David J. Schleich, PhD
Not infrequently these days, there is interest expressed among naturopathic professionals and certain of their allopathic colleagues to collaborate in practice as well as in education. How great it can be for patients when 2 or more professions learn about, from, and with each other. This collaboration, though, can be complex and even controversial. In our era of integrative medicine and coordinated care, the attraction to inter-professional collaboration (IPC) and inter-professional education (IPE) strengthens. It is all the more possible, from biomedicine’s point of view, because our programs are accredited. The naturopathic medical research agenda accumulates, with a steady increase in funded projects and participating naturopathic doctors.
In recent years, the literature points to the importance of IPC and IPE in the promotion of patient-centered and team-based care, in particular. As well, that same literature points out the importance of such collaboration to address urgent needs related to environmental and social determinants of health, prevention, early detection, and individualized care. An element of such sharing is also the growth of interdisciplinary/inter-professional translational research. Overall, such efforts lead to greater and broader respect for the uniqueness of professional expertise among different groups – so important if teamwork is to occur. Recent efforts by the Academy of Integrative and Holistic Medicine (AIHM), for example, to encourage inter-professional linkages and collaboration have resulted in an initial agreement with the Oregon Collaborative for Integrative Medicine (OCIM) in the training and assessment of MDs and DOs in the AIHM’s fellowship program – improved inter-professional understanding and respect, for sure, but also great potential for real-deal integrative education and training for allopathic professionals. When such partnering clicks, patients and the health professionals themselves benefit. However, there is apprehension, too, when clicking with the allopathic profession triggers concerns about co-optation by the darker side of the biomedicine juggernaut.
The AIHM/OCIM partnership is a strong reminder that naturopathic medicine and the allopathic professions have some least common denominators in their education, such as the basic medical sciences and public health knowledge. Even so, there are many things which prove to be barriers, both big and small. For example, apart from the AIHM, it is rare to find senior administrative leadership with real resources in hand for creating an inter-professional component for health professions students’ education. As well, some schools or groups interested in launching inter-professional learning find it tough to identify and partner with other professional schools, since there seem to be few potential partners willing to take on an inter-professional agenda.
There are practical issues too, such as the detail of scheduling and mixing and matching educational content, learning objectives, outcomes, and assessment strategies. Further, there are faculty development concerns in this arena too. Teachers of health professions need training to become effective inter-professional educators. The content and process of inter-professional learning depart from the academic content and sometimes even the methodologies with which they are familiar and which are pedagogically safe. And, there is the ever-present important need for assessment instruments to evaluate inter-professional competencies. The AIHM curriculum, as a case in point, has a particular challenge in having to evaluate what the participants in their fellowship program have learned in the natural medicine sector (naturopathic medicine, chiropractic, Chinese medicine). IPC advances this gap very effectively. At the same time, though, accrediting bodies in the broader health education landscape do not generally recognize inter-professional competencies easily, often eschewing such learning outcomes unless they are expressed in curricular terms with which they are comfortable. The literature shows that not only regulators, but educators themselves raise challenges to educational approaches that frame outcomes in terms of competencies (Reeves, Fox & Hodges, 2010; ten Cate & Scheele, 2007; Walsh et al, 2005). All too often, efforts to encourage more practice collaboration get diluted by what invariably amounts to the parceling out and reinforcing of conventional boundaries of practice across the professions. This shows up as too much specificity, and sometimes also complicated judgments emerging from multiple evaluators and regulators.
Reductionism & Holism
There are familiar philosophical considerations in this mix, too, such as the presence of a reductionist mindset coupled with inflexibility, which together are all too often at odds with the complex thinking entailed in a holistic response to certain clinical practice situations. Overall, it is a challenge for different professions to work through these issues, from specific content to the assessment of competencies where unfamiliar modalities or protocols are even tried. We are not without tools, though, in this worthy enterprise. There are those who contend that inter-professional education has not benefitted from reliable or even available theories. Two recent sources point to some appropriate theories to build an architecture of inter-professional education. Reeves and his colleagues, for example, have given us what is known as a “scoping review of theories” that can work to guide inter-professional learning (Reeves et al, 2007). There is also the work of Sargeant (2009) about specific social and learning theories that spell out the differences in the content and processes of inter-professional learning. Sargeant delves into complexity theory, and theories related to social identity.
