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Interdisciplinary
Education and Training Findings
As with the term “allied health,” there
is no widely accepted single definition
of the term “interdisciplinary.” There
are many terms—interdisciplinary, multidisciplinary,
transdisciplinary, crossdisciplinary,
and interprofessional—that are often used
interchangeably to describe a health care
team composed of professionals from various
disciplines. However, the actual responsibilities
of health care professionals participating
on such teams and the expected outcomes
have not been clearly or consistently
defined—there is no universally accepted
definition of interdisciplinary care.
In its First Report, released in November
2001, the Committee wrote, “Interdisciplinary
implies educational objectives and outcomes
that relate to practice between or among
professions and disciplines.”
The First Report goes on to state:
A multidisciplinary group becomes interdisciplinary
when its members transcend their separate
disciplinary perspectives and attempt
to weave together their unique tools,
methods, procedures, examples, concepts,
and theories to overcome common problems
or concerns. Members of the interdisciplinary
team perform their work in a collaborative
fashion, with team members providing the
group with the knowledge and skills of
their disciplinary perspective while they
incorporate that perspective with others.
Ultimately, the team should create solutions
to health care problems that transcend
conventional, discipline-specific methods,
procedures, and techniques (Hirokawa,
1999). Teaching how to effectively communicate
with professionals in other disciplines
is a worthy objective in training providers
who can be successful in delivering the
highest quality health care to the Nation.
Development of
Interdisciplinary Care
The interdisciplinary approach was developed
in the field, by clinicians facing complex
patient-care issues, not in academic settings.
In 1915, Dr. Richard Cabot of Massachusetts
General Hospital introduced the concept
of interdisciplinary care by forming teams
of a doctor, social worker, and educator
to promote clinical efficiency. Following
World War II, the provision of interdisciplinary
care continued to increase, especially
in the specialties of rehabilitation,
chronic care, family health, primary care,
psychiatry, mental retardation and developmental
disabilities, geriatrics, and end-of-life
care. In the early 1970s, the first evidence
supporting the effectiveness of interdisciplinary
care was released in the Institute of
Medicine (IOM) report “Education for the
Health Team.” The rise of health maintenance
organizations has in some cases resulted
in an increase in interdisciplinary care.
Challenges to Greater
Acceptance of the Interdisciplinary Care
Model
Despite research indicating the cost
effectiveness of interdisciplinary care,
such as the savings resulting from interdisciplinary
care models designed to reduce hospital
stays for frail elderly patients, and
increased patient satisfaction resulting
from interdisciplinary care, it has not
been widely integrated throughout our
Nation’s health care system. Various
barriers impede the integration of interdisciplinary
care. Significant barriers are listed
below.
Compensation/Reimbursement
- Perhaps the most significant barrier
is the issue of reimbursement for team
members—systems are not in place to compensate
all the disciplines providing care. Additionally,
interdisciplinary care is seen by many
to be more time consuming, although this
isn’t necessarily the case with some models.
For those models that do require additional
time on the part of team members, improved
patient outcomes and higher patient satisfaction
may balance out these costs.
Resistance by Health Professionals
- Some disciplines have been reluctant
to share responsibilities and decision
making. In particular, many physicians
and medical students have negative perceptions
of interdisciplinary care, which have
been attributed to the culture of autonomy
and the hierarchical structure in medicine,
as well as the “hidden curriculum” in
medical school that instills cynicism
and arrogance in students.
Resistance to Change in the Health
Care Industry - Change comes slow
to bureaucracies and there are few bureaucracies
that are more entrenched and rife with
special interest groups than the health
care industry. Integration of interdisciplinary
models requires resources, such as time,
space, and incentives. The provision
of such resources may not be attractive
in an industry that focuses on the bottom
line. Commitment at the highest institutional
levels will drive acceptance of and help
legitimize interdisciplinary care. Greater
use of technology, such as telehealth
and high-tech communications, can greatly
facilitate interaction across disciplines.
Embracing innovative approaches can facilitate
the integration of interdisciplinary care.
Lack of Skills and Training
- It is unrealistic to expect that a group
of health care professionals representing
various disciplines can be assigned to
work together and positive outcomes will
result. Successful participation as a
member of an interdisciplinary team requires
a unique skill set including group, communication,
conflict resolution, and leadership skills.
While some professionals possess these
skills, many require training in one or
more of these areas. In addition, many
disciplines “speak their own language.”
The lack of common definitions across
disciplines can impede communication by
team members. Finally, many health care
professionals do not have an in-depth
understanding of the roles of other health
care professionals. This can limit their
ability to work together as a team.
