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GLOBAL FORUM ON INNOVATION IN HEALTH PROFESSIONAL EDUCATION Establishing Transdisciplinary Professionalism for Improving Health Outcomes Workshop Summary Patricia A. Cuff, Rapporteur Global Forum on Innovation in Health Professional Education Board on Global Health

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the coun- cils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This activity was supported by contracts between the Academic Consortium for Complemen- tary and Alternative Health Care, the Academic Council of the American Physical Therapy Association, the Academy of Nutrition and Dietetics, the Accreditation Council for Graduate ­ Medical Education, the Aetna Foundation, the Alliance for Continuing Education in the Health Professions, the American Academy of Family Physicians, the American Academy of Nursing, the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Association of Nurse Anesthetists, the American Association of Nurse Practitioners, ­ the American Board of Family Medicine, the American Board of Internal Medicine, the Ameri- can College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists/ American Board of Obstetrics and Gynecology, the American Dental Education Associa- tion, the American Medical Association, the American Occupational Therapy Association, the American Psychological Association, the American Society for Nutrition, the American Speech-Language-Hearing Association, the Association of American Medical Colleges, the Association of American Veterinary Medical Colleges, the Association of Schools and Colleges of Optometry, the Association of Schools and Programs of Public Health, the Association of Schools of the Allied Health Professions, the Atlantic Philanthropies, the China Medical Board, the Council of Academic Programs in Communication Sciences and Disorders, Ghent University/European Forum for Primary Care, the John A. Hartford Foundation, the Josiah Macy Jr. Foundation, Kaiser Permanente, the National Academies of Practice, the National Association of Social Workers, the National Board for Certified Counselors, Inc. and Affiliates, the National League for Nursing, the National Organization of Associate Degree Nursing, the Physician Assistant Education Association, the Robert Wood Johnson Foundation, the Society for Simulation in Healthcare, the Uniformed Services University of the Health Sciences, and the Veterans Health Administration. The views presented in this publication do not necessarily ­ reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13:  978-0-309-28901-6 International Standard Book Number-10:  0-309-28901-7 Additional copies of this workshop summary are available for sale from the National Acad- emies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Establishing transdisciplinary profes- sionalism for improving health outcomes: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE FOR ESTABLISHING TRANSDISCIPLINARY PROFESSIONALISM FOR HEALTH1 Cynthia D. Belar (Co-Chair), American Psychological Association Matthew K. Wynia (Co-Chair), American Medical Association Elizabeth (Liza) Goldblatt, Academic Consortium for Complementary and Alternative Health Care Nancy P. Hanrahan, University of Pennsylvania School of Nursing Sandeep Kishore, Weill Cornell Medical College and Harvard Medical School Sally Okun, PatientsLikeMe Richard (Rick) Talbott, Association of Schools of the Allied Health Professions Richard (Rick) W. Valachovic, American Dental Education Association 1  Institute of Medicine planning committees are solely responsible for organizing the work- shop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. v

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GLOBAL FORUM ON INNOVATION IN HEALTH PROFESSIONAL EDUCATION1 Jordan Cohen (Co-Chair), George Washington University Afaf Meleis (Co-Chair), University of Pennsylvania Kenn Apel, Council of Academic Programs in Communication Sciences and Disorders Carol Aschenbrener, Association of American Medical Colleges Gillian Barclay, Aetna Foundation Mary Barger, American College of Nurse-Midwives Timi Agar Barwick, Physician Assistant Education Association Geraldine Bednash, American Association of Colleges of Nursing Cynthia Belar, American Psychological Association Joanna Cain, University of Massachusetts School of Medicine Linda Casser, Association of Schools and Colleges of Optometry Lincoln Chen, China Medical Board Yuanfang Chen, Peking Union Medical College Marilyn Chow, Kaiser Permanente Elizabeth Clark, National Association of Social Workers Thomas Clawson, National Board for Certified Counselors, Inc. and Affiliates Darla Spence Coffey, Council on Social Work Education Malcolm Cox, Veterans Health Administration Jan De Maeseneer, Ghent University Marietjie de Villiers, Stellenbosch University James G. Fox, Association of American Veterinary Medical Colleges Roger Glass, John E. Fogarty International Center Elizabeth (Liza) Goldblatt, Academic Consortium for Complementary and Alternative Health Care Yuanzhi Guan, Peking Union Medical College Neil Harvison, American Occupational Therapy Association, Inc. Douglas Heimburger, American Society for Nutrition John Herbold, National Academies of Practice Eric Holmboe, American Board of Internal Medicine Pamela Jeffries, Johns Hopkins University School of Nursing Rick Kellerman, American Academy of Family Physicians Kathryn Kolasa, Academy of Nutrition and Dietetics John (Jack) Kues, Alliance for Continuing Education in the Health Professions Maryjoan Ladden, Robert Wood Johnson Foundation 1  Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. vii

