6

Learning from Students, Patients, and Communities

Summary: In this chapter, students who have learned or are currently learning through interprofessional environments express their opinions on what they believe the educators did right in interprofessional education (IPE) and where IPE could possibly be strengthened. The description of the students’ views of IPE is followed by a description of Sally Okun’s presentation at the workshop. Okun spoke about the benefits of involving patients, caretakers, and communities in team-based and collaborative practices and about how patients can assist in IPE if given the information they need to understand its value. A key message from Okun’s presentation was to get to the “real place” by listening to patients and caretakers, then learn from them and work with them. A similar message was offered by students and the presenter Paul Worley, who encouraged educators to provide students with real-life opportunities that could transform their lives.

STUDENT EXPERIENCES AND TRANSFORMATIONS

In his closing address at the workshop, Paul Worley from the School of Medicine at Flinders University, Australia, described what he heard workshop participants repeatedly describe as a “transformation of the health care system.” However, Worley suggested, the transformation of a system starts with people or, more specifically, with individuals. He encouraged the audience to listen to students and to encourage that transformation to occur in their students. It is through the power of the students, Worley said, that



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6 Learning from Students, Patients, and Communities Summary: In this chapter, students who have learned or are cur- rently learning through interprofessional environments express their opinions on what they believe the educators did right in interprofessional education (IPE) and where IPE could possibly be strengthened. The description of the students’ views of IPE is followed by a description of Sally Okun’s presentation at the work- shop. Okun spoke about the benefits of involving patients, caretak- ers, and communities in team-based and collaborative practices and about how patients can assist in IPE if given the information they need to understand its value. A key message from Okun’s presen- tation was to get to the “real place” by listening to patients and caretakers, then learn from them and work with them. A similar message was offered by students and the presenter Paul Worley, who encouraged educators to provide students with real-life op- portunities that could transform their lives. STUDENT EXPERIENCES AND TRANSFORMATIONS In his closing address at the workshop, Paul Worley from the School of Medicine at Flinders University, Australia, described what he heard work- shop participants repeatedly describe as a “transformation of the health care system.” However, Worley suggested, the transformation of a system starts with people or, more specifically, with individuals. He encouraged the audience to listen to students and to encourage that transformation to occur in their students. It is through the power of the students, Worley said, that 75

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76 INTERPROFESSIONAL EDUCATION FOR COLLABORATION educators will find enthusiastic promoters of social accountability and “a whole lot of other things as well.” These “other things” Worley alluded to were made concrete in the example he offered about one of his students he called, “Lucy,” who is described in Box 6-1. In addition to the student Sandeep Kishore, whose comments are sum- marized in Chapter 2, the workshop participants also heard from a panel of four students who represented nursing, medicine, and pharmacy. The BOX 6-1 Lucy, M.D. Global Physician Trainee Photo courtesy of Paul Worley. Paul Worley, dean of the School of Medicine at Flinders University in Aus- tralia, spoke about a student he knew who was transformed by her educational process. She came from a city environment and had always wanted to be a city pediatrician. Like the other medical students at Flinders, this student had the op- portunity to study for an entire year in a small rural community in Australia—an opportunity that she accepted. She worked in a remote, underserved area where the need for health-related interventions and health care was immense. That experience transformed her, Worley said. After graduation this student—whom Worley referred to as “Lucy,” although that was not her real name—decided that instead of working as a pediatrician,

