Education of health care professionals has traditionally occurred in venues in which students have had limited exposure to other fields, and rarely has self-care been a focus within required curricula. Given the global challenge to improve health outcomes and reduce the cost of care, a focus on health, well-being, disease prevention, and health promotion is both critical and timely. It would help students improve personal health outcomes and equip them with the knowledge and skills to educate patients on how to better assume personal responsibility for their health and well-being. Well-being content is ideally suited for interprofessional education.
Frank deGruy, M.D., M.S.F.M.
University of Colorado School of Medicine
Health professional training and socialization has traditionally focused on the knowledge, skills, and attitudes needed by each health profession to perform its respective duties in caring for patients. This siloed approach to education and training typically includes little information or training on the work of other professions and how they fit together to make for successful team practice. We need to find new approaches to teach about transdisciplinary professionalism, defined for the purposes of the IOM workshop on Establishing Transdisciplinary Professionalism for Health as “an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, worthy of the trust of patients and the public.” We want methods to demonstrate to all health professional students: shared understanding, new forms of leadership, team support, and communication (Olueliyawa et al., 2009). This paper will offer some thoughts and examples drawn from training to integrate behavioral health into primary care and other areas of health care.
One of the first issues in changing the attitudes and skills of the health professionals of tomorrow involves how they are selected in the first place—admissions and hiring. Traditionally, medicine and psychology select people who value autonomy—highly competent individuals who prefer to control
their own work and distrust administration. Selecting for these attributes produces the workforce we have today. The alternative is to include in search and admissions committees members from other health professions, as well as patients, and select for mission-centric, team-ready, emotionally intelligent faculty and students—people who will align their practice with the values of transdisciplinary professionalism. After we have identified such students and professionals, we need to help them develop both strong professional identities and strong collaborative skills—whether they are physicians, psychologists, nurses, nutritionists, pharmacists, physical therapists, secretaries, or medical assistants. There are many barriers to this approach, ranging from financial segregation to the tribalism that is inherent in each discipline’s socialization—tribalism that can result in an “I’m okay, you’re not” approach to other disciplines.
Challenging Tribalism: Consciousness-Raising Exercise and Video
One exercise to raise the consciousness of professionals working to integrate psychologists into primary care is to ask the primary care professionals to provide adjectives that represent the public’s stereotypes of psychologists, then ask the psychologists to do the same for physicians. People typically go for more of the negative stereotypes, with just a few of the positive. This exercise has been used hundreds of times11 in more than 20 countries, including China, Germany, Mexico, and Romania. These are countries with vastly different cultures, languages, and systems to finance their health care. Surprisingly, the adjectives are universal. As a sampling: physicians are cold, controlling, arrogant, pressed for time, and technicians; psychologists are cerebral, impractical, touchy-feely, weird, and, according to a physician in London, “right-brained and left-winged.” If these stereotypes affect health professional behavior in any way, it is no wonder that teams are unable to effectively respect or work together.
A brief teaching video for providers illustrates this point further. The video shows a real family physician, Thomas Campbell, trying to work with a real psychologist, Susan H. McDaniel, to care for a fictitious patient (McDaniel and Campbell, 1986). Questions after the video include “Who is most realistic? The physician or the therapist?” Typically, the physicians say that no physician really behaves the way Campbell did in the video, but assert that the therapist was very realistic (though perhaps not crazy enough). The psychologists say that no psychologist is that nutty but argue that the physician was quite realistic (though perhaps not harsh enough). In mixed audiences, this response then produces good data for discussion about how each profession can be perceived. This satirical video articulates
11 By Thomas Campbell, M.D., and Susan H. McDaniel, Ph.D.
the many ways we can go wrong in trying to work together and is one way to address professional tribalism—by elevating, examining, and challenging it. This teaching model can be extended to stereotypes of all health professions.12
Improving Interdisciplinary Team Communication: The Team Collaborative
Eduardo Salas, a psychologist who studies team functioning across industries, including air transportation, the defense system, and health care, emphasizes the importance of what he calls “task interdependence.” Salas found that team training requires information, demonstration, practice, and feedback, but the most important of these elements are practice and feedback (Salas et al., 2005). An example of training that focuses on these elements comes from the University of Rochester Department of Family Medicine’s “Team Collaboratives,” a monthly meeting in which all teams explicitly work on team relationships and communication skills and share quality-improvement projects so that they can be generalized across the practice. In consultation with Stephen Schultz, residency program director, and a committee of staff advisors, Tziporah Rosenberg, a family therapist, has been running these interactive meetings of 120 people since she finished her postdoctoral fellowship in 2008. She provides information, addresses process, teaches task interdependence, models transdisciplinary professionalism, and highlights successes in an entertaining format.
