Profound Culture Change: IOM Workshop Reveals Alignments in Interprofessional Practice and Integrative Medicine/Health 

Note: This report is based on a similar report from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) to its members and participants following a two-day workshop of the Institute of Medicine (IOM) Global Forum on Innovation in Health Professional Education help November 29-30, 2012. The Global Forum has been called the most inclusive and diverse dialogue in Institute of Medicine (IOM) history, in part via the active sponsorship and participation of ACCAHC in representing the values of integrative health. This was the second of six such workshops which will be convened as part of the IOM Global Forum on Innovation in Health Professional Education. ACCAHC is one of over 40 academic and professional organizations sponsoring the forum. I produced this report as one of ACCAHC's "ambassadors" to the Global Forum and the workshop.

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The second two-day workshop of the IOM Global Forum on Innovation in Health Professional Education again demonstrated that remarkable innovation toward team care is not only underway, it is backed as a national campaign. As this report shows, the parallels, echoes and links with the values and challenges of integrative education, practice and research are profound. We are witnessing a remarkable convergence of integrative and health-oriented models into the main river of education and practice. 

The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) is one of over 40 academic and professional organizations sponsoring the Forum. ACCAHC chair Elizabeth (Liza) Goldblatt, PhD, MPA/HA is ACCAHC's member of the Forum. ACCAHC executive director John Weeks is also actively involved and attends the meetings as ACCAHC's alternate member. The workshops are available via high-quality webinar.

Held on November 29-30, 2012, the second Forum's theme continued that of the August 28-29, 2012 kick-off of this 3-year global initiative: Educating for Practice. The first was reported as Widening the Circle: ACCAHC Report from the 1st IOM Global Forum on Interprofessional Education and Care. The Global Forum has been called the most inclusive and diverse dialogue in the history of the Institute of Medicine (IOM). The November gathering of an estimated 85 academics and other professionals was the second of six workshops planned between 2012-2014. This report is made available in part via a foundation grant to ACCAHC.

Resources: The IOM has done an exceptional job of making the workshop contents available. This and future meetings are high-quality webcast for any interested party. Tune in and have it as your background in your office! The agenda of the November meeting is here. Videos of selected presentations are here.  All of the slide presentations are here. The workshops for 2013, scheduled for May 13-14 and October 2013 will also be available via webinar.

George Thibault, MD

1. A Major Innovation: Taking Medicine Out of the (Was it Ever?) Ivory Tower

The force behind the Global Forum and much of the robust campaign to transform health professional education toward team care and mutual, horizontal and egalitarian respect among the disciplines is the direct-speaking George Thibault, MD. Thibault is the CEO and president of the Josiah Macy Jr. Foundation, the lead funder of the Forum. Thibault has also brought Macy's substantial resources to a series of other strategic efforts relative to changing interprofessional practice and education in the United States. In the Forum's closing minutes, Thibault captured his reflections: "We need to become more expert in culture change. One [such change] is in breaking down silos. The other is the profound culture change [involved with connecting] the academic world and the practice world [and] the incentives driving the health system world. We need to learn a lot more about that. We need to be more explicit about that culture change."

Comment: Thibault's comments echoed the recommendations of the Lancet Report on Health Professionals for the 21^st Century, one of the inspirations for the Global Forum. Thibault's comments evoked the statement of Paul Grundy, MD, MPH, IBM's director of healthcare transformation, at the August 2012 Forum workshop. Grundy blasted the academic health centers for their lack of concern for creating a healthy population and, from an employer's perspective, workforce. To the assembled representative of academic health systems Grundy said: "You are nothing but milking machines." In short, academia's so-called ivory tower is not just tarnished. It's an utter misnomer.

Thibault takes that negativity and turns academia in an affirmative direction to connect and respond to real world needs. The way to get back the soul of academia is to leave the ivory tower and go meet the public that health professions education is supposed to serve. The theme came up various times. Then be explicit about the business models for doing this. What are the implications for educators in the integrative health and medicine fields? What new content is important to understand and work better with the "real world" culture?

