5
Workforce and Education

Enlarge the opportunity, and the person will expand to fill it.

—Eli Ginzberg


Dame Carol M. Black delivered the keynote for the summit session on workforce and education. Black described drivers and barriers of change in the area of workforce development and discussed the importance of “worklessness,” or unemployment, in undermining health. In the panel discussion, moderated by Dr. Elizabeth A. Goldblatt, the panelists elaborated on the implications of advances in integrative medicine for the education and training of the nation’s health professionals and researchers and discussed strategies for changing curricula, including interdisciplinary approaches, team-based training, and expansion of core competencies in healthy living and wellness.

An often-mentioned point in this session, described by Black and other panelists, is the need to expand interdisciplinary and multidisciplinary education to promote effective teamwork. This is increasingly important, because most health care interventions now require coordination and teamwork, said Sir Cyril Chantler. Yet, health practitioners typically are educated and trained in professional silos, hindering their ability to quickly transition and adapt to a team environment. Interprofessional education should begin early, particularly for physicians, to reinforce shared values and overcome the culture that rewards individual accomplishment, said Dr. Adam Perlman.

Demonstration projects also would be useful in developing more effective educational models for integrative health practitioners. One type of project, suggested by Dr. Mary Jo Kreitzer, would incorporate community health centers into interdisciplinary education opportunities. Another would involve training nonphysicians to be primary care providers; Dr. Richard Cooper viewed this prospect as inevitable, because of the looming shortage of primary care physicians. The latter model might be



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5 Workforce and Education Enlarge the opportunity, and the person will expand to fill it. —Eli Ginzberg Dame Carol M. Black delivered the keynote for the summit session on workforce and education. Black described drivers and barriers of change in the area of workforce development and discussed the impor- tance of “worklessness,” or unemployment, in undermining health. In the panel discussion, moderated by Dr. Elizabeth A. Goldblatt, the panel- ists elaborated on the implications of advances in integrative medicine for the education and training of the nation’s health professionals and researchers and discussed strategies for changing curricula, including interdisciplinary approaches, team-based training, and expansion of core competencies in healthy living and wellness. An often-mentioned point in this session, described by Black and other panelists, is the need to expand interdisciplinary and multidiscipli- nary education to promote effective teamwork. This is increasingly im- portant, because most health care interventions now require coordination and teamwork, said Sir Cyril Chantler. Yet, health practitioners typically are educated and trained in professional silos, hindering their ability to quickly transition and adapt to a team environment. Interprofessional education should begin early, particularly for physicians, to reinforce shared values and overcome the culture that rewards individual accom- plishment, said Dr. Adam Perlman. Demonstration projects also would be useful in developing more ef- fective educational models for integrative health practitioners. One type of project, suggested by Dr. Mary Jo Kreitzer, would incorporate com- munity health centers into interdisciplinary education opportunities. An- other would involve training nonphysicians to be primary care providers; Dr. Richard Cooper viewed this prospect as inevitable, because of the looming shortage of primary care physicians. The latter model might be 111

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112 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC an appropriate outgrowth of developing new competencies for nurse practitioners and others. A third type of project, advocated and pioneered by Dr. Victoria Maizes, organizes training programs built around core competencies in integrative health. Regardless of professional and specialty mix, health care practitio- ners today are not able to overcome some of the most important factors in health and disease—the socioeconomic factors raised by Black, such as employment, education, and poverty. In many respects, Cooper said, poverty constitutes the greatest of all the challenges facing the health care system. WORKFORCE AND EDUCATION KEYNOTE ADDRESS Carol M. Black, Academy of Medical Royal Colleges Even in the most affluent countries, people who are less well off have substantially shorter life expectancies and more illnesses than the rich. —Richard Wilkinson and Michael Marmot Black began her keynote address by observing that the challenges facing the American and British health systems are remarkably similar and reflect global forces. There are several drivers to change within the realm of health care, many of which were described by other presenters throughout the summit and many of which are globally applicable. These drivers include expectations of the public and of individual patients, inequalities in health and health care, variations in the quality of care, health needs reflecting demographic shifts, the impact of lifestyle on health, advances in medical sciences, rising costs, and inefficiencies and failings of the system, Black noted. These many drivers suggest a needed analysis of whether education is appropriately aligned to overcome im- portant barriers to change and meet the needs of the population. Person-Centered Care and the Social Determinants of Health Expectations of the health care system begin with care that is safe, effective, easy to access, and of high quality. People also want care that is personal; they want it to be geared to their own understanding of health and their expectations for restored or maintained capacity. Person- centered care should provide direct advice and support on lifestyle