Often, the Team Collaboratives focus on an essential aspect of professionalism: communication. For example, in one meeting, Rosenberg directed the teams to play the children’s game of Telephone. She gave each team the following message to convey down the line of people, each member whispering into the ear of the next:
Tuesday last week, there was the most incredible rainstorm. It seemed like it would never stop. I remember it was Tuesday because my car was in the shop and I needed to catch the bus; I started on the 11 and picked up the number 1 before I finally got the 14 to get to the mall. I needed to do some last-minute back-to-school shopping.
By the end, most communications were down to about 8–10 words with few of the significant points. For example, one team’s final communication was It was raining, it was raining. I had to catch the bus.
12 A similar satirical video of a large interdisciplinary team case conference was produced as part of the Primary Care Policy Fellowship. See McDaniel et al. (1999).
In the second round, the message included affect:
Last week on Tuesday, the day of the big rain, you told me that you were going to take care of that issue that I talked to you about. I told you it was really important to me. You said it would be no problem, and you could finish it before you left for the day, but you didn’t. I’m confused about what happened and frustrated it’s not done yet.
One group’s final communication was You said you would take care of it, but you didn’t.
After a large group discussion about the problems with multiple communications and how emotion affects them, the entire Team Collaborative developed “Communication Pearls” they could all agree to:
- Keep it short.
- Actively check for understanding.
- Electronic health records really are better for some communications.
- It is important to be kind when giving feedback.
Team Trust Exercise: Tell Us About Your Background
Patrick Lencioni, a business consultant, focuses on corporate team building. His five prerequisites of great teams are trust, conflict management, commitment, accountability, and a focus on results (Lencioni, 2002). Trust, the foundation of good communication, requires vulnerability to be open with one another around mistakes, weaknesses, and fears. It is important to clear out political and hidden motivations. Lencioni emphasizes that for trust to develop across disciplines, it is especially important for leaders not to promote the myth of invulnerability.
Sharing personal information helps to promote trust and provide new perspectives for individuals working together in teams. Lencioni (2005) suggests telling each other where you grew up, your birth order, your cultural background, and an important or challenging thing you had to deal with in childhood. The following is an example from McDaniel:
I grew up in South Florida, the oldest of three girls in a Southern WASP [White Anglo-Saxon Protestant] family. One of the most influential events for me was racial desegregation of the schools when I was in junior high. It challenged the stereotypes I had heard all my life, set me on a path to study stereotypes in college, and led me to work on cross-disciplinary teamwork in health care.
Another example involved a physician who was quite disruptive in team meetings. In this exercise, he said:
I grew up in a poor neighborhood in Jamaica with a lot of illegal activity, racism, and violence. I learned to hurt people in order to survive, but came to realize this was wrong. The hardest thing for me has been to socialize myself, to learn not to behave that way anymore, to treat people with respect.
This revelation changed the way his teammates understood him and changed the way he functioned in the team as a result.
Conflict-Management Exercise: How Did Your Family Air Differences?
Managing conflict is a key competency for transdisciplinary professionalism. Productive, even passionate, debate is important for healthy team functioning. Getting all ideas out on the table and being able to control discomfort, rather than dismiss differences, is more likely to yield positive outcomes. This kind of communication requires patient, active listening, and basing arguments on substance, not politics, pride, or competition. It means going after the best solution, rather than trying to win.
An exercise to work on conflict management begins with the following questions: “How did your family air differences? What are your preferences about acceptable and unacceptable behavior during debate and disagreement? (including language, tone of voice, emotional content, and whether you tend to participate or not)” (Lencioni, 2005). After discussion, the team works to develop its own norms for managing conflict and for what is acceptable and unacceptable behavior.
Issues of hierarchy and power inevitably arise in interdisciplinary work. We want a collaborative practice in which the power of each party is fully recognized—the power of the physician, psychologist, and other health professionals to diagnose and suggest treatment; the power of the patient to make sense of the illness experience and decide and embark on treatment; and the power of the family or social group to provide a healing environment.
In a paper called “Why Men Resist,” William Goode (1980) described how the sociology of superordinates states that there are predictable feelings and behaviors experienced by those higher in the hierarchy as well as by those perceived as lower. In particular, those who are higher tend to experience their position in terms of feeling burdened and responsible rather than powerful, blessed, or lucky. Those who are lower can feel that their talents or accomplishments go unrecognized. They are vulnerable to feeling invisible, unappreciated, disrespected, and eventually resentful.
