Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary (2014)

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Introduction¹

Efforts to improve patient care and population health are traditional tenets of all the health professions, as is a focus on professionalism. But in a time of rapidly changing environments and evolving technologies, health professionals and those who train them are being challenged to work beyond their traditional comfort zones, often in teams. A “new professionalism” might be a mechanism for achieving improved health outcomes by applying a “transdisciplinary professionalism” throughout health care and wellness that emphasizes cross-disciplinary responsibilities and accountability. Transdisciplinary professionalism was defined by invited individual experts² as an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and the public. This definition was based on the American Board of Medical Specialties definition of professionalism (ABMS, 2013). Such a professionalism would facilitate improved inter-

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¹ The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine.

² The individual authors of the definition also assisted with the planning of the workshop and include Cynthia Belar, American Psychological Association; Matthew Wynia, American Medical Association; Liza Goldblatt, Academic Consortium for Complementary and Alternative Health Care; Nancy Hanrahan, University of Pennsylvania School of Nursing; Sandeep Kishore, Weill Cornell Medical College and Harvard Medical School; Sally Okun, PatientsLikeMe;Rick Talbott, Association of Schools of the Allied Health Professions; Rick Valachovic, American Dental Education Association.

professional teamwork (multiple professional disciplines working together, each using its own expertise, to address common problems) and might even synthesize and extend discipline-specific expertise to create new ways of thinking and acting. It would also envision new ways of engaging individual patients and the public in balanced discussions over professionalism and how this approach could potentially improve health outcomes. In this regard, the definition might be updated to include an outcomes perspective. Transdisciplinary professionalism could be defined as “an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and the public in order to improve the health of patients and their communities.”

Implementing a transdisciplinary professionalism, with shared values and accountabilities, could serve to support patient and public trust in health care, but it would not be easy. To be worthy of such shared trust, diverse practitioners and others in health-related fields would likely need to develop radical new means of thinking and acting collaboratively. This effort might include working with educators in developing innovative and effective ways to transfer collaborative skills, values, and behaviors to students, and providing leadership that fosters ongoing research and innovation for transformative change.

Within this context an ad hoc committee planned and conducted a 2-day public workshop titled “Establishing Transdisciplinary Professionalism for Health.” The committee developed the workshop agenda, selected and invited speakers and discussants, and moderated many of the discussions. The issues addressed at the workshop came from the Statement of Task, which provided the structure for the workshop agenda; this statement can be found in Box 1-1.

CONTEXT

At the May 14–15, 2013, workshop of the Institute of Medicine’s (IOM’s) Global Forum on Innovation in Health Professional Education, Sandeep Kishore, a fourth-year medical student and workshop planning committee member, compared the collaborative nature of slime molds to a shared social contract. He noted that microscopic amoebas survive as single-celled organisms until their food sources dry up. In that moment, these independently living organisms undergo a transformation in which hundreds or thousands of amoebas join together as one sluglike being known as a slime mold. This slime-coated creature moves with a collective polarity toward a food source to ensure that most amoebas survive (Fields, 2011). If simple life forms can work together for the collective good of their community, then surely health professionals can work together with society in establishing a shared social contract, he said. Of course, one advantage slime molds have over health professionals is that amoebas are not concerned about crossing professional boundaries.

Turf Battles

Interprofessional collaboration requires health professionals to let go of historical differences that have impeded communication and cooperation in the past. Frederic Hafferty, workshop speaker from the Program for Professionalism and Ethics at the Mayo Clinic, termed these historical differences “interoccupational turf wars.” These battles over territory define which profession is permitted to perform an intervention or procedure and often, particularly in the United States, this decision is dictated by insurance companies, who determine which profession gets paid and reimbursed for their work.

Along with the turf wars, Hafferty described professionalism as a zero-sum game—in order for one group to acquire professional status or to increase professional status, something has to be taken away from another group that has more professional status (for X to gain, Y has to lose). Usually the loser, the one that is often the target of professional envy, is medicine. His prediction was that to have true transdisciplinary professionalism, health care professionals need to find a way of having professionalism along with notions of its acquisition and loss as being something other than a zero-sum game. In this scenario, all the professions win or, conversely, everybody loses. This will not be easily forthcoming, he said, and pointed to the Truth in Healthcare Marketing Act of 2013, H.R. 1427, to illustrate his point. H.R. 1427 is a bill being driven by the American Psychiatric Society that would curb or clarify which professionals are called medical doctors. The data for the bill suggest that patients are confused about which profes-

sionals are physicians versus Ph.D.-trained professions such as advanced practice nurses, pharmacists, and psychologists. In his opinion, legislation such as this will not foster transdisciplinary professionalism.

