John H. Tegzes
College of Veterinary Medicine, Western University of Health Sciences, USA
Dr. Jones, a small-animal general practice veterinarian, sees an 8-year-old golden retriever for a 3-month follow-up examination after the dog has been diagnosed with hypothyroidism and initiated on synthetic thyroxine replacement therapy. However, the dog does not seem to have improved since the start of the drug therapy; in fact, it seems quite a bit worse. The client was provided with a written prescription for the drug after diagnosis and had the prescription filled at a neighborhood retail pharmacy. She has brought the medication with her to the veterinary visit, and when Dr. Jones reads the label she realizes that the prescription was filled at one-tenth the dose that was prescribed. She quickly blames the pharmacist for making a mistake, unaware that the pharmacist’s scope of practice allows for alterations in dosage if they suspect an error on the part of the prescriber. Both professions believe that the other is to blame.
Dr. Smith is in the exam room with a mom, her 5-year-old daughter, and their pet rat. The rat is freely climbing over the girl’s shoulders and the child repeatedly kisses the rat every time it crosses in front of her face. Dr. Smith notices a sizable pustule on the girl’s upper lip. She asks the mom if she has seen her pediatrician for it. The mom replies yes, and that the pediatrician referred the child to her dentist, since she thought it was an oral health issue. The dentist has since prescribed two different antimicrobials, but neither has made any difference. Dr. Smith asks the mom if she mentioned to the dentist that her daughter has a pet rat that she regularly kisses. The mom responds that she hasn’t. “Is that important?” she asks. Dr. Smith calls the dentist to talk about the normal flora of the rat, and to suggest perhaps selecting a different antimicrobial that might be more efficacious.
As is apparent from these scenarios, veterinarians are important members of the healthcare team. While the One Health concept reminds us of that, it is important to work collaboratively in everyday practice. Interprofessional practice and education (IPE) prepares veterinary students to work collaboratively (see Figure 7.1).
The everyday practice of veterinary medicine is changing, and has been for the past few decades. Such change is evident everywhere there are animals. There are increasing numbers of veterinary specialty organizations with record numbers of clinicians achieving Diplomate status. There are many new internship and residency programs within academia and in private practice and industry. The availability of veterinary specialists is spreading far and wide, and the public demand for high-tech and high-quality care by competent veterinarians is increasing every year. Corporate veterinary practices are getting to be the norm in the United States, and the day of the solo veterinary practitioner is becoming a distant memory.
At the same time, the growth of the scientific body of knowledge and advances in the practice of medicine have challenged the veterinary curriculum. It has become extraordinarily difficult to prepare veterinary graduates with all the knowledge, skills, attitudes, and behaviors necessary to be successful veterinarians and meet the needs of a rapidly changing profession and demanding society within a four-year curriculum. Collaboration is the key to success, yet today’s veterinary curricula have not necessarily taken on the challenge of preparing veterinary graduates to be successful collaborators. IPE is one way for the veterinary curriculum to prepare veterinary graduates for the necessities of collaborative practice.
A One Health approach to healthcare was first formally introduced in Calvin Schwabe’s textbook Veterinary Medicine and Human Health in 1964. Today, virtually every veterinarian is familiar with the term One Health and the concepts that it promotes. Put simply, it calls for collaboration between human and veterinary medicine to effectively cure, prevent, and control illnesses that affect both humans and animals. Yet if we were to take a quick poll of the general public or even any of the other health professions, there would be very few who would recognize the term, or understand its focus.
The veterinary profession is somewhat insular, yet we often become defensive when other health professions seem to misunderstand our roles and responsibilities in improving the health of animals, humans, the environment, and society. It is time to share our wisdom! Again, IPE is an excellent way to begin educating health professionals during their early professional education so that collaboration and wisdom-sharing become a natural part of their practice. Many of those involved in the One Health initiative focus their efforts, research, and conferences on the science and treatment of zoonotic diseases. There is less emphasis on developing collaboration skills. IPE emphasizes collaboration and develops effective communication habits and professionalism. It is less focused on disease pathogenesis, diagnosis, and treatment protocols and therefore pairs well with One Health. This is the primary reason why it is important for veterinary curricula to embrace and participate in IPE.