Sam Thier, MD

2. Opening Perspective from Former IOM President Sam Thier, MD: "How many types of providers is enough?"

Sam Thier, MD is the former president of the Institute of Medicine of the National Academy of Sciences.  Thier has held leadership positions in hospitals, academic health centers and the Commonwealth Fund. He had little background or interest in IPE prior to taking the assignment of opening the workshop. Reflected Thier on his assignment: "Just writing down IPE puts chills through me as I think of the challenge."

He recalled an involvement decades ago in establishing the WWAMI program (Washington, Wyoming, Alaska, Montana, Idaho) to provide primary care in Alaska and the northwestern states: "They found [an MD], a nurse, a pharmacist is ‘enough'" to run one of their clinics."  Then he adds: "The question is, enough for what?" He reflected, recalling the Alma Alta 1976 declaration on primary care: "Alma Alta said that health is too important to leave to the doctors." He added dryly: "So, in places where doctors ruled, it failed."  He closed with a series of questions: "How do you deal with increased complexity? How many [types of providers] are enough?" And finally: "Are there irreplaceable professions?"

Comment: Thier's question - good enough for what? - cuts to the heart of why it is important to clarify that our goal is  not merely to suppress disease i but to create health. What one takes as one's charge defines who needs to be at the table. Who is needed to provide opioids? Who is needed to provide optimally integrated, team-focused pain care as recommended in the IOM's own 2011 blueprint? A chasm between reactive medicine and health creation yawns. If the health promotion, wellness and health creation agenda (requested by individuals and employers) is not in the IPE discussion, the circle shrinks.

One complaint: Thier did not specifically reference the financial gains in the present system that create these barriers. Consciously speaking to the deep financial commitment of the present system to doing the wrong things is step one in the academic medicine's 12-step movement away from its addiction, and out of its sullied tower. Speakers and dialogue frequently bordered on the overwhelming nature of the challenges. Thier's seasoned warning about the depth, height and breadth of the challenges facing IPE sends one to this last refuge of an activist. Former Czechoslovakian president and author Vaclav Havel wrote about hope: "Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."

Eric Holmboe, MD

3. Challenges Creating Evidence for Team Care Parallel Whole Systems/Whole Practice Issues in Integrative Health and Medicine

The chief medical officer and senior vice president for the American Board of Internal Medicine, Eric Holmboe, MD, had the intriguing but onerous charge of heading up a sub-group that asked:

How should the outcomes of interprofessional education be measured/assessed assuming the ultimate goal is better health, higher quality and improved value for individual patients and populations?

Comment: Team care and the whole practice of integrative health have in common that they are supported by waves of common sense but underwhelming bodies of research. The evidence that exists is not often what one most wants to know regarding the function of the whole system. Reasons are similar. Each engages the complexity of human life rather than the often false clarity of reductive trials.  (See Political-Economic Issues in Whole Systems Research Revealed by JACM Roundtable.) Each confronts the individuality of patients and situations. The parallels are profound. Many of the more substantive challenges addressed by the Research Working Group of the Academic Consortium for Complementary and Alternative Health Care are echoed here. As Thibault urged the academics to enter the real world, so Holmboe urged the researchers into a brave new world of, as the Lancet Report underscored, being more comfortably with ambiguity.

Comment: Again, one sees a remarkable convergence with the developing movement in integrative health. First, there is the practical matter Brashears notes of finding expert teachers when the movement hasn't matured enough to have produced them. What young program in integrative medicine or the licensed integrative health disciplines has not known that challenge? The second is this importance of space, which the Samueli Institute elevated via its Optimal Healing Environments initiative. Are new schools and clinic facilities in the integrative health arena being designed or re-designed with sufficient team and group spaces and relationships to foster collaboration?

Intrernational Classification of Functionality, Disability and Health

Stefanus Snyman, MD, with the partnership group of the Global Forum at South Africa's Stellenbosch University stated early in his presentation: "Our IPE strategy is not for IPE's sake. It's for social accountability and to make change." He was speaking to the tendency of the academics to get caught in their own towers of importance and forget their ultimate clients. He presented on his group's use of the World Health Organization's, real-world focused International Classification of Functioning, Disability and Health as a practical framework for IPE. He underscores the need for a "bio-psycho-social-spiritual approach" to be the basis of conceptualizing the team needs. (See Thiers, above: "Enough team members for what?") He focuses on patient outcomes such as body function and structure, activity limitations. The assumption is that "no profession alone can do that." Who will lead? "The person who will bring the most value now will be the conductor of the orchestra." Snyman's was one of two programs that directly mentioned the potential contributions from "Natural Medicine."

