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"Profound Culture Change" IOM Program Shows Alignments Between IPE and Integrative Medicine/Health |
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Written by John Weeks
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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.
_______________________________
Do you believe health care can be advanced through
innovation in the way healthcare professionals are educated?
 Sponsor of the Global Forum
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 21st 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?
Holmboe humbly
reported his group's discussion relative to the still paltry level of
research supporting the value of interprofessional education in bettering
treatment outcomes. Then: "We don't know for sure what we should be measuring."
He added: "We don't have clarity of purpose. We don't for sure know the unit of
analysis." Then: "We need to be embracing complexity." He then placed the
research need in the context of a team care that remains largely an aspiration
in most health systems: "We are preparing research for a practice that doesn't
exist." Holcombe called on the research community to not do what it does as its first nature: "[Researchers] will try to
reduce and break it apart but we need to do more than that." Said member
Patricia Hinton Walker, PhD, a vice president with the University of Health
Sciences, during discussion: "We need funding not just for IPE but for
developing the measures." A video of Holmboe's report-out is
here.
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.
This is a case of the misery loving
company. The ‘whole' in whole person and whole system approaches needs a whole
community of interests to break the hold of the current research establishment.
See closing comments from Martha Gaines, JD, below: "We need to be asking who else is doing parallel work in other fields."
Integrative health and medicine researchers who focus on researching the way
they practice are kindred spirits to Holmboe and his colleagues.
4. Shoe-Horning the
Change: Findings from Interprofessional Education (IPE) Experiences in the VA
Centers of Excellence in Primary Care and at U Virginia
A
presentation that one observer called a "proof of concept" for IPE was that of Kathryn
Wirtz Rugen, PhD, FNP-BC. Her presentation
ended with three slides on challenges and lessons learned that included: staying
patient-centered is difficult; co-leading is hard work; leveraging small
projects to change large systems is tough; co-location of learners with adequate learning space
is essential; formal instruction is the most well developed, next is workplace
learning, and least developed is least reflective learning; "breaking down
silos and the notion of hierarchy" is a challenge; and, "cultural
transformation is slow." Valentina Brashears, MD, FACP, FNAP, reported
outcomes from an IPE program at the University of Virginia. She provided a
curricular map on how IPE was integrated throughout the educational program,
rather than as an add-on. She commented on a start-up issue: "We lacked trained
facilitators. We had a lot of people who thought
they were good at this. Even those interested were not that well prepared."
Discussions
in how to model the new team care included not just changing minds but also
changing work environments. Noted the Forum member representing the Council on
Social Work Education, Darla Coffey, MSW,
PhD: "We are looking at assessing the value of space." This included the
"physical space to meet in" to discuss what is needed as teams and also, she
added, "reflective space."
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?
5. The Value of the
W.H.O.'s Real World Functionality Codes (ICF): "For medicine, this is rocket science"
 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."
They echo Snyman, above: "The work will be grounded in
the principles of social accountability." The webcast is
here.
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
21st 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 20th century was about taking the world
apart, the 21st 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.
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