Just as the One Health initiative can trace its roots back to the 1960s, IPE had its early beginnings in 1972 after an Institutes of Medicine (IOM) report entitled “Educating for the Health Team” called on academic institutions to begin educating students in the health professions to practice collaboratively. The IOM called on healthcare teams to share common goals and incorporate the patient, family, and communities as members of the team. Moreover, the report noted that the existing educational system was not adequately preparing health professionals for such teamwork. Initially, not much changed in how health professions students were educated; the same educational silos remained common throughout the 1970s, 1980s, and 1990s. Universities and health professions colleges remained rather insular, establishing their own cultures and educational practices without conferring much with other health professions. It was not until students entered the clinical environment that they even encountered other health professions, and then contact was brief and focused on specific functions. Even healthcare records were kept separate, with rarely a chance for sharing patient goals and treatment plans across professions.
The IOM (2000, 2001, 2003) published further reports identifying the need for healthcare delivered by interprofessional teams. These new reports largely cited preventable errors as the impetus for better collaboration, noting that communication failures are major obstacles in delivering quality care across the professions, and calling for systematic changes in order to create cultures of cooperation and coordination.
In 2003 the IOM sponsored a summit on health professions education where five competencies central to the education of all health professions were identified. The IOM competencies recommend that students should be able to provide patient-centered care; apply quality improvement; employ evidence-based practice; utilize informatics; and work in interdisciplinary teams. Every one of these competencies is just as relevant to the practice of veterinary medicine. In veterinary medicine, patient-centered care not only includes a focus on the individual animal patient, but also incorporates a client-centered focus, where the specific goals of the client/animal owner are addressed and the client is embraced as a member of the veterinary healthcare team.
The World Health Organization (WHO) has also noted the need for collaborative practice in mitigating the global health workforce crisis by publishing the “Framework for Action on Interprofessional Education and Collaborative Practice” in 2010. The WHO defines IPE as occurring when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes. From a global health perspective, this describes the One Health initiative to a tee.
Setting the One Health perspective aside, veterinary medicine still needs interprofessional practice and education to meet the ongoing needs and demands of society. In the developed world, increased veterinary specialization and vast improvements in diagnostic capabilities and treatment strategies are de rigueur. Just step into any general or specialty veterinary clinic in the United States to see the array of diagnostic equipment and therapeutic tools that are commonly used. Computed tomography (CT) scans, magnetic resonance imaging (MRI), digital radiography, endoscopy, arthroscopic and laparoscopic surgeries, chemotherapy regimens, ventilators, portable complete blood cell (CBC) and serum chemistry machines – the list goes on and on. All of these technologies and advances require special knowledge, skills, and behaviors. As a result, more veterinarians are pursuing advanced training, certifications, and specialty boards. With these advances comes an increased need for veterinary care delivered by teams. Often, educators will suggest that because veterinary students do not deliver human care, they need not participate in IPE. Yet this is the wrong assumption. IPE is not about human healthcare; rather, it is about team-based healthcare, regardless of the species of focus. As the WHO has defined it, IPE occurs when students learn about, from, and with one another to enable effective collaboration and improve health outcomes. Such students need not be treating the same patients, or even practicing in the same settings. Collaboration skills are universal, and can be learned and practiced across settings. When students are challenged to learn and practice such skills together, they will gain the added benefits of learning about all the health professions, and be better prepared to coordinate care when their professions do in fact intersect.
Veterinary medicine has continued to change in ways very similar to how human healthcare has evolved over the past three or four decades, with increased specialization and, unfortunately, fragmented healthcare delivery as a consequence. Let us face the challenge of providing coordinated, collaborative care by learning from the other health professions, examining their systems, and proactively shaping the future of veterinary practice so as not to repeat those professions’ past errors. IPE can help with this too, by providing veterinary students and faculty with insights into the systems that have driven and shaped the human healthcare system.
Collaborative care saves lives. Plainly and simply, creating healthcare that is coordinated and collaborative can prevent suffering and premature deaths. Based on 1984 data, the IOM estimated that up to 98 000 Americans die each year from medical errors, with most of those errors a result of communication failures. An updated analysis published in 2013 estimated that more than 400 000 human patients experience premature deaths annually associated with preventable harm in healthcare (Interprofessional Education Collaborative Expert Panel, 2011; James 2013). While such a high number of incidents does not occur in veterinary practice, increased specialization and the challenges that it poses to care coordination and communication mean that it is not unreasonable to assume that veterinary patients may also experience preventable harm. While most veterinary curricula incorporate communications skills, these are largely focused on doctor–client communication, with less time devoted to building communication skills within the veterinary or interprofessional healthcare team. Even the veterinary primary literature notes the incidence of patient harm due to communication failures between veterinarians and pharmacists (Cima, 2014; Wells et al., 2014). Such examples of preventable errors in veterinary practice are the reason that IPE is needed universally across veterinary education today.