Sargeant’s work also considers professionalism, stereotyping, situated learning, communities of practice, reflective and experiential learning, and transformative learning. Cognitive theories, such as cognitive apprenticeship, even show up in this literature (Brandt, Farmer & Buckmaster, 1993), as well as the ecological approach to team cognition (Cooke, Gorman, & Rowe, 2009). All of these provide really interesting and practical frameworks which we could get familiar with if we move forward with more substantial inter-professional team-based learning in our programs and schools. And finally, in this regard, let us not forget the role new educational technologies such as online learning, distance technologies, networking innovations, and simulation approaches can have in overcoming traditional barriers to inter-professional learning, especially as these relate to the ever-present worry about time and space (Weinstein et al, 2010). Using these tools, we could soon model real-world practice, most usefully where teamwork needs to happen asynchronously across time and space.
IOM Competency Domains
As a backdrop to these ideas, it is useful to note that back in 2011 the Institute of Medicine (IOM) came up with a number of “competency domains” for health professionals. The IOM’s intention was to encourage among allopathic professions inter-professional education and inter-professional collaboration. The IOM suggests that there are competency domains which we all share, ranging from values and ethics, to diversity of experience, an aptitude for professional communication, and teamwork skills.
Naturopathic doctors and other health professionals typically consider values and ethics content an element of professionalism, which, as Baldwin explains, has significant overlap with constructs of humanism and morality (Baldwin, 2006). In this regard, Berwick and his colleagues contend that older approaches to professionalism are often seen as self-serving and barriers between the professions, meddling with any real progress in improving health care (Berwick, Davidoff, Hiatt & Smith, 2001; IOM, 2001; McNair, 2005). The other side of that same coin are, as Blank and his colleagues suggest, newer approaches characterized by more trust (Blank, Kimball, McDonald & Merino, 2003; McNair, 2005). Dombeck (1997) writes that such inter-professional ethical values become a core part of one’s professional identity – a kind of “professional personhood.” This growing body of literature, though, also explores how the area of inter-professional ethics needs rethinking. Banks and others, for example, write about how collaborating professions deal with the confidentiality of the practitioner-patient relationship in team-based care delivery. (Banks et al, 2010; Clark, Cott & Drinka, 2007; Schmitt & Stewart, 2011).
In IPC, the literature also shows, the categorical differences among team members constitute a useful diversity or variety which at one and the same time have presented in attempted collaborations as a resource and a problem (Edmonson & Roloff, 2009). On the one hand, diversity of experience is a key strength of effective teams. Such diversity of background or cultural characteristics can add to a collaborating, inter-professional team’s capacity and range. Unfortunately, though, that very same diversity can potentially undermine not only mutual respect but also effectiveness. Hean points out this tension, indicating that positive and negative stereotyping of professional roles and demographic/cultural differences affect the success of health professions working together (Hean, in press).
Inter-professional Communication
Inter professional communication, though, can help overcome such diminishing returns. Suter et al’s (2009) study of front-line health professionals declares that even though basic communication skills are a core aspect of inter-professional collaborative practice and a common area for health professions education (eg, AAMC, 1999), health professions students often have little knowledge about or experience with IPC. This weakness can impact teams and teamwork; however, when such teams (including naturopathic doctors, such as in the OCIM/AIHM collaboration) include strong leaders, the focus on patient and community needs can prevail. As Zaccarro and his colleagues remind us, those same strong leaders can draw out potential contributions and benefit the collaborating team (Zaccaro, Heinen, & Shuffler, 2009).
The literature tells us that IPC and IPE can be strengthened as a characteristic of professional formation by beginning in our classrooms. The Student Alliance for Integrative Medicine (SAIM) is a recent example of such early adaptation. This group, affiliated with OCIM, has been operating in Portland, OR, for several years and attracts several-hundred students to its educational and placement activities. The idea is to encourage and facilitate, through inter-professional learning activities, exposure to students across the professions. Modifying a framework from Kirkpatrick (1967), Barr, Koppel, Reeves, Hammick, & Freeth (2005) readily showed how this early approach helps. They explain that primarily “college-led” activities produced more effective inter-professional collaboration. Organizational change and clinical outcomes, they reported, were more commonly associated with practice-based inter-professional learning by practitioners. Naturopathic medical education has long understood in its design the value of purposive engagement between education and practice for building competency. Building, then, from the classroom up, can transform the clicking of professions from an encounter with the dark side to a healthy sharing by equals.
David J. Schleich, PhD, is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).
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