Interprofessional education in academic family medicine teaching units

Description of program

The McMaster FHT consists of 2 teaching units: McMaster Family Practice and Stonechurch Family Health Centre. The units conduct approximately 70 000 patient encounters per year. There are 25 academic full-time physicians and 8 community or part-time faculty physicians. Other professional staff include 15 nurses (8 nurse practitioners, 1 registered nurse, and 6 registered practical nurses), 2 consultant psychiatrists (who provided patient care 1 half-day per week at each unit), 6 social workers, 2 dietitians, 3 pharmacists, and a chaplain; all of them work in various combinations of full- and part-time positions, with some shared staff between the units.

Most learners in the units are family medicine residents and undergraduate medical students. There are also nurse practitioner, social work, dietitian, and pharmacist students. There are more than 55 family medicine residents based in the 2 units, with more than 15 of them working full-time during any 1 period.

The components of the interprofessional education program activities are shown in Table 1. The program includes formal and informal learning opportunities and programmatic enablers. Formal clinical learning opportunities are based on purposeful pairing of learners and teachers and include interprofessional teacher-learner patient encounters (eg, double-booking), shadowing, and case consultations. Other formal activities include various rounds and group learning sessions that include or are led by interprofessional learners and teachers. Informal encounter-based teaching opportunities are also key elements of the program. Much of this happens as a result of quick consultations on patient care issues in team rooms. Nonphysician professionals and their learners have opportunities to contribute to conversations between medical residents and physicians, in which they are able to provide important input on patient care, thereby being role models for teamwork and teaching the skill sets of various health professionals.

Programmatic enablers include the physical layout, the information technology system, and the leadership support of the clinics. Physical layout is seen as one of the main enablers of interprofessional practice and education in the clinics. One clinic was built in 2002 and the other in 2006. The layout of each clinic was designed to allow for informal encounters among staff. The central area in each clinic is a visually and acoustically private team room for all health professionals, which is crucial to providing interprofessional education experiences. The team room at the newer clinic is centrally located in the building and is next to the kitchen and social meeting area.

Interprofessional education takes additional time and resources for “purposeful pairing” in clinical encounters. For example, double-booking requires approximately 10 minutes before and 15 to 30 minutes after the patient visit for the learner and teacher to discuss learning needs and evaluate the outcome of the encounter. In a 3-month period there are approximately 50 appointments booked in this manner, 30 of which involve residents as learners, and mostly with social worker teachers, but also with the pharmacists and nurses. The leaders of the department and clinic units support this extra use of resources as part of the standards of teaching in the department.

Evaluation

We performed a formative descriptive evaluation using qualitative methods. One author (M.H.) interviewed 2 physicians, 4 nurse practitioners, 1 social worker, and 1 pharmacist using a semistructured interview guide to elicit opinions about the successes and challenges of interprofessional education program activities. The interview guide was developed from concepts of successful interprofessional education in the literature. Data collection and analyses were iterative, with revisions to the interview guide occurring while data collection was ongoing. Interviews were tape-recorded. One analyst (M.H.) created a coding template based on themes and categories driven by the study objectives and the interview guide. A second analyst also independently created a coding template. The 2 analysts discussed and merged the themes and categories after an agreement was reached. Member-checking of results was used to ensure verifiability of findings, as several interviewees were also co-authors. Data saturation was reached when no new information was provided in the final interviews.

In describing the successes of the interprofessional education activities, staff characterized the culture of interprofessional education as mirroring the culture of interprofessional practice in the clinics. Interviewees referred to the perceptions the different professionals’ had of one another, the methods of communication, the team dynamics, and the atmosphere in the units. Staff described the culture as nonhierarchical, holistic, synergistic, and trusting. They described mutual respect and egalitarianism, where “everyone is a clinician” with a unique and valued contribution to patient care. They also described comfort and trust in situations where roles overlap between professions, resulting in an absence of “turf defending.” Interviewees who had previously worked in different family practice environments described a fundamental difference in the culture of the Hamilton FHT, compared with situations where non-physician professionals work alongside physicians and simply receive instructions to carry out. They stressed the collaborative working relationship, in which they “co-plan” patient care with physicians.

Interviewees described how some learners undergo a shift in their professional socialization. Medical residents and other learners are introduced immediately to the idea that not only physicians but also other health professionals will be their teachers. Nurse practitioners and social workers described examples of how new residents hesitate to consult them for advice and often verify information with physician preceptors. However, within a few months, residents begin to seek out the most appropriate professional for a particular issue. Interviewees noted that this model of learning provided necessary exposure for nonphysician learners in prelicensure training in particular, as they learn to appreciate their unique contributions to patient care while simultaneously learning how other professionals approach clinical care. Evidence of the need for this was apparent when interviewees described that nonphysician learners are often initially very passive in their interactions with physicians. We believe the program assisted in shifting professional socialization of these learners by engaging them in a model of collaborative care.

Interviewees discussed 2 main categories of enablers to the interprofessional education program: attitudes and logistics. Staff noted that the attitude of the leaders supported the culture of interprofessional education by allowing health professional hours to be used for those teaching strategies that require resources in practice. Another example of positive attitudes is the collaborative decision-making process in the clinics, ensuring the views and values of all members of the team are included. Interviewees noted that there was support from the leadership for innovations of all team members in practice as long as they benefited patient care.

In the design of both buildings, there was deliberate interprofessional involvement to ensure that teamwork would be enabled (eg, patient care areas shared by all professionals) rather than physicians having separate space from other team members. The other main logistic enabler is the Web-based electronic medical record, which enables seamless information flow between team members. Team members can use the messaging system to communicate with one another about issues that require attention, as many have administrative responsibilities and are not always physically present at the clinic. All health care providers add information to patient charts on the same “page,” making it more likely that others involved in the care will see and learn from their colleagues’ notes.

Conclusion

With the recent reforms in primary care emphasizing interprofessional practice and quality of care, there might be challenges when various health professionals begin working together—possibly for the first time. Although our setting is different from community family practices that are beginning to engage in interprofessional care, there are several elements of success that can be extrapolated (Box 1). We believe that working in teams has increased our efficiency. Staff anecdotally report that the volume of patients seen daily, while still meeting the needs of our roster of patients, has eased and that they are able to see patients more effectively and for a longer period of time, which might contribute to improved quality of care.

This paper describes a program of interprofessional education that features the key elements of deliberate interprofessional pairing in the context of patient care and case consultation, and logistic and leadership enablers; the program also provides learners with an example of an established culture of collaborative care.