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113 WORKFORCE AND EDUCATION choices, such as smoking, nutrition, exercise, and drugs and alcohol. It also should offer support and advocacy for family problems, poverty, housing, and education. Unfortunately, the health professions education systems are not focused on the personal aspects of care. Personal care is compromised by time pressures on clinicians; the average seven-minute patient encounter with British physicians is not conducive to developing a therapeutic relationship. Truly person-centered care will take into account the socioeconomic determinants of health, which include poverty or wealth, stress, early life experiences, social support or exclusion, work and unemployment, ad- diction, nutrition, oral health, and transportation (Marmot, 2004). Com- bined, these factors are major influences on longevity and health status throughout the course of one’s life, and they need to be considered in the development of health policy, said Black. This shift would entail provid- ing incentives for promoting healthy ways of living, rather than primarily reimbursing drugs and surgery (Chopra et al., 2009). Relationship of Work and Health Employment is one of the leading modifiers of health and illness, yet it is a factor rarely recognized by the health care system. Work has long been recognized as a fundamental social determinant of health. Galen observed that employment is nature’s physician and is essential to human happiness; Voltaire said it banished boredom and poverty; and Osler said it brings hope to the young, confidence to the middle-aged, and repose to the elderly. Theodore Roosevelt declared, “Far and away the best prize that life offers is the chance to work hard at work worth doing.” The findings of nearly 500 articles about the positive effects of work on physical and mental health and well-being were recently compiled in a single review (Waddell and Burton, 2006). The long-term effects of worklessness require special attention in the current recession, suggested Black. Worklessness—especially over a long term—is a greater risk to health than many diseases. It poses greater risks to health than many hazardous occupations, such as construction, and it doubles or triples the risk of mental illness. Children who grow up in workless families have a five times greater incidence of mental illness than children living in a family with stable employment. Illness related to worklessness and work absences related to sickness cost the United Kingdom £100 billion annually, the same as the cost of running the Na- tional Health Service.

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114 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Black noted that while health care providers often discuss many health behavior and environmental factors with their patients, they rarely discuss patients’ employment in a meaningful way. Health care providers need to know about the benefits of good work; they should use return to functional capacity and to work as a clinical indicator of success; and they should be aware of work-related concerns in the health care setting, such as communication with employers. Efforts are now under way in the United Kingdom to develop training programs that help physicians, especially in family medicine, focus on the health aspects of work and worklessness. Workforce Reorientation Meeting the expectations of patients and the public, providing per- son-centered care, and incorporating greater awareness of social deter- minants of health into health care necessitates change in health professional education. Trust, the fundamental component in the rela- tionship between patients and providers, requires providers who demon- strate a number of attributes that include communication skills, empathy, nonjudgmental behavior toward patients, integrity, a commitment to quality and safety, and the ability to work in teams. Black noted that these attributes should be instilled throughout the education process. Teamwork is especially important in meeting public expectations and addressing social determinants of health. Teamwork within profes- sions and across professions is an increasingly essential component of success in health care; it also helps solidify relationships with both pa- tients and other providers. Effective teamwork includes the ability to transfer tasks within a multiprofessional team, especially as tasks tradi- tionally performed by physicians devolve on other professionals in the care team. Teamwork also includes competence in the coordination of care, which requires awareness of the skills and attributes of other team members. Yet, teamwork is an area of weakness in physician education and training. In the United Kingdom, teamwork in health care has been found to be somewhat unstructured, short-lived, rushed, and opportunis- tic, rather than strategic. To meet the need for change in workforce education, the Academy of Medical Royal Colleges in the United Kingdom has developed a Medical Leadership Competency Framework that encompasses five do- mains: personal qualities, working with others, managing services, im-

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115 WORKFORCE AND EDUCATION proving services, and setting direction. Each of the five domains includes subdirectives. For example, working with others includes developing collaborative networks, building and maintaining relationships, and en- couraging others to contribute, as is shown in Figure 5-1. The framework includes a generic curriculum for physician training that can be adjusted to specific specialties. Use of the framework in the training of nurses and dentists is also planned. The competency framework highlights teamwork. Black emphasized that all health professions students should learn to collaborate effectively across disciplines, because the best health care plan may include a com- bination of treatments provided by diverse practitioners. Some health professionals may fear losing their professional identity within a team, but clustering in teams tends to be additive to professional skills and knowledge, as each team member provides unique expertise. Specialty Distribution of Health Professionals and Medical Education Changing educational content to focus on teamwork is only one way to meet rising public expectations and address patients’ full needs, in- cluding those involving the social determinants of health. Another vital aspect of change involves shortages of practitioners in some fields, such as gaps arising from the unbalanced specialty distribution of physicians. Black noted that concern exists in both the United States and the United Kingdom that too many physician specialists, such as surgeons, and too few primary care physicians are being trained. Additionally, new cohorts of health professionals may be required to adequately meet the health needs of the populations in an integrated way. Nursing, Black said, has a seminal relationship to integrative medicine, and much of what is now called complementary and alternative medicine has sat within the domain of nursing for generations. Nurses are educated to be holistic practitio- ners—attentive to mind, body, and spirit, and with an understanding of

