What Are We Thinking? (Part Two)

Last month I wrote about the looming movement to expand the capacity to produce more health professionals of every stripe. I called for us to consider what work these health professionals would move toward, how they would be organized for practice, and what new technologies might change the demand curve for their skills. Most of my comments were focused on the practice world and what might be done there to lessen or redirect the demand for health workforce. This month I want to return to the same question of whether or not we should build new capacity, but approach it from the perspective of education.

There are five interrelated themes that are important as we think about how those being educated to be health professionals today will meet the challenges of a system of care over the next four decades. For me these themes are: teams, critical thinking, integration with practice, organizational mastery, and disruptive technology. This essay addresses teams and, to a lesser extent, critical thinking and organizational mastery. I believe that the way in which education is realigned will be a prime determinant of whether or not the overall health care system will come to a soft landing around change or run into the wall of expanding needs and demands with increasingly limited capacity to change and grow.

The critique of the practice world started with teams, so it is important to begin with teams for education as well. There has been much rhetoric and many noble efforts to move health professional education to a more team orientated basis since the early 1960s. However, if we are truthful about the real condition today, we will conclude that professional boundaries are higher, opportunities for collaboration fewer, and the distance between the professions at our academic health centers greater than ever before. This is not to say that important experiments have not been attempted, or that at every campus there are a few individuals who work together year in and year out to improve the level of collaboration. There are even a handful of places that have struggled to develop and maintain these elements as a vital part of their program. However, these exceptions are in glaring distinction to the common reality.

Most students at health professional schools do not work together in training and there is little effort to understand the modalities of practice developed by each profession. There are few places where students come together to look at the overall needs of patients, to think about these needs critically and systematically, and to bring the wonderful skills and competencies from the various professional traditions together to serve these needs. These students miss out on the most vital of all team lessons. They miss out on learning that it is not about their individual professions and skills, but instead about the patient's needs and the team's ability to restore health or maintain well-being.

Moving toward a more team orientated reality sounds so seductively simple and desirable that it is surprising we have not made more progress. However, the forces arrayed against the integrative power of interdisciplinary teams are themselves muscular and important to how health care and science are understood. From the mid-nineteenth century onward, the attraction of specialized and more reductionistic knowledge has grown. All of the health professions we have today emerged or took on their modern identify in the years around the turn of the last century. It was a time when everyone looked to the force of modern science to empirically examine problems with analytical skills and derive a disinterested and objective remedy. This approach grew in power because it worked, but it also generated the domains of inquiry and practice which would solidify in the twentieth century as the health professions. These professional modalities led to the creation of a model of success that included movement to university-based professional schools, the proliferation of research agendas, the conception of research institutes, emergence of accreditation and licensure policies, and a seemingly unending growth in the years of training to practice.

All of this has produced walls between the professions that are thick and high. It is these walls that protect the integrity of professional identity generating many of the positive outcomes of the health system today. On the darker side these walls protect the interest of the professions and keep them from moving forward together to break through the gridlock of the current system where more resources than are needed are spent in ways that produce suboptimal outcomes and increasingly leave provider and consumer dissatisfied with the ways things are.

Here are three ideas to consider that could help move the team agenda forward:

First, make teamwork a common agenda early on and make it as intertwined with the curricula as possible. Generations of change agendas towards teamwork in the educational curricula have failed once reaching the professional level for a lack meaning and functionality across all health professions. Before any teaching in the disciplines takes place I suggest we bring new health professional students together from the gamut of disciplines including medicine, nursing, dentistry, pharmacy and allied health to start. We have them work through the areas of knowledge, problem solving and collaboration that they will have in common. These areas would likely include the care system, epidemiology, what it means to be a health professional, what each profession does and how they work, provider patient relations, working in teams, and ethics. Typically, these topics are added on after the students have gotten the technical skill, which very likely sends the message that these things aren't important and that they aren't shared among the disciplines.

The second way I would enhance our team competence is by making all of these introductory experiences problem-based challenges that require critical thinking. In teams, the new students could develop the capacity to think critically about what the patient needs are and how those needs could be met. The students might then be more able to offer answers naturally with a non-professional bias. We often see this skill set when an older student returns to professional training already grounded with problem solving and critical thinking skills, or when someone trained in one profession migrates to another for additional training. By encoding problem solving before we create the discipline bias, we will generate professionals who will approach a career with a different framework.

Finally, I would give these groups team skills. This would include content and practice in areas such as self-awareness, conflict management, giving and receiving feedback, decision making, systems thinking, and managing change. These are the skills that will make them successful throughout a career. We rarely touch on them in professional training and do even less when others are present. If we want these skills to manifest later we should start with them early.

A comprehensive introduction of this type across the professions, which is problem focused and skill-based, might productively occupy the first four of five weeks of new professional students' time. I realize the curriculum is crowded, time is scarce, and few really know how to teach such topics, but can we really continue to ignore such a pressing area of concern?