It is important to study what counteracts these problems. In his book Outliers, Malcolm Gladwell (2011) gives a compelling description of how Korean Air transformed its safety record from one of the worst to
one of the best by understanding how culture and hierarchy had resulted in flawed and incomplete cockpit communication. Desperate to fix the problem, Korean Air examined cockpit recorders and found that, consistent with their culture, power and authority were never challenged. They found that, worldwide, planes are safer when the least-experienced pilot is flying, because it means that the second pilot is not afraid to speak up. After identifying the problem, Korean Air set about creating a different kind of culture in the cockpit, one in which hierarchy is flattened, first names are used, and the copilot is rewarded (rather than dismissed) for disagreeing or speaking up. The same principles of communication and flattened hierarchy have been found to increase safety in surgery and other health care teams.
Encouraging Feedback: A Physician Communication Coaching Program
Many issues of power and communication are taught through the so-called hidden curriculum in professional training, that is, what students see modeled by professors, regardless of what is taught formally (Hundert et al., 1996). Changing the hidden curriculum means creating a culture that welcomes, rather than avoids, feedback.
To increase communication skills and change the hidden curriculum around issues of professionalism, McDaniel developed and directs a physician communication coaching program at the University of Rochester. This program was developed in response to patient complaints and patient experiences as a driver for reimbursement.
To begin this program, leadership endorsed a set of professionalism values (integrity, compassion, accountability, respect, and excellence), and physician faculty articulated 32 physician behaviors associated with these values. They then voted for the top eight, and McDaniel culled these down to three primary behaviors associated in the literature with improved quality and patient satisfaction (Gerteis et al., 1993; Stewart et al., 2000; National Quality Forum, 2003; Wolf et al., 2008): (1) introduce yourself and your role to new patients and families; (2) ask about patient and family concerns early in the interview; and (3) check for understanding about the diagnosis and treatment plan. Trained coaches complete an expanded version of the Cambridge Patient-Centered Observational Coding sheet (Kurtz and Silverman, 1996) for each physician–patient encounter. The observation period typically lasts 4 hours. A report is written to provide quantitative information (e.g., “You asked about the patient’s concerns directly with 6 of 10 patients”; average time spent per encounter), qualitative descriptions (e.g., “Your relationship-building skills are very strong. You typically ask each child what their career plans are.”), and a list of strengths and concrete behavioral suggestions for improvement. The report
is then sent to the physician and is not shared with anyone else. After reading and digesting the report, the physician meets with the coach to discuss his or her reactions, what was expected, what was a surprise, and plans for improvement (including a future coaching session).
This program started with McDaniel coaching the senior associate deans, clinical chairs, and other senior clinicians. It now includes faculty who wish to be coached to improve their skills, faculty whose leaders wish for them to improve their skills, and new faculty.
Physician response has been almost universally positive in evaluations solicited through an anonymous survey. Sixty percent of physicians in the first year (2012) gave the coaching a rating of 5, “Very Helpful,” on a scale of 1 to 5; 40 percent rated it a 4, “Helpful.” No participants gave any lower ratings for the experience. Comments included “I believe this type of experience is valuable since habits (good or bad) creep into communication. … Very professional and insightful. I would like to do this again” and “Very helpful indeed, even though it was truthful!”
In order to increase coaching capacity and meet the needs of the medical center, the coaching team, headed by McDaniel, now includes five coaches from different disciplines. One of these coaches, psychologist William Watson, remarked:
An advantage of coaching is that (1) it is innovative, (2) [it is] interdisciplinary, and (3) it vividly conveys the important idea that a necessary foundation of transdisciplinary professionalism is openness to feedback, diminishment of professional hubris, and respect for the value that other disciplines bring—the idea that we all have blind spots, do not know everything, are constantly missing things, can improve our practice in critical ways, and, most importantly, can learn from others who are not of the same discipline. One could say that coaching is subversive (in a good way) to the dominant culture of the disciplinary silo. (Personal communication, W. Watson, 2013)
Next steps include research to evaluate the effectiveness of coaching and other exercises to inform the teaching of transdisciplinary professionalism (McDaniel, in preparation), as well as studies that bear directly on physician–patient communication and teamwork (see “Physicians Criticizing Physicians to Patients,” Journal of General Internal Medicine, 2013). Improving the level of transdisciplinary professionalism requires innovation in education, training, and research as a significant part of health care practice and educational transformation.