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116 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Working within teams uraging contribution Enco aintaining relat and m ions ing hip ild Bu s loping networks Deve Working with Others Ma rvices Qualit al ies n Se nagi Perso ng Delivering the Service S n er o v cti Im pr ices ire ting ov Dt ing Se FIGURE 5-1 Competency framework: Working with others. SOURCE: National Health Service Institute for Innovation and Improvement, 2009. the range of complementary therapies that are available. To advance the workforce and redress imbalances, advances in medical education are necessary. Lifestyle and prevention need to be the cornerstones of the future health care system and thus a larger component of education. To help produce the necessary changes, medical education in the United Kingdom is being refocused around general principles that could be expanded to other professions. The regulatory body, the General Medical Council, requires adherence to several concepts: preparation for

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117 WORKFORCE AND EDUCATION lifelong learning, a shift from acquiring knowledge to acquiring clinical skills, an emphasis on communication and caring, and greater attention to ethical and legal issues. The Medical Schools Council is responding by updating curricula and teaching methods, professionalizing teaching, and carefully auditing the results. In addition, the General Medical Council now explicitly requires that all medical undergraduates be made aware of a wide range of comple- mentary and alternative therapies, how and why patients use them, and how they might affect patients’ other treatments. All 33 British medical schools have informed Black that they are implementing this mandate in a variety of ways including through elective courses. At Bristol Univer- sity, for example, medical students are taught the role of the fine arts in medicine, psychoneuroimmunology, and similar topics. Complementary and alternative medicine is presented as a model of care with a holistic approach. Students at Bristol may also elect to concentrate on the global environment in human health, where they consider climate change, water scarcity, mass migration, and food policy in health. A survey of British graduate medical education indicates that these programs appear to be lagging in the incorporation of integrative medi- cine. The core curriculum for all 65 specialties includes requirements in such areas as communication, recognition of important risk factors, con- sideration of family history, and patient characteristics and preferences, and contains an attitude and behavior component that calls for the ability to show empathy for patients using complementary and alternative thera- pies, as well as for patients whose first language is not English. How- ever, there is no explicit inclusion of integrative medicine or complementary and alternative medicine in the curricula. For example, the chair of the Joint Committee on Higher Surgical Training informed Black in January 2009 that “none of the surgical curricula contain any elements of complementary or alternative medicine.” Barriers to Change Black noted that there are a number of barriers to reorienting the workforce to a more integrative approach to health. Competing demands for time and resources in health services and health professions training are formidable. Training the trainers can be difficult in the face of com- peting interests. Integrating the needs of patients with workforce compe- tencies presents an enormous challenge that requires strong leadership.

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118 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Integrative health approaches also require a willingness to break free of professional silos. Overcoming these barriers is difficult, Black said, be- cause the resistance to change and the immense authority of the status quo stand in the way; it is much easier to do nothing, especially in sys- tems as complex as health care. PANEL ON WORKFORCE AND EDUCATION Panel Introduction Elizabeth A. Goldblatt, Academic Consortium for Complementary and Alternative Health Care I am convinced that the progress or decline of humanity rests very largely with educators and teachers, who therefore have a tremendous responsibility. If you are a teacher, try not to merely transmit knowledge, but try at the same time to awaken your students’ minds to basic human qualities such as kindness, compassion, forgiveness, and understanding. —Tenzin Gyatso, 14th Dalai Lama Goldblatt characterized education as the foundation of a compas- sionate and caring health care system and posed the question of what the role of education is in moving toward integrative medicine. The desire by people and patients for collaboration among their health care providers suggests a need to create innovative multidisciplinary educational ex- periences, training, and guidelines for all licensed health professionals. In Goldblatt’s view, this multidisciplinary approach is appropriate in the didactic, clinical, and research spheres—especially in clinical out- comes research, which can accommodate multifactorial approaches of integrative medicine. It also is relevant to the undergraduate, graduate, and continuing education levels, because training is needed at all levels to improve collaboration, teamwork, and the patient referral process. The practice of truly integrative, patient-centered medicine requires interprofessional education, rather than educational silos, Goldblatt stated. Silos reinforce fragmentation and impede the collaboration that helps patients access combinations of treatments provided by diverse