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LEARNING FROM STUDENTS, PATIENTS, AND COMMUNITIES 77 moderator of the session, Mohammed Ali, a founding member of the Young Professionals–Chronic Disease Network based at Emory University, commented that it is not just the future employers or the supply side that has a vested interest in educating students to work collaboratively; the students themselves are seeking these opportunities. In the end, he added, it might be the students who propel educators to do more interprofession- ally because it seems that students are beginning to demand an IPE to learn she wanted global physician training. She went to work in Southern Sudan with Médecins Sans Frontières because none of the doctors who had been trained in Sudan wanted to work in this challenging area. While in South Sudan, Worley said, Lucy lived in what was called a “privileged hut” because it had a dug-out section in the hut beneath the level of the ground in which she slept. The reason it was dug out and the reason she was privileged was that when the bandits came through with their submachine guns and terrorized the village, the bullets would fly over her, rather than at her head level, as they would have if she had slept on a bed above the ground. As Worley put it, “Some would say that just going and working there is evi- dence enough that there was a transformation in this person.” But there was more. Lucy e-mailed him one night asking his advice as to whether she had “done the right thing.” Lucy described being confronted by a patient who came to her seek- ing medical attention because she had been bleeding for a week post-delivery. The reason for the bleeding, which Lucy understood, was that the woman had not delivered her placenta. Lucy knew what to do technically to be able to stop the bleeding, Worley said, and she also knew that the woman needed a blood trans- fusion. The challenge Lucy faced was to try to find an HIV-negative, O-positive blood donor. Worley described what Lucy did next as “the real transformation.” Knowing that she herself was O positive, Lucy lay down on a mat next to her patient, put a needle into her own arm, took a liter of blood and gave that blood to the patient. In her e-mail to Worley she asked, “Did I do the right thing?” Lucy knew that if the woman did not get blood quickly, she would die no matter how good Lucy’s technical skills were or how she learned them. Lucy had the head knowledge, Worley said, and she had the hand knowledge, but it was equally important that she had the heart knowledge. Worley said that he sensed that the transformation that Lucy experienced was what many of the workshop participants were trying to convey to their stu- dents. The goal is not just to give technical skills or to transmit information or to inspire, but to change the hearts of the people who are the next generation of health professionals. Lucy did not learn what she did from a textbook or from a curriculum—she learned it from being given the space in the curriculum to get to know her patients as people. Getting to know her patients as people, Worley said, was the transformational opportunity that changed Lucy’s life.

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78 INTERPROFESSIONAL EDUCATION FOR COLLABORATION how to work more effectively together in an effort to improve patient- and person-centered care. Angella Sandra Namwase spoke first in the session. Namwase is cur- rently at Makerere University in Uganda pursing a degree in nursing while holding several leadership roles with the Medical Students Association and the Students Professionalism and Ethics Club in Uganda. According to Namwase, IPE helps students appreciate other professionals and helps students avoid developing negative stereotypes that could impede future work with other students. Although the size of the IPE class at Makerere can at times be overwhelming, Namwase said, she was quick to point out the advantages of shared learning. The example she offered came from her hospital rotation where the students noticed that challenges in the hospital wards that could best be addressed with assistance from the biomedical engineering students on their team. In essence, Namwase said, the main advantage of IPE is that it helps students appreciate teamwork and build an interprofessional social network while being trained as health professionals. The social perspective of interprofessional education resonated with Erin Abu-Rish, who presented next. Abu-Rish is a second-degree nurse who said she is now pursuing a Ph.D. from the University of Washington because of the extensive opportunities for interdisciplinary research. Ac- cording to Abu-Rish, social interactions outside of work time are important for students and faculty to continue learning about each other’s roles. This extracurricular activity adds tremendous value to the interprofessional ex- perience for both faculty and students, she said. In addition to pointing out the value of extracurricular activities, Abu- Rish offered four other suggestions for IPE leaders from her perspective as a student. The advice, she said, drew on her varied IPE experiences, including dental service learning trips to a small community in Honduras, starting the Institute for Healthcare Improvement (IHI) open school chapter at the Uni- versity of Washington, and publishing in the Journal of Interprofessional Care. One of these messages was that small group activities, problem-based learning, and interactive approaches to education draw students in and make the education more memorable. And, she added, team debriefs are effective and need to be positively oriented and well facilitated. A third sug- gestion was to encourage positive interactions early and often in order to develop an interprofessional culture that includes social interactions outside of class time. This has been an important part of their IPE approach with their IHI open school group where people can get to know other health professional students by name and on a personal level. Fourth, said Abu-Rish, support for and facilitation of student involve- ment helps increase the sustainability of student organizations and reduces barriers to participation. She cited the example of her work with the Proj- ect Chance grant. As Abu-Rish explained it, her interprofessional team of