Need for More Research -
There is a growing body of evidence supporting
the effectiveness of interdisciplinary
care in improving patient outcomes, increasing
cost effectiveness, and increasing patient
satisfaction. However, more evidence
is necessary if these practices are to
be widely integrated into the health care
system. Outcome measures are needed to
determine the impact of interdisciplinary
care. Best practices must also be identified
to facilitate the adoption of evidence-based
approaches.
Integrating Interdisciplinary
Education and Training into Academic Settings
For there to be greater integration of
interdisciplinary care in the overall
health care system, health professions
students require training in the provision
of interdisciplinary care. Contemporary
academic institutions are not characterized
by a great deal of flexibility. Universities
are made up of different colleges and
specialized schools, all with their own
bureaucracy and numerous departments.
This results in multiple academic silos,
which are not conducive to fostering an
interdisciplinary approach. In order
to foster cooperation across disciplines
there needs to be greater interaction
among them. However, challenges exist
to the greater integration of interdisciplinary
education and training opportunities.
Integration into the Curriculum
- Courses that incorporate interdisciplinary
approaches are often offered as electives,
attracting only those students that already
have an interest in interdisciplinary
approaches. Few institutions have stand-alone
courses on interdisciplinary care or have
integrated the concept of interdisciplinary
care into the overall curriculum. Initiating
curricular change can be difficult. Curricula
in many health professional schools are
already very crowded and the addition
of another topic is often met with resistance.
Greater integration of interdisciplinary
courses and concepts will require convincing
decision makers, such as curriculum committees
and accrediting agencies, of the importance
of education and training in interdisciplinary
care.
Lack of Institutional Support -
Just as in the real world, integration
of interdisciplinary approaches into health
professions education and training requires
resources. Unfortunately, many institutions
of higher education are experiencing significant
budget constraints. Programs are being
cut, not expanded. To initiate change
in academic settings, the administration
must foster top-down support and make
the necessary resources available to implement
and institutionalize the changes.
Faculty Support - The teaching
of interdisciplinary practice is vastly
different from traditional didactic lectures.
Team approaches to education include problem-based,
case-based, and service-learning models
as well as multi-specialty team diagnosis
and management clinics. To effectively
teach interdisciplinary practice, faculty
will require training and support in order
to adopt new teaching methods. Some institutions
utilize consultants to build skills.
For example, consultants have been used
to provide teamwork training. It is important
to note that currently, many interdisciplinary
opportunities, whether required or elective,
are the result of the efforts of a single
individual, either a faculty member or
a student, who is passionate about interdisciplinary
care. These efforts are often tenuous,
since faculty members and students may
leave or interests may shift.
Need for Community Partners
- Interdisciplinary education and training
lends itself to a service-learning approach.
Providing students with clinical opportunities
in community settings can benefit students,
community-based organizations, and patients.
This experience is especially valuable
if students work in communities with underserved
populations—populations that students
might not ordinarily serve. Academic
institutions need to create linkages with
community organizations. It is important
to acknowledge that community organizations
require resources to support the training
opportunities provided to students.
Outcome Measures - Interdisciplinary
education and training programs must evaluate
the effectiveness of their efforts. Most
of the outcome measures currently used
by the Title VII Interdisciplinary, Community-Based
Training Grant Programs do not assess
the quality of education and training
efforts. This type of program evaluation
can be challenging. The 3-year funding
cycle for many of the Title VII Interdisciplinary,
Community-Based Training Grant Programs
makes outcome assessment difficult, since
the cycle does not provide enough time
to demonstrate outcomes. Graduates must
be tracked into professional practice
to measure the impact of programs. Also,
the measurement of outcomes requires both
resources and expertise. Many Title VII
Interdisciplinary, Community-Based Training
Grant Programs do not possess the expertise
to carry out sophisticated outcome analysis.
Finally, quantitative data do not tell
the whole story. Qualitative data need
to be collected to help programs more
effectively demonstrate the impact of
their efforts.
Best Practices
Education and training programs need
effective models that can be utilized
in the development of interdisciplinary
courses and the integration of interdisciplinary
practices within curricula. Multiple
disciplines should participate in the
development of these best practices.
The identification of core interdisciplinary
learning objectives, applied across all
disciplines, would assist in the integration
of interdisciplinary practices in health
professions education and training programs.
From Training to
the Real World
The Committee is charged with providing
advice on the Title VII Interdisciplinary,
Community-Based Training Grant Programs
and interdisciplinary health professions
education policy and program development.