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119 WORKFORCE AND EDUCATION practitioners across disciplines. By contrast, collaborative education can serve to increase health professionals’ knowledge of core competencies, which could include disease prevention, lifestyle change, diet, nutrition, exercise, stress reduction, environmental toxins, and issues in health pol- icy—areas where most traditional education programs are weak, said Goldblatt. Collaboration also has been shown to increase patient satisfac- tion, improve health outcomes, and reduce costs. As education changes, the workforce will change, Goldblatt said. The shortage of primary care practitioners could be alleviated, as the mantle of primary care is assumed not only by physicians but also by other competent practitioners, such as nurse practitioners, physician as- sistants, naturopaths, chiropractors, and traditional Chinese medicine practitioners, many of whom already serve as the first contact for patients in the health care system. The workforce also may change as the nation shifts to a focus on wellness rather than disease, and as providers regu- larly begin treatment with less invasive interventions before resorting to more invasive ones. Goldblatt echoed other participants in saying that our country needs to focus on health promotion and disease prevention. Education—at all levels—will have a key role in this fundamental shift. Education Curricula Mary Jo Kreitzer, University of Minnesota Kreitzer expressed the view that shifting the focus of the health care system from disease to health requires new models of care—models that will use all appropriate licensed health care practitioners as primary care providers and allow them to practice to the highest and best use of their educations and capacities. Educating heath professionals in integrative medicine is as daunting a task as transforming health care. The status quo is deeply entrenched as a result of the strength of traditional medicine in academia, said Kreitzer. Still, progress has been made in medical and nursing education, as inte- grative health content is being moved from elective to required core cur- ricula. More graduate programs now offer specialization in integrative health; for example, the University of Minnesota is initiating a DNP de- gree (doctorate of nursing practice) in integrative health and healing. At the same time, educational institutions oriented to complementary and alternative medicine are expanding their course content on critical think- ing and the role of evidence.

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120 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC The National Center for Complementary and Alternative Medicine (NCCAM) has stimulated many of these changes. However, the neces- sary transformation in education requires shifts in content and process, and must go beyond the incremental changes that have been made so far, said Kreitzer. A shift in content could include an increased focus on health rather than the disease orientation that is currently used for educat- ing biomedical professionals. The scope of training for both conventional providers and complementary and alternative practitioners is often nar- row, failing to focus on health, wellness, nutrition, exercise, stress man- agement, and other lifestyle issues, or on the social and environmental factors of health. Students are merely introduced to integrative therapies, without the necessary depth of exposure. The process for education also needs to shift, Kreitzer reiterated. Education in silos hinders students’ ability to quickly transition and adapt to a team environment. She pointed out that a range of providers is re- sponsible for the care of the same patient in the same setting, yet there is almost no overlap in the education of those providers. Systematic inter- disciplinary education is necessary for true collaboration. According to Kreitzer, disruptive innovation is needed in both health professions education and health care delivery. Generally, innovation must come from outside, as leaders in a given field—whether in manu- facturing, energy, or health care—tend to be victims and not initiators of disruption, due to their resistance to change and their failure to perceive its advances (Christensen et al., 2009). Faculty cultures in both tradi- tional and nontraditional health professions are deeply ingrained and may be a barrier to change. Disruptive innovation must focus on the future vision of health care, emphasizing health instead of disease, a different mix of health professionals, a broader array of therapeutic approaches, and consumers who actively take charge of their health. To match the health needs of the public, external investments in edu- cation should be predicated on innovation, Kreitzer said, and integrative health can provide the impetus for innovation. A new model of care sug- gests a different mix of health professionals, such as more nurse practi- tioners, physician assistants, and others to provide primary care, and a diminished focus on specialty care. A potential example of innovation could involve the 7,000 community health centers across the country that provide a medical home to indigent patients, furnish well-baby care, and fill other gaps in the health care system. Schools of nursing and comple- mentary and alternative health professional training programs could part- ner with community health centers to create a comprehensive, holistic

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121 WORKFORCE AND EDUCATION integrative model for health care. The American Recovery and Rein- vestment Act of 2009 included funding for the Health Resources and Services Administration (HRSA) to launch pilot projects that could be used to develop integrative health programs in the centers. In this way, “crisis would serve as a catalyst for reform,” said Kreitzer. Core Competencies Victoria Maizes, University of Arizona Maizes noted that medical competence is defined as the possession and use of the requisite knowledge, technical skills, and humanism (Jon- sen, 1990). The word competency is derived from the Latin root com- petere and has three meanings. The first meaning is to compete, as in a race or game. The competent contestant was one who could run the race from start to finish. Maizes pointed out that educational leaders in inte- grative medicine have identified four domains of competence. First, inte- grative medicine practitioners should possess a broader set of knowledge, such as familiarity with nutritional recommendations for both specific conditions and optimal health, and knowledge about mind–body skills, physical activity, and spirituality. Second, practitioners should demon- strate a broader set of attitudes, such as awareness of how a practitioner’s own personal, cultural, and spiritual beliefs affect his or her treatment recommendations, and an appreciation of the importance of self-care. Third, they should own a broader set of skills, such as the ability to communicate effectively with patients about all aspects of their health when taking a comprehensive health history. The fourth, and the final, domain reflects a second meaning of the Latin competere which is to seek together. It consists of a set of values that are timeless and relate to this deeper Latin meaning, and are exemplified by the dedication of the practitioner’s own human experience to benefit patients. Several model programs are now in place that incorporate these core competencies, noted Maizes. They exemplify another aspect of seeking together—namely, collaboration. One model is a 15-hour elective called The Healer’s Art that was developed in the early 1990s by Dr. Rachel Naomi Remen at the University of California, San Francisco. This course is now taught to medical students in 70 medical schools, with plans to adapt it to nursing schools. The students write their own personal mission statement—in effect, their own personal Hippocratic Oath. An excerpt from a male medical student’s oath reads:

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122 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC May you find in me the mother of the world. May my hands be a mother’s hands, my heart be a mother’s heart. May my response to your suffering be a mother’s response to your suffering. May you know through our relationship that there is some- thing in this world that can be trusted. Another model teaches clinicians to use the new patient-centered, decision-making tools that are emerging in health information technol- ogy. For example, Adjuvant! Online is a tool that assists breast cancer patients and their clinicians. Based on a woman’s age, diagnosis, and pathology, the tool calculates the benefit of a specific hormonal therapy, such as tamoxofen, expressed in terms of a percentage reduction in the risk of a recurrence. When offered, for example, a 5 percent reduction, one woman may decide that this benefit is not worth the risks of the treatment, whereas another woman may feel the benefit is an opportunity to be seized. The tool facilitates patient–physician communication, pa- tient-centered care, and informed decision making. A third model is the Integrative Medicine in Residency (IMR) pro- gram developed at the Arizona Center for Integrative Medicine. IMR is being piloted, collaboratively, in eight residency programs around the country. IMR includes 200 hours of mandatory training and could even- tually be applied to training programs for primary care physicians, spe- cialty physicians, physician assistants, and nurse practitioner programs throughout the United States and abroad. Maizes said that residency programs are the area within the medical education system that is most amenable to change, and they offer fertile ground for educating physicians in integrative medicine. Medical school curricula are packed, and it is in residency that physicians learn valuable practical skills. The number of trainees is typically small, offering an advantage to the use of a common online curriculum. Building evalua- tion into the system helps meet certification requirements. Maizes said that we have the opportunity to embody all the meanings of competency by finishing the task of building competency-based curriculum, seeking solutions together, and collaborating.

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123 WORKFORCE AND EDUCATION Interprofessional Education Adam Perlman, University of Medicine and Dentistry of New Jersey Perlman compared the progress of interprofessional education (IPE) to the stages of change model commonly referred to in behavior change interventions. 1 He noted that the time for advancing IPE from the con- templative and preparation stages to action has come. IPE is “any type of educational training, teaching, or learning session in which two or more health and social care professions are learning interactively” (Reeves et al., 2008). The need for IPE grows out of the fragmentation of modern health care, as patients are typically treated by multiple practitioners. Yet, these practitioners often do not communicate with each other ade- quately nor do they coordinate their services to assure quality care that is effective, efficient, and free of medical errors. Perlman emphasized that the lack of IPE in physician education may render many physicians reluctant to collaborate or refer patients to other providers. For example, a primary care physician may resist discussing nutrition or acupuncture options with a patient, because these conversa- tions may require time the physician does not have, information the phy- sician is not familiar with or expert in, and possibly a referral to a provider with whom the physician is not acquainted. To be most effective, Perlman said that IPE should be initiated early in the education and training process—in medical school, in the case of physicians. Students then can be introduced to other professions and be- gin to learn to work together effectively in teams. It is during the didactic phase of education that students in different disciplines can best develop shared values and master agreed-upon competencies. To facilitate this practical component of IPE, the curriculum must reflect the real-life ex- perience of clinical teams, in order to prepare students for the dynamic environments they will be practicing in. Active learning methods must be implemented, including the use of simulated patients and clinical scenar- ios. Students should also learn how historical relationships among pro- fessions affect collaboration and where the frictions tend to occur. Perlman described multiple challenges facing IPE, including the conventional medical mindset or culture, in which individual accom- plishments are highly prized. Trained to find it and fix it, physicians are seldom rewarded for practicing effectively within teams. Lack of truly collaborative teams can reinforce professional territorialism, perhaps the 1 Stages of change model includes five stages: precontemplation, contemplation, action, maintenance, and relapse (Prochaska and DiClemente, 1983).