Snyman noted cross-application to employer interest in such real-world outcomes as productivity and presenteeism. In the comment period, one participant noted that the U.S. is the nation with the least interest in, or participation with, these W.H.O. ICF codes that took 25 years to develop. With tongue not at all in cheek Snyman noted: "For medicine, this is rocket science, believe it or not.

Comment: The charge from the ACCAHC board for work with the IOM is to elevate the idea of the innovation in health professional education known as whole-person care that is focused on actually creating health in the individuals and populations, rather than being reactive and solely disease oriented. Why not then a coding system that announces "health" and "functionality" in its title rather than what is announced in the US standard International Classification of Diseases? Should the integrative health and medicine communities, and their allied educational institutions, be leaders in exploring and promoting uptake of these ICF codes in the United States.

Sarita Verma, MD

6.  The Canadian Collaborative on the New Leadership: "Transcends professional and historical boundaries"

The Lancet Report underscored the importance of not just educating "experts" or "professionals" but, for this era, "change agents" and leaders. The presentation from Sarita Verma, MD and Maria Tassone, PhD, from the Canadian Health Interprofessional Leadership Collaborative focused their findings on the leadership attributes that health professional education should cultivate. They answered with a resounding "Yes!" to a question about whether the effort to create a new kind of practitioner means also creating a new kind of leader. Such leadership "unlocks the full human potential," "engages diverse perspectives," "transcends professional and historical boundaries." It will move from limited to "dramatically increased innovative capacity." The group is in the process of developing collaborative leadership competencies. After an extensive review of the emerging leadership literature, their first stab at a definition of "collaborative leadership" is:

"Collaborative leadership is a way of being, reflected in attitudes, behaviours and actions that are enabled by individuals, teams and/or organizations, and integrated within and across complex adaptive systems to transform health with people and communities, locally and globally."

Comment: Those of us in the U.S. rather than Canada nor Snyman's South Africa face an additional challenge relative to social accountability. The private sector corporation in U.S. medicine must, to keep its contract with shareholders, be grounded not in social accountability but profit-making. These emerging leadership characteristics may be an awkward fit. Perhaps it would serve the Canadian team to more directly and significantly seek to cross-pollinate with emerging leadership ideas in the progressive, reform, and socially conscious sectors of the business community.

7.  Some Short Notes and Observations: "An IPE spring" and "IPE terrorists"

The sections noted here in no way diminish the value of the remaining 95% of the presentations and discussion. This was a content-rich event. Here are a few additional short notes.

David Collier, MD in his presentation on team-based obesity treatment in North Carolina  focused on a trio of medical, nutritional and physical activity practices and interventions: "We are a three-legged stool sitting in a pool of motivational interview" ... Collier put a strategy regarding addressing the harmful the legacy of top-down hierarchy in school ground terms: "We need to address bullying" ...  The felt need for major change facing major obstacles created revolutionary references. One commented in discussion: "I am no longer what I would have been thought of 15 years ago - an IPE terrorist. I'm now a dean ..." The excitement of students in interprofessional experience provoked a  joke line that caught on. We need to see a "student uprising" or an "IPE spring" ...

Polly Bednash, RN, PhD

Malcolm Cox, MD with the VA: "When you look at your colleagues you find much non-suitability for health professional education." Often they aren't "focused on the altruistic" or suited for collaboration ... Lloyd Michener, MD in a keynote on a Duke program serving poorly-served communities: "This is a problem of chaos. Doing more medical care is not likely to help. Often what is needed is a failure of our delivery not a failure of the patients. We need to look at the ways we are part of the problem." In his program, he says, "we are weaving in health." And: "The thing we had to do was learn how to listen, to get out of our offices - it was a painful experience that were telling us all the ways we had failed them."

