TEAM approach in medical education

Modern medicine is a team sport, leaders in the field say, meaning no doctor can provide patient care without the support and contributions of other health professionals. Yet medical students typically have received little or no preparation for this aspect of medical practice. Until now.

This year the UI Carver College of Medicine’s Clinical Beginnings program, which facilitates the transition third-year medical students make from classroom to clinical learning, debuted a new approach to preparing students for their roles as clinicians. For part of the weeklong orientation in June, the students worked in teams with their counterparts from other health and allied professions to address hypothetical cases written specifically to bring each member’s professional knowledge and perspectives into play.

Health care "is teams working together with the goal of improving patient care," said Joel Gordon, MD, professor of internal medicine, Sahai Family Professor of Medical Education and director of curriculum for the M3 and M4 years. Clinical Beginnings’ case-based team learning exercise was designed to "represent the real-world interaction between these different professionals," Gordon said. "When a student [on a clinical rotation] gets on a team that involves a pharmacist or a nurse, he or she will know what his or her roles are."

Indeed, the Association of American Medical Colleges has convened a task force of leaders from across the health professions to identify how to boost what it calls interprofessional education at the national level.

The Clinical Beginnings exercise included students in medicine, nursing, pharmacy, public health, physical therapy, social work and the physician assistant program.

Just organizing the small groups involved "a huge effort across the campus," said Helen Damon-Moore, PhD, curriculum coordinator with the Office of Student Affairs and Curriculum. In the end, 250 students (including 133 medical students) and 67 group facilitators representing seven disciplines participated in the exercise—even more if you count reference librarians at the Hardin Library of the Health Sciences who helped the students track down information to address issues raised by their cases.

Feedback from students and group facilitators alike was positive, Damon-Moore said. "The medical students especially were enlightened about how other disciplines contribute to the medical team and humbled by the knowledge other professionals bring to the table," she said. Many of the facilitators commented that they wished they’d had a similar experience during their training, she added.

The involvement of students and practitioners from other health care fields gave medical students "the recognition that for the rest of their professional lives, they are going to work in teams," Gordon said. "Hopefully it was one of those pivotal moments when they could say, ‘My goodness, I don’t have to know everything. I can call on these other experts when I need to.’"

While the knowledge of front-line professionals such as nurses, physician assistants and pharmacists is essential to the health care effort, both Gordon and Damon-Moore noted that many of the medical students were surprised to learn how dieticians and social workers contribute to patient care. "Students in other disciplines are not as aware of their roles as they could be," Damon-Moore said. Social workers, in particular, have an "almost invisible role" in health care, she said. One of those social workers, Tara Clark, participated in Clinical Beginnings as small-group co-facilitator. Clark has been with UI Hospitals and Clinics’ Department of Social Service since 1999, and in addition to working with oncology patients in the Holden Cancer Center also supervises other social workers.

"It was wonderful to be included in the process," Clark said. "We always emphasize interdisciplinary collaboration with our staff."

The Clinical Beginnings group Clark co-facilitated included medical, nursing, pharmacy, physician assistant and physical therapy students. Members, she said, "were surprised at how much they needed to consult with the interdisciplinary group" in order to address all aspects of the case they were given. "The students who were able to reach across those lines certainly benefited from it."

Clark, who has lectured on social work to UI medical students in the Community Health Outreach course, helped to plan and organize this year’s Clinical Beginnings program and hopes to be involved next year as well. "Here we are in this university setting," she said, "and we should take advantage of these opportunities to learn from each other."

Another new element of Clinical Beginnings this year was introduction of the core competencies that resident physicians must demonstrate during specialty training. The six competencies, established by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, cover patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and systems-based practice.

In line with these initiatives at the graduate level, the Liaison Committee on Medical Education, which oversees undergraduate medical education, has incorporated the competencies into its standards. So Gordon has been meeting with clerkship directors since the beginning of the year to build awareness of the competencies and support for integrating them into evaluation of students’ performance during their clinical rotations.

The goal, Gordon said, is to make sure Iowa medical students are familiar with the core competencies and can put them into practice. When they encounter assessment for the competencies in residency training, he said, he wants them to be able to say, "Great, that’s exactly how we were evaluated in medical school."

Gordon doesn’t think the relevance of the competencies ends there, however—he expects the competencies or something like them to gain a place in continuing medical education for practicing physicians. "I believe in the next five to 10 years we’ll see CME activities that involve a demonstration of the competencies," he said.

In the meantime, there is next year’s Clinical Beginnings program to plan and organize. "We’re going to build on our success and continue to emphasize interdisciplinary teams and the core competencies," Gordon said. He also hopes to enhance content devoted to learning how to convey bad news to patients and make more time available for the new third-year students to spend with fourth-year students, he said.