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Lucinda Maine, American Association of Colleges of Pharmacy Beverly Malone, National League for Nursing Mary E. (Beth) Mancini, Society for Simulation in Healthcare Damon Marquis, Alliance for Continuing Education in the Health Professions (until July 2013) Lemmietta G. McNeilly, American Speech-Language-Hearing Association Donna Meyer, National Organization of Associate Degree Nursing Fitzhugh Mullan, George Washington University Thomas Nasca, Accreditation Council for Graduate Medical Education Andre-Jacques Neusy, THEnet Warren Newton, American Board of Family Medicine Kelly Wiltse Nicely, American Association of Nurse Anesthetists Liana Orsolini, Bon Secours Health System, Inc. Rajata Rajatanavin, Mahidol University Scott Reeves, University of California, San Francisco Edward Salsberg, Health Resources and Services Administration, U.S. Department of Health and Human Services (until September 2013) Madeline Schmitt, American Academy of Nursing Nelson Sewankambo, Makerere University College of Health Sciences Stephen Shannon, American Association of Colleges of Osteopathic Medicine Susan Skochelak, American Medical Association Harrison Spencer, Association of Schools and Programs of Public Health Richard (Rick) Talbott, Association of Schools of the Allied Health Professions George Thibault, Josiah Macy Jr. Foundation Jan Towers, American Academy of Nurse Practitioners Richard (Rick) W. Valachovic, American Dental Education Association Sarita Verma, University of Toronto Patricia Hinton Walker, Uniformed Services University of the Health Sciences Shanita Williams, Health Resources and Services Administration, U.S. Department of Health and Human Services Holly Wise, Academic Council of the American Physical Therapy Association Brenda Zierler, University of Washington Sanjay Zodpey, Public Health Foundation of India viii

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IOM Staff Patricia A. Cuff, Senior Program Officer Rachel M. Taylor, Associate Program Officer Megan M. Perez, Research Associate Audrey Avila, Intern Nikita Srinivasan, Intern Christen Woods, Intern Julie Wiltshire, Financial Officer Patrick W. Kelley, Senior Board Director ix

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Reviewers This workshop summary has been reviewed in draft form by indi­ viduals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to ­ provide candid and critical comments that will assist the institution in ­making its published workshop summary as sound as possible and to ensure that the summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: Martha N. Hill, Johns Hopkins University School of Nursing Maxine Papadakis, University of California, San Francisco John Weeks, Academic Consortium for Complementary and Alternative Health Care Christine S. Zambricki, American Association of Nurse Anesthetists Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the work- shop summary before its release. The review of this workshop summary was overseen by Carol Pearl Herbert, University of Western Ontario. A ­ ppointed by the Institute of Medicine, she was responsible for making certain that an inde­ endent examination of this summary was carried out p in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this work- shop summary rests entirely with the rapporteur and the institution. xi