Polly Bednash, PhD, RN, FAAN the member from the American Association of Colleges of Nursing offered two factoids for integrative healthcare discipline educators who think that they have special challenges because of their silos away from academic health centers: "Eighty-three present of nursing program are not co-located with medical schools." A wide set of educators are faced with creating IPE  strategies that jump institutional boundaries ... In reports from breakouts on the team that focused on leadership underscored that in the emerging system "everyone needs to be change agents, everyone must be leaders." Meantime, the "lead (as in the metal) anchors" that hold back change are accreditation, licensing, and payment rules" ...

8.  Schwartz and Gomes: Views from ACCAHC Observers Present Via Webinar

Jan  Schwartz, MA and Stacy Gomes, EdD, are two ACCAHC leaders who chose to listen to the Global Forum via webinar. Schwartz, an ACCAHC Board member, co-chairs the Education Working Group (EWG) and on which Gomes serves. Each also serves on the ACCAHC Task Force on Leadership Development. Gomes reflected: "My take away was that participants are still challenged to create meaningful opportunities for the disciplines to work together." She added that "the hierarchical structure in healthcare settings is so entrenched and this may take years of getting healthcare students together sooner to create ‘team' thinking."

Jan Schwartz, MA

Schwartz, a web-education specialist, first gave kudos to "the quality of the stream - the tech people made it extremely easy to watch from a distance." She notes: I share this on that basis I would recommend future sessions to others." Then:

"The section on IPE and leadership caught my eyes and ears.  Because I'm on the (ACCAHC) Task Force on Leadership Development and because I'm interested in leadership in general I found these statements interesting: "Leaders are not 'them' they are ‘us."And: "Leaders may be your teammates." And: "What is your relationship to these leaders? Building trust." It is a given that leaders need to buy-in to IPE for it's inclusion in curriculum. But I thought that emphasizing the ROI [return on investment] and how IPE can solve specific problems that leaders face is something that we don't necessarily focus on. In many cases we emphasize the importance of IPE to healthcare, but we fail to ‘sell' not only through connecting and relationships (which ACCAHC does well), but also in terms of economies of scale.  And maybe this is how we get conventional medicine to pay more attention to the inclusion of CAM therapies and providers and what they have to offer in terms of health care costs."

9.  The Closer: "The 21^st century is about putting the world back together"

The job of summing up the wealth of the day and a half was given to not a health professional but a lawyer. Martha Gaines, JD, is the director of the Center for Patient Partnership at the University of Wisconsin. She is also, as she shared in her closing comments, a 19-year cancer survivor. Gaines referenced comments of one of the non-U.S. members of the Forum who, on listening to the dialogue, had wondered at how much time the U.S. $2.8-trillion (and growing) medical industry has in which to change: "Our colleagues in other countries are warning us. Do we have to be in the scorched earth place before we change?" Gaines hopes that we were at the hour of change now. She betrayed her roots:  "I quote Janice Joplin: ‘Freedom's just another word for nothing left to lose.'" 

Martha Gaines, JD

Gaines offered strategic advice: "From what I am hearing we have two armies out there that can help us - patients and students." Numerous speakers referenced how much health professions students of all kinds like interprofessional education. The assumption is that patients are on board. Gaines concluded: "If the 20^th century was about taking the world apart, the 21^st is about thinking it back together again." To her, interprofessional education "is an iteration of a broader way of putting the world back together again." She adds: "We need to be asking who else is doing parallel work in other fields." And, somewhat wistfully: "What holds us back from letting go of the traditional models of care?"

Comment: IPE as a complex, changing, hard to research, unit of healing that must reach out and connect to such similarly oriented "broad ways of putting the world back together again." Those located in this broad view of integrative care's charge to create health, anyone deeply embedded in those cultural challenges, will feel happily at home in this room, this movement, if only because these leaders are beginning to embrace the magnitude of the change that is begged by the rather benign notions of "interprofessional education" and team care. Only for integrative health care, the chills to which former IOM president Thiers alluded as he considered the ramifications of IPE are not just of fear for the beasts in the woods likely to oppose. These are chills also of anticipation and potential of a new world opening.