AMA Journal of Ethics^®

During an intensive care rotation as a third-year medical student, I asked the physician supervising me if I could break off from the team of physicians for the morning, and instead spend the time with a nurse as she cared for patients. I had heard from classmates that the ICU nurses spent more time at the bedside than the physicians and that they were often fantastic teachers. The physician, however, was unenthusiastic about my idea. He replied that I wouldn’t learn very much spending my time with a nurse. Not only was this a missed opportunity for me to learn about patient care, it sent a message that the work of nurses is less important, and less interesting, than the work of physicians.

A few months later, during my family medicine rotation, my faculty preceptor set aside time for me to learn about the work of the receptionist, nurse, and medical assistant in the clinic. From my interactions with each of these team members, I developed a more comprehensive understanding of patient care. By asking each team member to share her expertise with me, I transitioned from being simply a medical student working with one physician to an integrated member of the team. By understanding the multiple dimensions of care for a single patient visit, I was better able to care for my patients.

From my own experience as a medical student, I have had a glimpse into how critical interprofessionalism is for improving patient care and for providing health professions students with a more accurate and holistic understanding of health care delivery. My experience is not an isolated one; students, educators, and leaders in health care are increasingly recognizing the importance of interprofessionalism. In 2015 the Institute of Medicine (IOM) published a report on the impact of interprofessional education on health care delivery and patient outcomes [1], citing “widespread and growing belief that IPE [interprofessional education] may improve interprofessional collaboration, promote team-based health care delivery, and enhance personal and population health” [2]. The IOM report enumerated the negative consequences of inadequate interprofessional training.

Inadequate preparation of health professionals for working together, especially in interprofessional teams, has been implicated in a range of adverse outcomes, including lower provider and patient satisfaction, greater numbers of medical errors and other patient safety issues, low workforce retention, system inefficiencies resulting in higher costs, and suboptimal community engagement [3;citing 4-7].

Accordingly, the IOM’s recommendations called for a “coordinated series of well-designed studies of the association between interprofessional education and collaborative behavior, including teamwork and performance in practice” [8] and for ongoing interprofessional education efforts. Encouragingly, leaders in health professions education have called for interprofessional education on a national scale [9]. In 2011, the Interprofessional Education Collaborative (IPEC) released a report titled “Core Competencies for Interprofessional Collaborative Practice,” which called for interprofessional skills to be included as a core competency for health professions students [10]. The effort to create this report was itself interprofessional: IPEC was formed as a collaboration between the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health. Of four key recommendations of the IPEC report, one centered explicitly on the ethics and values that undergird interprofessional collaboration. The report delineated specific ethics-based interprofessional competencies, such as “place the interests of patients and populations at the center of interprofessional health care delivery” and “respect the unique cultures, values, roles/responsibilities, and expertise of other health professions” [11]. Yet it also acknowledged that interprofessional ethics is an emerging domain requiring further development [10].

What, exactly, are the ethics and values of interprofessional practice? How should these values be passed on to the next generations of health professions students? How should individuals, teams, and organizations respond when the environments in which they learn and work make it difficult to express these values? Drawing from recent research, innovative education models, policy analyses, and team-based clinical experience, this theme issue of the AMA Journal of Ethics^® explores these questions.

Detrimental Effects of Hierarchy in Health Care

Medical students can find themselves in thorny situations when their clinical learning environments inadequately value the contributions of all team members. In her commentary on a case of a medical student who is reluctant to communicate with a nurse about a scheduling conflict, Aimee Milliken discusses how a medical student might respond when instructed by his superior to interrupt nursing care. The detrimental effects of medical hierarchy on teamwork are even more apparent in a case of potential conflict between a medical student and faculty member whose words and actions undermine interprofessional collaboration. In their commentary on this case, Angel Chen and Maureen Brodie examine how the student might approach the faculty member and lead by example through her interactions with her nurse colleagues.

Why Interprofessionalism Matters

Spanning discussions of medical education to legislation, several articles in this issue explore why an interprofessional culture that flattens hierarchies and values contributions across disciplines is critical for patient care. Paul Burcher argues for the importance of interprofessional education in his commentary on a case of a medical student on an obstetrics rotation who refuses to spend time with a nurse midwife, and, in the podcast, Lachlan Forrow discusses how medical education could be changed to improve interprofessional team-based care. From the perspective of a student rather than a teacher, Shara Yurkiewicz shares what she learned on her physical medicine and rehabilitation rotations from physical therapists, speech therapists, occupational therapists, and nurses about patient-centered carewhen she observed and listened to rather than questioned her patients. Two articles examine the implications of recent legislation. Meghan Rudder, Lulu Tsao, and Helen E. Jack broaden the conception of the health care team and physicians’ role in evidenced-based policy by analyzing recent Massachusetts legislation that limits first-time opioid prescriptions to a seven-day supply. Providing a historical and legislative perspective on interprofessionalism, Lisa Simon examines the split between oral and general health care and the detrimental effects this split has on some of our health care system’s most vulnerable patients.

Speaking Up, Making Change

Recognizing the potential of interprofessionalism for improving the experiences of patients, students, and clinicians, several contributors examine how interprofessional values can be instilled in clinical education and patient care. Melissa J. Kurtz and Laura E. Starbird review the literature on the benefits and effectiveness of interprofessional education interventions and discuss the promise of clinical ethics-focused, problem-based learning curricula. Kirsten Meisinger and Diana Wohler describe the Crimson Care Collaborative at Cambridge Health Alliance, a family medicine clinic in which students from different health professions programs are integrated into team-based care. Focusing on a quality improvement measure—the checklist and, specifically, the surgical time-out—Nancy Berlinger and Elizabeth Dietz argue that without a culture of inclusion and the space for team members to speak up, a tool like a checklist will be insufficient for improving patient safety. Anna T. Mayo and Anita Williams Woolley apply lessons from organizational behavior research to clinical teams, identifying communicative processes that can turn a group of capable individuals into a collaborative, high-functioning team.

True interprofessionalism is much more than putting nurses and physicians in the same workspace or educating dental students and medical students in the same classroom. True interprofessionalism must have a foundation of shared ethics and values. The diverse voices of this theme issue—from bioethics, dentistry, mediation, medicine, and organizational behavior—illuminate the social and cultural underpinnings, teaching, and application of interprofessional ethics and values. In so doing, they collectively create a vision for a more collaborative, communicative, and inclusive clinical culture.