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LEARNING FROM STUDENTS, PATIENTS, AND COMMUNITIES 79 students spent the vast majority of the funding period trying to figure out how to work together, how to engage patients, and how to obtain institu- tional review board approval. That is the point that students want to get to—they want to be able to work with patients together as a team. The final two thoughts Abu-Rish offered to the workshop participants were to strengthen linkages between interprofessional education and practice and to facilitate more interprofessional faculty development in order to expand the pool of faculty members who are IPE competent and willing to support innovative approaches to education. Thomas Lewis, a first-year psychiatry resident from the Medical Uni- versity of South Carolina (MUSC), was the next to speak. He discussed his interprofessional education experiences at medical school and how he ap- plied those experiences in a clinical setting. Lewis said he first got involved with IPE through the Student Interprofessional Society (SIPS) at MUSC. SIPS is a part of the Creating Collaborative Care initiative established by his mentor, Amy Blue, several years ago. Lewis said that this program was similar to the one discussed by Erin Abu-Rish in that it focused more on the social aspect of interprofessionalism. According to Lewis, the program brought students together from different health professional schools for monthly meetings that highlighted examples of good teamwork going on at the medical university as well as in community service projects. The group provided students a chance to get to know each other as students, to talk about their different programs’ strengths and weaknesses, and to compare the challenges that each was facing in his or her own professional education. Another important educational opportunity Lewis discussed was his participation in the pilot IPE course at MUSC. The course was optional at first but is now required. In that class, he worked on root cause analyses with an interprofessional group of students; they would look at a patient’s case and discuss what went wrong with the case, what could have been done differently, and where communication broke down among the differ- ent professions. That, said Lewis, was very helpful for him, especially when he started his clinical rotation as an intern and already knew how to engage with other health professionals, such as nurses, respiratory therapists, and physical therapists. Those are examples of the way in which interprofessional education shaped his thinking, Lewis said. “I say it really helped me understand where the other professions came into play, how we can work together, and at the end of the day the common theme is patient care. It really boils down to providing good patient care and understanding our own professions to do that together.” A point brought up by Lewis in his presentation—and echoed by the next speaker, Jenny Wong, a third-year pharmacy student from the Uni-

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80 INTERPROFESSIONAL EDUCATION FOR COLLABORATION versity of Minnesota—concerned the message being sent to students when interprofessional education is an optional instead of a required course. When it is required, Lewis said, it sends a clear message that it is something important that the student needs to learn. Wong agreed with that. In her ed- ucation, she said, there was one required interprofessional course. But, she said, that course exposed her to IPE, which was the impetus for her pursuit of more interprofessional opportunities at the university. As she reflected upon her IPE experiences at the university, she said that she felt that the elective IPE courses helped her learn about what interprofessionalism is and that her experience at the student-run clinic helped her apply the theoreti- cal knowledge in practice. Despite her high regard for the interprofessional opportunities afforded to her at the university, Wong would have liked a broader exposure to other health professions, such as physical therapy, den- tistry, public health, and medicine; most of her interprofessional experiences were with nursing only, she said, which she found limiting. A key observation that Wong said she made during her IPE experience was that in the rotations there is a difference between actual collaboration and a team made up of multiple different disciplines. As she put it, “I can have teammates from medicine, nutrition, and nursing, but if they do not talk to each other, then that is not IPE, and that is just a different Skittles mix of professionals.” Wong also said that she would have liked more practice-based inter- professional experiences earlier in her education. According to Wong, it was not until her third year that she had a simulation in which nursing and pharmacy students were working together that was not paper-based. It was through her academic experience and working with patients that she was able to appreciate the value of interprofessional work. As Wong explained it, it really helped her “see how this interdisciplinary system helped my patient, because now [my patient] is actually fully controlled in all three disease states because he had a continuation of care with every single one of those professions that actually came to help him.” LEARNING FROM PEOPLE Sally Okun from PatientsLikeMe, who led the breakout group on en- hanced access, provided a synopsis of that group’s discussions. Her small group was asked to consider five areas of potential innovation within the general area of enhanced access; those five areas were culture, pedagogy, curriculum, metrics, and human resources for health (HRH). Okun started her report to the workshop participants by saying that one of the things her group was charged with was to think about enhanced access in terms of the education of patients and populations as learners and educators of team-based, collaborative care. She reported trying to address this charge