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124 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC greatest barrier to IPE. Differences in philosophy and language also cre- ate barriers between professions. Additionally, IPE is challenged by a lack of interdisciplinary, interinstitutional, and even interprogram rela- tionships within schools. In terms of research, IPE suffers from an overall dearth of well- developed studies and evidence. Most studies are small, most interven- tions are heterogeneous, and most methodologies are limited. Evidence is needed on the key elements of effective IPE, including skills and knowl- edge, but especially elements that influence attitudes. Models of best practice need to be developed in order to assess the effects of IPE on quality of care, service delivery, and patient satisfaction. Most impor- tantly, Perlman said, an evidence base is needed for changing reim- bursement policies to foster interprofessional collaboration in education, in research, and in the delivery of services to patients. Workforce Reorientation Richard A. Cooper, University of Pennsylvania Cooper has developed projections of a large and critical nationwide shortage of physicians; a deficit of 200,000 physicians, approximately 20 percent of the needed supply, could arise by 2025. Because federal offi- cials and other policy leaders maintain competing visions, current poli- cies do not account for this shortage and provide no buffer against its likely effects, said Cooper. As a shortage comes to bear, the medical education pipeline, which can be up to 12 years in length, will prevent a quick response and remedy. Signs of a shortage are already becoming apparent, Cooper said. Many physicians practicing in the United States are graduates of interna- tional medical schools, as U.S. medical schools fail to fill current needs. Many patients complain about long waits for appointments with a physi- cian, or even about trouble finding a physician. A rapidly escalating physician shortage would, like the recent col- lapse of the financial sector, produce a new reality unknown to any living American. Cooper said that it would upend many of the expectations ex- pressed by previous speakers at the summit. Implicit in many of the speakers’ prescriptions for change is the notion that physicians will play a crucial role in integrative medicine. However, in a shortage situation, physicians are likely to withdraw into “ever more narrow scientific and technological spheres, while other disciplines evolve to fill important

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125 WORKFORCE AND EDUCATION gaps” (Cooper et al., 2002). In Cooper’s view, physicians will continue to fill the specialty roles they are uniquely trained for, abandoning pri- mary care and leaving it almost entirely to nonphysician providers. Coo- per noted that the notion that future patients may experience regular 30- minute visits with a primary care physician is not credible in economic or personnel terms. A long historical trend supports this prediction, he said. As physi- cians have fallen from almost one in three health care workers in the United States in 1920 to about 1 in 12 today, nurses and others have assumed tasks previously reserved to physicians. Until just a half-century ago, physicians resisted the notion that nurses could measure blood pres- sure. Yet today, nurses and other nonphysician health professionals do so routinely, and many are gaining broad competencies through doctorates and other graduate degrees. Their climb up the education ladder facili- tates the shift away from physician dominance in performing health care functions. In short, Cooper said that physicians are sharing the platform of care with an expanding array of nonphysician clinicians, whose train- ing and responsibilities are increasingly congruent with providing pri- mary care. Additionally, Cooper observed that specialty care is being redefined by technology and that primary care is an amalgam of wellness, preven- tion, and illness care. He suggested that a new workforce strategy be de- veloped that includes economic and structural plans developed around the realities of the current situation. Society will have to determine the margins of personal and collective responsibility for primary care, as do- ing everything that primary care conceivably could do is not possible. While there are many challenges to the current health care system, Cooper contended that the greatest challenge is poverty. People with the lowest 15 percent of income consume almost double the health care re- sources as people with the highest 15 percent of income. The health care crisis cannot be solved without coping with this major challenge. Standards, Regulation, and Patient Safety Cyril Chantler, The King’s Fund Chantler divided his remarks between two exhortations: primum non nocere, first do no harm, and deinde adjuvare, next do some good. To prevent harm, regulation of the practice of medicine was initiated in Europe and the United States in the 18th and 19th centuries. The regula-

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126 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC tory scheme prohibited the unauthorized practice of medicine, which led to the criminalization of the practice of traditional or complementary medicine by nonphysicians. As recently as 1998, complementary medi- cine could be practiced in the Netherlands only by those who were medi- cally qualified. In 2002, however, the World Health Organization recommended that governments adopt legislation and regulations for practice, education, training, and licensing in complementary medicine. Chantler said that policy makers should assure that laws and regula- tions are truly necessary, and avoid overregulation that restricts innova- tion and increases costs; they should be proportionate, matching the degree of regulation to the extent that an activity can cause harm; and they should be enforceable. In the United Kingdom, physicians are regu- lated by the General Medical Council, which (like state boards of medi- cal examiners in the United States) maintain a registry of physicians and can discipline physicians for ethical and other infractions. The General Medical Council also regulates osteopathic physicians, chiropractors, dentists, nurses, midwives, opticians, and pharmacists, while the Health Professions Council (HPC) covers 13 professions: art therapists, bio- medical scientists, chiropodists/podiatrists, clinical scientists, dieticians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, prosthetists/orthotists, radiographers, and speech and language therapists. Legally, only those registered can use these titles. The HPC is currently seeking to regulate herbalists, acupuncturists, Chinese medicinal practitioners, and clinical psychologists, but assimilat- ing all modalities into the regulatory framework would be enormously expensive and cumbersome. As another means to distinguish a well- trained practitioner who subscribes to an ethical framework of practice, a new self-regulatory body, the Complementary and Natural Healthcare Council, has recently been established. All practitioners who wish to, and who provide evidence of their proper training and ethical and safe prac- tice, may register with this new council. Regulatory agencies are very competent at testing knowledge and re- sponding to complaints, but, Chantler said, they are less adept at measur- ing clinical practice skills, such as surgical talent or ability in psychotherapy. He suggested that practitioners undertaking a specific technique, such as the Alexander technique in the management of chronic back pain, should all be held to the same standard of perform- ance, regardless of profession.