However, it is important to note that
throughout the testimony it was emphasized
that system-wide change is necessary within
the Nation’s health care system if interdisciplinary
care is to become a reality. Currently,
interdisciplinary opportunities in the
“real world” are rare. Health professions
students, even if they are receptive to
interdisciplinary practice, may not avail
themselves of interdisciplinary training
if there are no opportunities to apply
these skills once they graduate and begin
their professions. The greater integration
of interdisciplinary practices in health
professions education is dependent on
opportunities to participate on interdisciplinary
teams in professional life. All grantees
are required to incorporate interdisciplinary
practice into their education and training
efforts, but the degree of success varies
significantly.
Role of Title VII
Interdisciplinary, Community-Based Training
Grant Programs in Providing Interdisciplinary
Education and Training
As the name implies, Title VII Interdisciplinary,
Community-Based Training Grant Programs
focus on the training of health professionals
at various levels, from pipeline programs
to undergraduate, graduate, post-graduate,
and continuing education programs.
Allied Health Projects
The program requires grantees to train
a minimum of two or more distinct allied
health disciplines in interdisciplinary
health care. In FY 2006, more interdisciplinary
interaction will be required.
Area Health Education Centers Program
AHEC grantees are required to conduct
and participate in interdisciplinary training
that involves physicians and other health
personnel including, where practical,
public health professionals, physician
assistants, nurse practitioners, nurse
midwives, and behavioral and mental health
providers.
Geriatric Education Centers Program
The program is designed to strengthen
interdisciplinary training of health professionals
in the diagnosis, treatment, and prevention
of disease and other health concerns of
the elderly.
Geriatric Academic Career Award
Program
The program is designed to increase the
number of junior faculty at accredited
schools of allopathic and osteopathic
medicine and to promote the development
of their careers as academic geriatricians
who emphasize training in clinical geriatrics,
including the training of interdisciplinary
teams.
Geriatric Training for Physicians,
Dentists, and Behavioral/Mental Health
Professions Program
The program provides support, including
fellowships, for geriatric training projects
to train physicians, dentists, and behavioral
and mental health professionals who plan
to teach geriatric medicine, geriatric
behavioral or mental health, or geriatric
dentistry.
Graduate Psychology and Geropsychology
Training Program
The program trains health service psychologists
to work in primary care settings and as
members of collaborative, multidisciplinary
health care teams. It also teaches other
health care providers to work with and
utilize the skills of psychologists, which
is a significant issue for psychologists
given the lack of a common language and
culture with health care.
Quentin N. Burdick Rural Program
for Interdisciplinary Training Program
The program provides support for the
interdisciplinary education and training
of health care professionals that encourages
and prepares them to enter into and/or
remain in practice in rural America.
Sources
Hall P and Weaver L. Interdisciplinary
education and teamwork: a long and winding
road. Medical Education (35):867-875,
2001.
Marino C. The case for interdisciplinary
collaboration. Nursing Outlook (6):285-288,
1989.
McCallin A. Interdisciplinary practice
– a matter of teamwork: an integrated
literature review. Journal of Clinical
Nursing (10):419-428, 2001.
Recommendations
for Interdisciplinary Education and Training
8) The Committee recommends that the
following definition for interdisciplinary
educational development and training be
used by BHPr for all Title VII Interdisciplinary,
Community-Based Training Grant Programs.
“Interdisciplinary educational development
and training is defined as the collaborative
process by which an interdisciplinary
team of health care professionals—faculty,
clinical preceptors, community health
care providers—collaborate, plan, and
coordinate an interdisciplinary program
of education and training. The collaborative
process requires the preparation and functioning
of interdisciplinary teams who share knowledge
and decision making with the purpose of
creating solutions to health care problems
that transcend conventional discipline-specific
methods and work together in service of
patient-centered and/or community-centered
health care needs.”
The lack of a single definition for interdisciplinary
education and training has led to a lack
of understanding and misconceptions about
what constitutes interdisciplinary education
and training and the benefits it can provide.
Adoption of a single definition will help
increase understanding about interdisciplinary
education and training. Greater understanding
will hopefully facilitate the broader
integration of interdisciplinary approaches
throughout the education and training
of health care providers.
9) BHPr should require through the
grant guidance application process that
applicants describe the interdisciplinary
learning objectives, identify the interdisciplinary
competencies, describe how these will
be evaluated and measured in all Title
VII Interdisciplinary, Community-Based
Training Grant Programs, and discuss plans
for institutionalizing these interdisciplinary
education and training projects.
In its discussions, the Committee noted
that the interdisciplinary education and
training opportunities are rarely a required
part of the curriculum, receive minimal
support from the administration, are ignored
by curriculum committees, and are often
the work of a single “champion” who is
committed to the concept. As a result,
interdisciplinary education and training
opportunities can be short lived.
