfortable working in fully integrated teams from the start of their careers. At the University of Louisville, all nursing and medical students complete the IPE palliative care training that includes chaplains and graduate-level social work students, as well. “Making it mandatory sends a powerful message about the value of IPE,” Dr. Pfeifer added.
As fellows or trainees, “We have to look at each other, hear everyone’s perspective, and honor the pride that people have in their own disciplines,” Dr. Pfeifer said, adding reassuringly that “we’re not trying to make a chaplain a nurse or a physician a social worker. We’re honoring that there is a value in our differences.”
“It is eye-opening for learners to see what these other disciplines do, appreciate what matters to them, and hear the language of other disciplines so we can better understand each other,” he added. “By the time we get to the bedside of a real-life patient, we’ve experienced this and have a better ability to work as a team for patient-centric, not discipline-specific, care.”
Indeed, IPE programs are expanding into different disciplines. Following the recommendation of the 2013 Institute of Medicine (IOM) report, the Coleman Palliative Medicine Training Program, Chicago, IL, expanded its 2-year program, which is offered at no cost to fellows.
“Initially, the program focused on advanced practice nurses (APNs) and physicians in a wide variety of medical centers across the Chicagoland area, including academic medical centers, but mostly community hospitals and palliative care teams that work in home-care and long-term-care settings,” said Sean O’Mahony, MB BCh BAO MS, of Rush University, Chicago, who codirects the Coleman program with Stacie Levine, MD FAAHPM, of the University of Chicago. Today, mentors and fellows from medicine and nursing, social work, chaplaincy, and pediatric palliative care work together to problem solve, learn from one another, and identify priority areas for workforce development. Moreover, program didactics include a dedicated track in pediatric palliative care.
Changes also are occurring in palliative care at the University of Washington Medical Center (UW Medical Center), Seattle, WA. As one of 57 hospitals certified by The Joint Commission in advanced palliative care, UW Medical Center’s palliative care team comprises physicians, nurse practitioners, a chaplain, a pharmacist, and social workers who provide bereavement counseling to patients and their families as well as to hospital staff, volunteers, and the palliative care team members. Future plans call for the team to include an ethicist, a physician assistant, and a nurse coordinator. UW Medicine, which includes an interdisciplinary team in all four of its hospitals, also extends to the outpatient setting under the umbrella of the Cambia Palliative Care Center of Excellence at UW Medicine, which coordinates the UW system’s palliative care activities in clinical care, education, and research.
March 2015 began the inaugural year of a 9-month palliative care training program for community clinicians from an array of disciplines, according to Lucille R. Marchand, MD FAAHPM, director of palliative care at the UW Medical Center. The Cambia Palliative Care Training Center will continue annual programs. For further information, visit their website.
“The best way to provide quality patient care is to have multiple experts from various disciplines working together.”
—VJ Periyakoil, MD, VA Interprofessional Fellowship Program
Networking within IPE groups occurs on many levels, starting with trainees. VJ Periyakoil, MD, of VA Palo Alto (CA) Health Care System and Stanford University School of Medicine, notes that fellows in her IPE program are friends who hang out together all the time. Rather than regard each other as professional distractions, they see each other as “amazing resources with wonderful expertise,” she said. (Visit aahpmblog.org to read more from Dr. Periyakoil.)
Likewise, fellows in the Coleman training program are developing meaningful and rewarding networks. “They share phone numbers so if they’re having an issue with a patient, they can call someone across town and troubleshoot,” Dr. Levine said.
“Rather than compete in this field, everyone realizes that we’re all in this together to solve problems.”
—Stacie Levine, MD FAAHPM, Coleman Palliative Medicine Training Program, Chicago, IL
Networking in the Coleman program also extends to mentors and fellows and patients and providers, which helps the program meet its major objective of developing a support network among its 30 participating Chicago-area organizations. “There’s just a lot of networking that goes on,” said Dr. Levine, who noted that mentors often present and hold small-group sessions at conferences. “We’re constantly referring people to one another for resources. It’s wonderful to see people reaching out to one another and giving up their time to help with this program. Rather than compete in this field, everyone realizes that we’re all in this together to solve problems,” such as developing staffing models to help alleviate the workforce shortage.
Dr. O'Mahoney added: “One of the nice things is that people can navigate patients to clinicians who can provide a service not available in a community setting. When they are shadowing their mentors, some of our learners have actually seen patients whom they have taken care of before in specialty centers. Those patients have been gratified to see physicians who may have provided them primary care in a community medical setting.”
More Learning Modalities
These sources also emphasize the necessity of instituting both real-life learning and flexible scheduling in IPE curriculums. Some examples include the following:
iCOPE: This 5-year, mandatory IPE program, which was funded by the National Cancer Institute, centers on three components: case-based online learning; real-life clinical experience coupled with reflective writing, which is offered with flexible scheduling; and case problem solving known as interdisciplinary case management experience (ICME). To further enhance scheduling, the ICME incorporates video vignettes of actors playing oncology patients who need palliative care as a basis for team discussions.
“Scheduling logistics is a major barrier for interprofessional education and it’s one you have to solve,” Dr. Pfeifer said. “You need the support of the school’s leadership in each discipline; it’s the only way really to bend scheduling a little. But scheduling is manageable and doable.”