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127 WORKFORCE AND EDUCATION Regulation has been viewed as necessary ever since Adam Smith famously observed, in The Wealth of Nations, that “[p]eople of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public.” But, in The Theory of Moral Sentiments, Smith suggested that it is the conscience of the pro- fessional, not regulation, that provides the greatest protection to the pub- lic. To do some good, Chantler said, the evidence base for complemen- tary medicine should be built on effectiveness. While it is always desir- able to understand the efficacy of an intervention—that is, whether an intervention works under ideal conditions, such as those of a clinical trial—it is possible to study the effectiveness of a treatment for patients in routine clinical care without having a full understanding of its efficacy. This may be particularly important with complex interventions that have psychological as well as pharmaceutical or physical components. Evalua- tion should ensure that a treatment is safe, beneficial, and cost-effective. The latter is especially important in establishing the value for public in- vestment. The evidence base, in Chantler’s opinion, should include a combina- tion of clinical outcomes, measures of patient satisfaction, and patient outcome measures, such as normal activities of daily living. It is impera- tive to know how well patients with chronic diseases are functioning over the course of time. Most interventions, Chantler pointed out, now require integration— within and among different professions, different care modalities, and different locations, because much of the care provided takes place out- side the hospital. This gives fundamental importance to maintaining an up-to-date and thorough medication record, including treatments pro- vided through complementary modalities. Even if a single electronic health record for patients in all circumstances is not yet feasible, Web- based systems are being developed so that a contemporary summary can be made available to all practitioners involved in the patient’s care. Chantler emphasized that integrative care requires such thorough com- munication. Chantler concluded that, while the paramount concern is to ensure the patient’s safety, the purpose of regulation is also to assure a high standard of care. Standards for professional competence should be clear and consistently applied, and outcomes, particularly patient outcomes, need to be measured, recorded, and audited. One important standard for

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128 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC the future will be the adequacy of teamwork and an assessment of how well health professionals communicate with each other. Panel Discussion Members of the panel responded to questions from the audience in a discussion moderated by Goldblatt. Selected points of discussion follow. Collaborative Clinical Training One question raised the issue of competence-based certifications for broadly defined practices, such as health-life coaching that could be un- dertaken by a variety of professions including health educators, nurses, and nutritionists. Maizes commented that people who train together often end up practicing together, so that interprofessional credentialing would be a logical extension of interprofessional education. Agreeing, Kreitzer suggested that community health centers can serve as both an integrated clinical site and a site for integrated education. Incorporating Integrative Medicine into the Curriculum Another question prompted further panel discussion on how to make integrative medicine part of the curriculum in medical schools, as well as in education programs for other health professions. Maizes suggested that it takes a champion within the school to promote the change. It also takes tools, such as a user-friendly program, with built-in evaluation, that meets applicable accreditation requirements. Kreitzer added that faculty development is needed, in order to help members of the entire faculty become comfortable with the presence of integrative medicine and be more accepting of a change in culture. The importance of faculty devel- opment has been demonstrated in the R25 educational grant program of the NCCAM. Chantler noted that medical school deans are frequently asked to add new material to the curriculum. He also noted that the purpose of medi- cal school is to provide education, with training to come afterward. He said that the education should include a common set of values, across professions, but the experience of interprofessional education is best

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129 WORKFORCE AND EDUCATION placed at the graduate level. There, in residency programs, members of different professions can learn together, as they prepare to work together. Physician Shortage Asked to elaborate on issues of physician supply and distribution, Cooper stated that the physician shortage is mostly a matter of supply and demand—the population requiring health services is expanding, while new medical schools are not being built. A second major cause consists of advances in medicine and technology. Cooper noted that dis- eases that were once considered lethal, such as some forms of lung can- cer, are now treatable, further increasing demand for physician services. Regarding physician distribution, Cooper commented that the geo- graphic distribution of physicians is not truly a maldistribution; physi- cians distribute themselves across the country in the same patterns as teachers and other professionals. Communities with more resources have more physicians and more teachers; that is a consequence of how our society distributes wealth, Cooper said. Maizes challenged Cooper’s formulation that primary care would not attract physicians in the coming years. As with end-of-life care, where skeptics who thought that hospice would be too expensive were proved wrong, primary care also can produce savings. Maizes said that the cur- rent model of care needs to evolve; it is based on outdated assumptions that most diseases are infectious diseases that require one-to-one clinical encounters. However, the chronic disease epidemic calls for a new model of care that emphasizes education and peer support that can be provided in a group visit with a team-based approach. Achieving Interprofessional Education Panel members were asked how to achieve interprofessional educa- tion in institutions that may not see the value of this type of education. Kreitzer stated that powerful countervailing incentives to encourage change in education are required in order to balance the skewed incen- tives of the current payment system. These forces could include accredi- tation agencies or federal grants for innovations. Maizes noted that graduate programs that offer training in integrative medicine often recruit