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Acknowledgments A landmark event for the Global Forum on Innovation in Health Pro- fessional Education took place in Washington, DC, with the first gathering of the forum members in early 2012. At this meeting, members discussed how they might begin to consider addressing some of the challenges high- lighted in the two reports that laid the foundation for the work of the forum. One of these was an independent Lancet Commission report led by Julio Frenk and Lincoln Chen titled Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Inter­ dependent World. The other was a report of the Institute of Medicine (IOM) titled The Future of Nursing: Leading Change, Advancing Health. Both the Lancet Commission and the IOM reports provide a high-level v ­ ision for the health professions around the world. Some of the discussions at that first forum meeting were to consider how this group, made up of multiple health professionals representing edu- cation and practice from different sectors and drawn from four continents, might come together in deciding on what topics the forum is best positioned to ­ddress. An agreement was reached to focus the first year on inter­ a professional education (IPE). IPE was a particularly appropriate topic given that four members from Canada, India, South Africa, and Uganda were brought into the forum specifically because of their interprofessional work addressing leadership and professionalism—topics that received considerable attention in the Lancet Commission and The Future of Nursing reports. Forum members came together twice in 2012 to attend workshops on IPE hosted by the Global Forum. Presentations at these events highlighted the importance of working together for improved safety and quality of xiii

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xiv ACKNOWLEDGMENTS health care, as well as the importance of collaboration for improving the health of communities and populations. How students and faculty acquire these skills was a key part of the discussions. Discussions also set the stage for the next workshop by grappling with whether health professionals could come together in a unified manner to engage in public discourse with society about the important topic of professionalism. This workshop stimulated many unique ideas of how society and the health professions might work toward a unified goal and who might lead such an auspicious undertaking. As co-chairs of the forum, we are grateful to all who made this event a resounding success. These include the workshop planning committee co-chairs, Cynthia Belar and Matthew Wynia, along with the planning committee members: Liza Goldblatt, Nancy Hanrahan, ­ Sandeep Kishore, Sally Okun, Rick Talbott, and Rick Valachovic. It goes without saying that the workshop would not have been possible without the adept skills of the IOM staff—Patricia Cuff, forum director; Rachel Taylor, associate program officer; and Megan Perez, research associate. And special thanks go to Patrick Kelley for his leadership in directing the IOM’s Board on Global Health, which oversees the Global Forum. Finally, we are deeply indebted to our 45 sponsors and 60 members of the Global Forum for making it possible to hold workshops like the one on establish- ing a new professionalism. Jordan Cohen, Forum Co-Chair Afaf Meleis, Forum Co-Chair

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Contents 1 Introduction 1 PART I: WORKSHOP SUMMARY 2 Understanding Professionalism 9 3 Professionalism in Education 21 4 Behaviors of Interprofessional Professionalism 35 5 Transdisciplinary Professionalism 43 6 Making It Real 55 PART II: PAPERS AND COMMENTARY FROM SPEAKERS II.1 Introducing Transdisciplinary Professionalism 71 Cynthia D. Belar II.2 Professionalism and Medicine’s Social Contract 75 Richard L. Cruess and Sylvia R. Cruess II.3 Interprofessional Professionalism: Linking Professionalism and Interprofessional Care 86  atthew C. Holtman, Jody S. Frost, Dana P. Hammer, M Kathy McGuinn, and Loretta M. Nunez II.4 A Patient Perspective 90 Barbara L. Kornblau II.5 The Case for Integrating Health, Well-Being, and Self-Care into Health Professional Education 96 Mary Jo Kreitzer and Elizabeth Goldblatt xv

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xvi CONTENTS II.6  Innovations in Teaching About Transdisciplinary Professionalism and Professional Norms 101 Susan H. McDaniel, Thomas Campbell, Tziporah Rosenberg, Stephen Schultz, and Frank deGruy II.7  Toward Transdisciplinary Professionalism in the Teaching of Public Health 108 Jacquelyn Slomka APPENDIXES A Workshop Agenda 121 B Speaker Biographical Sketches 127 C Summary Updates from the Innovation Collaboratives 145