Requiring grantees to develop a plan
for institutionalizing interdisciplinary
education and training projects, which
includes specific learning objectives,
identifies competencies to be obtained
by trainees, and has an evaluation strategy
to measure impact, will help projects
take the necessary steps that will lead
to the integration of interdisciplinary
education and training on a permanent
basis.
10) BHPr should develop common interdisciplinary
performance and outcome measures to evaluate
the effectiveness of interdisciplinary
education and training programs funded
under Title VII, Part D.
There is a lack of data demonstrating
the effectiveness and impact of interdisciplinary
education and training programs, which
makes it difficult to demonstrate the
value of these programs. While BHPr is
taking steps to strengthen program evaluation
through the development of logic models,
few of the performance and outcome measures
proposed address interdisciplinary education
and training.
Given that the interdisciplinary emphasis
is a key element of the Title VII Interdisciplinary,
Community-Based Training Grant Programs,
BHPr should develop common interdisciplinary
performance and outcome measures that
all Title VII Interdisciplinary, Community-Based
Training Grant Programs can use to demonstrate
the impact of their efforts. The measures
should focus on learning outcomes to help
programs assess their impact on students.
Such findings could also be used to enhance
education and training efforts.
11) BHPr should support interdisciplinary
education in all programs through its
guidance, technical assistance, and creation
of opportunities for mentorship, networking,
and dissemination of best practice models.
There is an inconsistent and varied use
of the term “interdisciplinary” throughout
BHPr programs, which adds to the confusion
surrounding the term, creates challenges
to cooperation and collaboration across
programs on interdisciplinary projects,
and makes it difficult for programs to
identify appropriate interdisciplinary
activities. Because the interdisciplinary
aspects of the programs are what make
Title VII Interdisciplinary, Community-Based
Training Grant Programs unique, BHPr should
provide greater support to grantees and
applicants in this area. This can be
done through technical assistance, revision
of program guidance, and the creation
of mentorship and networking opportunities.
Key areas for support include:
- Use of a single definition of “interdisciplinary”
throughout BHPr guidances and clear
descriptions of interdisciplinary requirements
within the guidances;
- Establishment of mentorship opportunities
focusing on interdisciplinary education
and training;
- Development and dissemination of best
practice models that Title VII Interdisciplinary,
Community-Based Training Grant Programs
can integrate into their programs; and
- Technical assistance for applicants,
especially for the Geriatric Academic
Career Award Program, to help them develop
applications that are responsive to
the interdisciplinary requirements in
the guidances.
Increased support for interdisciplinary
education and training will result in
greater integration of interdisciplinary
approaches by Title VII Interdisciplinary,
Community-Based Training Grant Programs,
more effective programs, and better education
and training outcomes.
12) Based on the growing body of evidence,
including multiple Institute of Medicine
(IOM) reports, that interdisciplinary
care results in increased patient satisfaction
and improved health outcomes, the Committee
recognizes the importance of interdisciplinary
education and training and recommends
that BHPr facilitate a joint meeting of
appropriate advisory committees or advisory
committee representatives to discuss interdisciplinary
education and training.
Some health care disciplines appear more
receptive to participating as part of
interdisciplinary care teams than others.
Even when providers are receptive, they
may not possess the skills necessary to
effectively participate because they have
not received the necessary training.
Participation in interdisciplinary training
opportunities can often lead to continued
use of interdisciplinary approaches after
graduation.
The Committee focuses on programs that
already include a significant interdisciplinary
component in their education and training.
In order to explore how interdisciplinary
education and training is addressed by
other health discipline training and education
programs, the Committee would like to
hold a joint meeting with the National
Advisory Council on Nurse Education and
Practice (NACNEP), the Advisory Committee
on Training in Primary Care Medicine and
Dentistry, and the Council on Graduate
Medical Education (COGME). Such a meeting
may result in joint recommendations addressing
interdisciplinary education and training.
13) The Committee recommends that
HRSA convene a consensus conference on
interdisciplinary professional education
and training or make interdisciplinary
professional education and training a
significant topic of the next BHPr all
grantee meeting.
A consensus conference on interdisciplinary
education and training could bring together
experts and stakeholders—those people
who are able to bring about change to
the overall education and training system—such
as representatives of accrediting bodies.
Such a meeting could also serve as a forum
for identifying best practices and establishing
outcomes. While the meeting may lead
to the development of consensus statements
and/or white papers, it could also result
in the development of tools that can be
of use to providers in the field.
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