He added: “Nursing has one of the tightest curricular structures. We started to put the reflective writing sessions on the same day as the ICME so that senior nursing students could efficiently be away from their required clinical rotations. Based on feedback from all trainees, we shortened the modules and removed any redundancy in the curriculum to make it cleaner and more efficient.”
UW Medical Center: This mature palliative care program encompasses inpatient consultation service and an interdisciplinary training on the palliative care service for medical and nurse practitioner students, geriatric and palliative care fellows, resident physicians, chaplain residents, social work students, and, soon, pharmacy residents and physician assistant students.
Dr. Marchand emphasized that clinicians from community palliative care services, many of which are just getting under way, are shadowing inpatient providers “to learn about how to provide palliative care in a more sophisticated, interdisciplinary way.” Palliative care training focuses on two levels of trainees: those clinicians and students who will deliver primary palliative care in their various future practices, and geriatric and palliative care fellows who will deliver specialized or secondary palliative care.
Coleman Palliative Medicine Training Program: This 2-year training program features biannual face-to-face group workshops, online learning, and shadowing or experiential learning. Drs. Levine and O’Mahony highlight the mentoring piece of the program, stressing that it allows for individualized learning and professional development, particularly when leadership at participating sites actively engages in the program.
“[Peer mentorship] helps build resiliency against burnout and allows us to find strategies that are effective in the workplace.”
—Sean O’Mahony, MB BCh BAO MS, Coleman Palliative Medicine Training Program, Chicago, IL
“We’re very fortunate in Chicago to have people from many different institutions and organizations, both hospitals and hospices, who are willing and enthusiastic about working together,” Dr. O’Mahony said. “The peer mentorship extends to people who are acting as faculty in this program. It helps build resiliency against burnout (particularly among APNs, according to Dr. Levine) and allows us to find strategies that are effective in the workplace.”
“Being able to speak to someone who works in your own community and is accessible for a periodic face-to-face meeting is very important,” Dr. O’Mahony continued. “Those of us who built this program can share our experience and encourage people in much earlier phases of their careers. We can give them a sense of what is realistic, what they should focus on, how they should present themselves to their leadership, and how palliative care teams can best serve patients and families.”
These experts say their next steps are to share their curricula with others and take their programs to the next level. Dr. Marchand, for example, says that within 2 years, the UW Medical Center hopes to establish a dedicated inpatient care unit for palliative care patients and their families, which will be a healing environment that offers art therapy, bioenergetics, guided imagery, and other healing modalities.
“We want all of our palliative care programs to be potential places for us to conduct cutting-edge palliative care research.”
—Lucille R. Marchand, MD BSN FAAHPM, The Cambia Palliative Care Training Center
Meanwhile, these leaders stress the importance of conducting robust research and developing outcome measures in palliative care education. Dr. Marchand reports that the Cambia Palliative Care Center of Excellence at UW is integrating clinical and health services research into the palliative care services to identify better ways to provide high-quality palliative care to all patients with serious illness. “We want all of our palliative care programs to be potential places for us to conduct cutting-edge palliative care research,” she said, including studying how palliative care consultations and interdisciplinary team interventions can improve quality care for patients and families.
The Coleman team is collaborating with Health Science Management researchers to evaluate the impact of fellows’ educational and quality improvement projects on palliative medicine knowledge and skills and access to hospice and palliative medicine services for patients and their families.
For now, however, these IPE experts warn that it takes hard work to collapse the silos separating the many disciplines working and training in palliative care. Developing iCOPE, for example, required more than a year and a half for 25 people to complete, and leaders there are looking at developing train-the-trainer programs for other IPE programs. The message: organizations must be fully committed to leading the hospice and palliative care field and other medical subspecialties in IPE.
“IPE isn’t just about working in teams; it’s also about outcome measures for patients and their families, clinicians, and learners, as well as respecting everyone in the team.”
—Laura J. Morrison, MD FAAHPM, Interactive Educational Exchange
According to Dr. Morrison, “This whole idea goes beyond hospice and palliative medicine or pediatrics, geriatrics, or physiatry-team settings. IPE isn’t just about working in teams; it’s also about outcome measures for patients and their families, clinicians, and learners, as well as respecting everyone in the team, knowing what others’ roles are and what they bring to the table, and working with diverse people. This trend is happening across health professions’ education. It’s a big priority.”
Dr. Morrison noted further evidence of IPE at “Advancing Compassionate, Person- and Family-Centered Care Through Interprofessional Education for Collaborative Practice,” a November 2014 conference spearheaded by the Schwartz Center for Compassionate Healthcare and the Arnold P. Gold Foundation. National healthcare experts created recommendations and competencies for compassionate, collaborative care through an IPE lens (see www.theschwartzcenter.org).
For more information, visit the Coleman Palliative Medicine Training Program and the Cambia Palliative Care Center of Excellence at the University of Washington. The iCOPE website, which is currently under construction, will feature case studies and curriculum maps. For an in-depth, personal perspective on IPE, visit aahpmblog.org to read more from Dr. Periyakoil.