In 2011 a multidisciplinary health professions panel (IPEC) convened to define and establish educational competencies to be used across health professions and IPE programs throughout the United States. Four competency domains and specific competencies within each domain were established. IPEC published its report, findings, and recommendations that same year (Interprofessional Education Collaborative Expert Panel, 2011). A similar effort in Canada had already published a national interprofessional competency framework the year before (Canadian Interprofessional Health Collaborative, 2010). A similar report was published in the United Kingdom even earlier (UK Centre for the Advancement of Interprofessional Education, 2007). All of these reference similar core competencies across the health professions, yet individual national reports are necessary considering the differences in how both health professions education and healthcare delivery are regulated, accredited, funded, and delivered in each nation. This section will refer primarily to the US publication.
In the United States, the four core competency domains for IPE that have been established are (Interprofessional Education Collaborative Expert Panel, 2011):
- Values and ethics for interprofessional practice.
- Professional roles and responsibilities.
- Interprofessional communication and collaboration.
- Teams and teamwork.
The competency domains and the specific competencies that follow are purposely general in nature and are meant to function as guidelines, allowing flexibility within the professions and at the institutional level. The desired principles of the interprofessional competencies are (Interprofessional Education Collaborative Expert Panel, 2011):
- Patient/client/family centered.
- Community/population oriented.
- Relationship focused.
- Process oriented.
- Linked to learning activities, educational strategies, and behavioral assessments that are developmentally appropriate for the learner.
- Able to be integrated across the learning continuum.
- Sensitive to the systems context/applicable across practice settings.
- Stated in language common and meaningful across the professions.
- Outcome driven.
As is evident in Box 7.2, the overarching goals of the IPE competencies reach beyond educational methods and professional behaviors. The general nature of these competencies therefore poses significant challenges in assessment, since the specific competencies describe skills more than they do knowledge. Likewise, specific curriculum components tend to focus on skills development, such as communication, rather than on knowledge acquisition, which requires more complex assessment strategies. Other competencies are more knowledge based and can be assessed with traditional multiple-choice format exams, for instance professional roles and responsibilities.
As this is an educational endeavor that crosses professions and universities, it is important to note that the stated goals aim for changes in systems and policy as well as in the education of health professions students. While this is very useful in the formative years of interprofessional education globally, it makes it particularly difficult to design and evaluate curricula. Suddenly, designing curricula around the basic sciences seems easy! Specific strategies for designing curricula around these competencies will be described later in this chapter.
Table 7.1 lists the specific competencies under each competency domain. Additionally, it details specific types of educational assessment that can be used to assess students’ proficiency and mastery of the competency.
Table 7.1 Core competencies for interprofessional practice
|Specific competencies||Assessment strategies (knowledge, skills, attitudes, behaviors)|
|Place the interests of patients and populations at the center of interprofessional healthcare delivery||Attitudes, behaviors|
|Respect the dignity and privacy of patients while maintaining confidentiality in the delivery of team-based care||Attitudes, behaviors|
|Embrace the cultural diversity and individual differences that characterize patients, populations, and the healthcare team||Knowledge, skills, attitudes, behaviors|
|Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions||Knowledge, attitudes, behaviors|
|Work in cooperation with those who receive care, those who provide care, and others who contribute to, or support the delivery of, prevention and health services||Attitudes, behaviors|
|Develop a trusting relationship with patients, families, and other team members||Skills, attitudes, behaviors|
|Demonstrate high standards of ethical conduct and quality of care in one’s contributions to team-based care||Attitudes, behaviors|
|Manage ethical dilemmas specific to interprofessional patient/ population-centered care situations||Knowledge, skills, attitudes, behaviors|
|Act with honesty and integrity in relationships with patients, families, and other team members||Attitudes, behaviors|
|Maintain competence in one’s own profession appropriate to scope of practice||Knowledge, skills|
|Communicate one’s roles and responsibilities clearly to patients, families, and other professionals||Knowledge, skills, behaviors|
|Recognize one’s limitations in skills, knowledge, and abilities||Attitudes, behaviors|
|Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs||Knowledge, skills, behaviors|
|Explain the roles and responsibilities of other care providers and how the team works together to provide care||Knowledge|
|Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable||Knowledge, attitudes, behaviors|
|Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention||Knowledge, skills, behaviors|
|Forge interdependent relationships with other professions to improve care and advance learning||Attitudes, behaviors|
|Engage in continuous professional and interprofessional development to enhance team performance||Knowledge, skills, behaviors|
|Use unique and complementary abilities of all members of the team to optimize patient care||Attitudes, behaviors|
|Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function||Knowledge, skills, behaviors|
|Organize and communicate information to patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible||Knowledge, skills|
|Express one’s knowledge and opinions to team members involved in patient care with confidence, clarity, and respect, working to ensure common understanding of information and treatment and care decisions||Attitudes, behaviors|
|Listen actively, and encourage ideas and opinions of other team members||Skills, behaviors|
|Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others||Attitudes, skills, behaviors|
|Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict||Attitudes, behaviors|
|Recognize how one’s own uniqueness, including experience level, expertise, culture, power, and hierarchy within the healthcare team, contributes to effective communication, conflict resolution, and positive interprofessional working relationships||Knowledge, skills, attitudes, behaviors|
|Communicate consistently the importance of teamwork in patient-centered and community-focused care||Attitudes, behaviors|
|Teams and teamwork|
|Describe the process of team development and the roles and practices of effective teams||Knowledge|
|Develop consensus on the ethical principles to guide all aspects of patient care and teamwork||Knowledge, attitudes, behaviors|
|Engage other health professionals – appropriate to the specific care situation – in shared patient-centered problem-solving||Attitudes, behaviors|
|Integrate the knowledge and experience of other professions – appropriate to the specific care situation – to inform care decisions, while respecting patient and community values and priorities/preferences for care||Knowledge, attitudes, behaviors|
|Apply leadership practices that support collaborative practice and team effectiveness||Knowledge, skills, attitudes, behaviors|
|Engage self and others to constructively manage disagreements about values, roles, goals, and actions that arise among healthcare professionals and with patients and families||Skills, attitudes, behaviors|
|Share accountability with other professions, patients, and communities for outcomes relevant to prevention and healthcare||Skills, attitudes, behaviors|
|Reflect on individual and team performance for individual, as well as team, performance improvement||Skills, attitudes, behaviors|
|Use process improvement strategies to increase the effectiveness of interprofessional teamwork and team-based care||Knowledge, skills, attitudes, behaviors|
|Use available evidence to inform effective teamwork and team-based practices||Knowledge, attitudes, behaviors|
|Perform effectively in teams and in different team roles in a variety of settings||Knowledge, skills, attitudes, behaviors|
Source: Adapted from Interprofessional Education Collaborative Expert Panel (2011).
It is clear from this table that a variety of teaching methods need to be developed and implemented to achieve these competencies. Likewise, a variety of assessment strategies are also necessary and may include traditional written exams, objective structured clinical exams (OSCEs), portfolio evaluations that include reflective practice exercises, and evaluations by clinical preceptors using rubrics developed for interprofessional practice, such as the ICAR (Curran et al., 2011).
As it is a relatively new educational endeavor, there is no one single formula for creating and implementing an IPE curriculum. Although many of the health professions accrediting bodies now require IPE as an accreditation standard, they do not specify during which years of the curriculum or even how much IPE is required. There are many logistical challenges that must be met and each individual academic institution has unique needs and cultures to be considered. The approach used at Western University of Health Sciences (WesternU) to overcome these challenges is highlighted in Box 7.3. This is just one example of the work that is sometimes necessary to create an educational program that spans multiple professions in various colleges and programs.
Some academic institutions introduce learners to IPE during the clinical years of instruction, while others begin during the preclinical stages of the curriculum. There are advantages and disadvantages to both approaches. Beginning early in the preclinical years allows learners to begin thinking differently and critically about their own roles and responsibilities as well as those of the other health professions. Students will then enter their clinical years with new ideas about how their profession fits into the healthcare team. On the other hand, if IPE is offered during the clinical years, learners can apply new concepts and collaboration strategies right away while they rotate in the clinics; such an approach may cement the learning more deeply.