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130 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC more residents, and Perlman asserted that, ultimately, it comes down to leadership. PRIORITY ASSESSMENT GROUP REPORT 2 Dr. Aviad Haramati provided the report for the priority assessment group on reorienting the workforce. This summary includes the priorities discussed and presented by the assessment group to the plenary for its discussion and consideration; these priorities do not represent a consen- sus or recommendations from the summit. Haramati began the report by putting education in context—all health professions’ mission statements include some notion of training, knowledge, skill, compassion, and ethics. Yet, medical education gener- ally misses the opportunity to reinforce the compassion of future physi- cians, the group suggested. One study indicated that empathy scores of University of Arkansas medical student cohorts declined steadily over the four years of medical education, as is shown in Figure 5-2 (Newton et al., 2008). Haramati remarked that students reflect the existing culture, and that the status quo is simply unacceptable. The assessment group identified three top priorities: improving the workforce, academic curricula, and professional education. To improve the workforce, the assessment group suggested beginning with identify- ing the supply and distribution needs, as well as related data needs. This information will show whether the number of health professionals being trained reflects today’s needs or for the demands that will develop over at least the next decade. Information gathering can start with building on what already has been done, as in geriatric team training. To improve curricula, the designs of academic curricula should be examined to determine whether students are acquiring the necessary core competencies, skills, and attitudes required for meeting the future health needs of the population. Core competencies, including the ability to work in teams, need to be established through a national education dialog. To improve professional education, the sphere of education should be widened to help current health professionals make the transition to integrative medicine, and to help patients assume more self-care. Primary 2 See Chapter 1 for a description of the priority assessment groups. Participants on this assessment group included Victor Sierpina (moderator), Aviad Haramati (rapporteur), Adam Burke, Lee Chin, Timothy Culbert, Patrick Hanaway, Mary Jo Kreitzer, Roberta Lee, Karen Malone, Bill Meeker, and David Rakel.

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131 WORKFORCE AND EDUCATION care physicians and other integrative medicine practitioners should model behavior change for their patients, as well as build multiprofes- sional partnerships and educate patients in self-care. These activities can enrich primary care and make it more satisfying to physicians. 70 60 Mean score 50 40 30 20 M1 M2 M3 M4 Women core Women total Women non-core Men core Men total Men non-core FIGURE 5-2 Decrease in empathy among medical students. NOTES: Mean scores, by medical school year, specialty preference, and stu- dents’ gender, for 419 men and women in the classes of 2001–2004, the Univer- sity of Arkansas for Medical Sciences. Scores are for students’ vicarious empathy (i.e., to have a visceral empathic response); responses were to a well- established measure of the various emotional qualities of empathy, administered at the beginning of each medical school year. The figure shows that vicarious empathy significantly decreased during medical education (P < .001), especially after the first and third years. Students choosing core careers had higher empa- thy than did those choosing noncore careers. Core refers to core specialties, (i.e., internal medicine, family medicine, obstetrics-gynecology, pediatrics, and psy- chiatry, which have greater patient contact), and noncore refers to all other spe- cialties, where patient contact is less. SOURCE: Reprinted, with permission from A cademic Medicine, Newton, B. W., L. Barber, J. Clardy, E. Cleveland, and P. O’Sullivan. Is there hardening of the heart during medical school? 83(3):244-249. Copyright 2008 Wolters Kluwer Health.

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132 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Key players are federal officials, especially in HRSA and the White House Office on Health Reform. Academic institutions, professional so- cieties, and accrediting agencies also are involved, especially in curricu- lar issues. Patient advocacy groups should help direct efforts in professional education. Changes in education must happen quickly. The group identified 3- year goals that included development of economic incentives, which are essential to change the health care system; an interdisciplinary consensus on core competencies; and establishing national priorities for health care and health professions education. Academic institutions should recognize a responsibility to go beyond professional education and open their doors to educating the public. The assessment group described a number of next steps that should be taken to advance the health service workforce. Convening key players, in all disciplines, in order to determine workforce needs is an important next step. Dialogue among stakeholder groups, including professional associations, educators, and academic institutions, must be increased. Finally, advocates of integrative medicine should make their voices heard, such as in academic journals.