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LEARNING FROM STUDENTS, PATIENTS, AND COMMUNITIES 81 from a global perspective of what persons and patients and populations and communities might need to understand about IPE and what it might mean to them. To do this, her group positioned its core values within a framework that focuses on social accountability. She reported that with this structure it could become possible to determine what patients or persons would need to know about IPE and that, with this better understanding, patients could then become the teachers of health providers and the educators of students in how health professionals might better engage them and their community. The main message Okun and her group promoted was to turn the dis- cussions into actions by getting to the “Genba,” which is a Japanese term for the real place. There are a number of resources that could be helpful in creating actionable next steps where real people with real problems are located, she said. For example, input from the community regarding its priorities and how health professional educators and providers could best meet these community-defined priorities would be helpful. Okun said that accomplishing this will involve knowing who the best person is to lead an intervention and when and where the intervention should take place. To obtain this information, Okun and her group encouraged optimizing nontraditional pathways of health care delivery and health care education in order to more fully uncover what patients and their families and people within a community think would benefit them the most. Okun empha- sized the importance of community engagement for health providers and educators to better understand the selected priorities of the people in the community they serve. Without that understanding, educators may end up designing curricula in different settings that do not meet the overall needs of the people who reside in that community. By framing IPE within a social accountability context, educators can begin to integrate a culturally diverse IPE with collaborative care models at the person, community, and population level. Involving multiple profes- sions in one team, created with the “real place” in mind, will likely better reflects the community the team is designed to serve with regard to race and ethnicity, said Okun. This team will be made up of culturally sensitive members who are more likely to connect with and possibly build a trusting relationship with their patients and thus make positive health outcomes more probable. In considering pedagogic innovations—or as some Forum members pre- fer “androgogic” innovations that targets adult teaching methods—Okun stressed that it is important to create active learning processes that enhance access to “the right people at the right time.” This could include better use of technology by learners and patients of all ages and in all communities. It could also include a meaningful involvement of students by providing

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82 INTERPROFESSIONAL EDUCATION FOR COLLABORATION them access to communities and patients, which can provide a unique and memorable form of education. For curricular innovations, Okun said that she believes feeling that the redesign of the curriculum needed to be developed after a full inventory of the resources had been conducted and after there was a firm grasp of the needs of the individuals and populations being served within the system. Educators should be integrating with patients and people within the com- munity so that they can understand and learn from those who would be the beneficiaries of their efforts. Like the other presenters at the workshop, Okun reported that she and her group struggled with how to measure the impact of the programs that would be designed based on her group’s ideas. However, she did comment that the members of her group emphasized their desire to consider the return on investment or the impact of such community-based innovations on health at both the individual level and the population level. When these community and population impacts are understood, Okun said, it might be possible to suggest metrics that measure outcomes for patients, as measured by patients first and understood by the health professionals second. Okun added that a good social accountability metric does not yet exist, but she said that having such a tool would be useful in assessing student learning and in evaluating IPE programs. In her comments, Okun described her group’s desire to include care- givers from within the community and the population in designing IPE, explaining that the patients themselves are vulnerable because they are ill. Okun also emphasized the urgency for acting immediately if IPE innovators in the United States are to seize current opportunities through accountable care organizations, primary care, medical home models, and accreditation standards. However, Okun warned innovators to be careful not to create IPE in silos, which could then develop its own set of silos. Finally, she said, educators and health professionals need to get to the “real place” where real people with real problems are. Listen to the patients and the caretak- ers, she said, learn from them and work with them to identify resources and reveal redundancies that should be removed and that do not provide a return on investment. Uncover gaps in the health and educational systems, correct them, and then ultimately find ways of measuring success and of integrating the social accountability piece into that the model. Empowering Patients Forum member and workshop speaker Marilyn Chow from Kaiser Permanente suggested that an interesting perspective might arise if patients and their caretakers were educated and empowered to select their own team. What might this look like? One possibility, Chow said, is that patients