In today’s complex systems of health and health care, it is proving a challenge to bring different health professionals together even if it is for the collective good of society.³ However, various speakers at the workshop pointed to the Patient Protection and Affordable Care Act (ACA) of 2010, which attempts to force health providers to come together for more coordinated care. Richard Cruess and Sylvia Cruess from McGill University in Canada discussed how the Canadian nationalized health system has fundamentally changed the dialogue not only among the health professionals but also between health professionals and patients, as well as society. They observed that in the United States, no forum exists that can serve as a venue for this kind of dialogue, whereas in other countries, such as the United Kingdom and Denmark, there are structured interactions between the health professions and the public.

A patient representative at the workshop, Barbara Kornblau from the Center for Participatory Medicine, noted that federally qualified health centers in the United States must have at least 51 percent of their board members drawn from the community they serve (Kornblau, 2006). And to maintain their nonprofit status under the IRS, nonprofit hospitals must conduct a community health needs assessment. As U.S. health professionals work toward implementing the requirements specified under the ACA, they can learn from global neighbors about how their countries have adapted to working more collaboratively to include meaningful engagements with patients and society for improving health, value, and education.

This brief summary represents some of the creative thinking that took place at the IOM Global Forum’s workshop titled “Establishing Transdisciplinary Professionalism for Health.” Most of the 59 members making up the Global Forum at that time were present at the workshop and engaged with outside participants in active dialogue around issues related to professionalism and how the different professions might work effectively together and with society in creating a social contract.

The structure of the workshop involved large plenary discussions, facilitated table conversations, and small-group breakout sessions. In this way, the members—representing multiple sectors, countries, health professions, and educational associations—had numerous opportunities to share their own perspectives on transdisciplinary professionalism as well as hear the opinions of subject-matter experts and the general public. This

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³ For the purpose of the workshop and this summary report, society could include all persons that make up a local, national, regional, or global community, and/or a special population such as patients.

open discussion of views included invited speakers and panel moderators whose names can be found in the workshop agenda in Appendix A of this report. This format was similar to the two previous workshops hosted by the Global Forum on Innovation in Health Professional Education that is part of the Board on Global Health of the Institute of Medicine, the health arm of the National Academies. In 2012, when the Forum was established, members and the public delved into various aspects of interprofessional education (IPE) in the Forum-hosted workshop series. The first workshop was titled “Educating for Practice: Improving Health by Linking Education to Practice Using IPE,” and the second was titled “Educating for Practice: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice.” At these workshops, participants heard from the Global Forum members from Canada, India, South Africa, and Uganda, and about their work in IPE. Known as the Global Forum’s Country Collaboratives, these members were selected to join the Global Forum on the basis of their demonstration projects involving at least a school of public health, a school of nursing, and a school of medicine. Brief summaries of the three presentations that took place at this workshop can be found in Chapter 5 of this report, and more detailed descriptions of their work can be found in Appendix C.

ORGANIZATION OF THE REPORT

The following five chapters explore the possibility of whether different professions can come together and whether a dialogue with society on professionalism is possible. A major goal of such an assemblage would be to open a conversation among stakeholders that promotes trust between the health professionals and those they serve. Chapter 2 introduces the discussion by considering different ways one might think about professionalism. One way that was proposed by Hafferty was to think less about the actions and acts of individuals and more about a profession as a whole that parallels notions of collective responsibilities. Some participants clearly agreed with this perspective, whereas others believed that professionalism could only be defined and measured through observable behaviors. How one defines professionalism would impact how the subject is taught to students. Chapter 3 provides examples of how university professors with expertise in psychology, public health, medicine, and business are educating students about professionalism in a single discipline as well as interprofessionally. This chapter also has descriptions of curricula addressing interprofessional leadership and professionalism from Canada, India, and South Africa. Chapter 4 looks at individual behaviors in professionalism and how the Interprofessional Professionalism Collaborative based in Washington, DC, is developing a tool for assessing interprofessional professionalism behaviors. In Chapter 5, the

thoughts and opinions of students and young professionals on inheriting a shared social contract are captured along with a patient’s and an educator’s perspectives on the discussions of transdisciplinary professionalism that took place at this workshop. Chapter 6 is an attempt to move the discussion from a theoretical construct to actionable next steps based on individuals’ views on what might lead to a shared social contract and who might be in a position to lead the charge.

REFERENCES

ABMS (American Board of Medical Specialities). 2013. ABMS professionalism definition. http://www.abms.org/News_and_Events/Media_Newsroom/features/feature_ABMS_Professionalism_Definition_LongForm_abms.org_040413.aspx (accessed September 14, 2013).

Fields, H. 2011. The world’s smallest farmers. http://news.sciencemag.org/2011/01/worlds-smallest-farmers (accessed September 14, 2013).

Kornblau, B. L. 2006. Measuring quality of life through participation: A qualitative study. Sydney, Australia: World Federation of Occupational Therapy Congress.