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LEARNING FROM STUDENTS, PATIENTS, AND COMMUNITIES 83 and their families might fire a poorly functioning team. Forum member and workshop speaker Elizabeth Goldblatt from the Academic Consortium for Complementary and Alternative Health Care added that if individu- als assembled their own health care teams, the makeup of a team might include both conventional and alternative health providers. She supported her comment by referring to the work of David Eisenberg and colleagues (2001, 2012), which suggests value in combining conventional care with complementary and alternative medicine. But as one participant pointed out, the public still does not know which places provide safe care. Patient advocate Rosemary Gibson from Archives of Internal Medicine asked, “How might patients learn to trust their providers within a team-based system?” This triggered a response from speaker Paul Grundy, the Global Director of IBM Healthcare Transformation. He said that the trust issue is why IBM has been pushing so hard for the medical home model. The most trusting relationship that exists in humanity outside of one’s family is that between a patient and his or her healer, he said. IBM wants to put in place a structure that makes that trust trustworthy. As Sally Okun remarked, mechanisms need to be put in place that will help patients know they can trust and depend on the systems being built. Furthermore, educators and practitioners can learn from patients, who can be a source of data. This sort of relationship will reinforce the partnership between patients and their providers. Trust among health providers is also important, and speaker Craig Jones, the executive director of Vermont Blueprint for Health, com- mented that providers work within two systems of trust. The first involves trusting a new organization of care in a situation in which providers fear losing revenue and control. The second involves demonstrating an objective way of evaluating care under the new system, so that trust can be obtained through measurable outcomes. When providers realize their livelihoods are not threatened and when there is verifiable objective evidence that the concept works, Jones said, then trust evolves among providers of care and between providers and patients. Workshop speaker Stefanus Snyman from Stellenbosch University high- lighted person- and people-centered care when responding to a question about how patients reacted to receiving a more holistic clinical assessment through the World Health Organization (WHO) International Classifica- tion of Functioning, Disability and Health (ICF) framework (described in Chapter 2). He replied that patients were thrilled. They were thrilled be- cause for the first time they felt they were being treated as persons and that health providers took into consideration all aspects of their lives. But the real value came, he said, when students and communities joined together. In the example Snyman cited, students identified a longstanding pediatric diarrhea problem in one township while conducting home visits. They then worked with parents and city officials to resolve the diarrhea in 2 days

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84 INTERPROFESSIONAL EDUCATION FOR COLLABORATION versus the months or years it usually takes to resolve such issues. By us- ing the ICF framework, Snyman said, students were forced to take greater ownership and to find solutions to problems affecting all aspects of their patients’ lives. This example shows that students are equipped to become change agents to improve patient outcomes and to strengthen health sys- tems. And, as Paul Worley said, “The key is to give learners enough space to be the amazing creative individuals they are.” Key Messages Raised by Individual Speakers • Students are beginning to demand an interprofessional educa- tion. (Abu-Rish, Ali, Lewis, and Wong) • IPE helps students appreciate other professionals and avoid developing negative stereotypes. (Lewis and Namwase) • When IPE is a required course, it sends a message to students that IPE is important. (Lewis and Wong) • Provide interprofessional education experiences that are real and memorable and that enhance access of students to patients, caretakers, and communities. (Abu-Rish, Okun, Snyman, Wong, and Worley) • Include caregivers from within the community and the popula- tion when designing IPE, and for understanding the needs and selected priorities of target populations. (Okun) REFERENCES Eisenberg, D. M., R. C. Kessler, M. I. van Rompay, T. J. Kaptchuk, S. A. Wilkey, S. Appel, and R. B. Davis. 2001. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey. Annals of Internal Medicine 135(5):344–351. Eisenberg, D. M., J. E. Buring, A. L. Hrbek, R. B. Davis, M. T. Connelly, D. C. Cherkin, D. B. Levy, M. Cunningham, B. O’Connor, and D. E. Post. 2012. A model of integrative care for low-back pain. Journal of Alternative and Complementary Medicine 18(4):354–362. Frenk, J., L. Chen, Z. A. Bhutta, J. Cohen, N. Crisp, T. Evans, H. Fineberg, P. Garcia, Y. Ke, P. Kelley, B. Kistnasamy, A. Meleis, D. Naylor, A. Pablos-Mendez, S. Reddy, S. Scrimshaw, J. Sepulveda, D. Serwadda, and H. Zurayk. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923–1958.