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Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary (2014)

Chapter:II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka

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Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
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II.7 TOWARD TRANSDISCIPLINARY PROFESSIONALISM IN THE TEACHING OF PUBLIC HEALTH

Jacquelyn Slomka, M.A., Ph.D., R.N.
Case Western Reserve University Frances Payne Bolton School of Nursing

Professionalism and Public Health

Teaching transdisciplinary professionalism to students in the clinical professions presents a multitude of challenges. Extending this teaching to encompass students in the field of public health involves a somewhat different set of issues and modes of thinking than in clinical professions. This paper elicits and describes some of these issues by briefly reviewing the current standards regarding professionalism and public health. Next, some of the differences and similarities in professionalism across public health and clinical medicine will be highlighted as a means of targeting areas amenable to the shaping of transdisciplinary professionalism. Finally, strategies and challenges involved in teaching transdisciplinary professionalism to public health students will be identified.

In the United States, professionals as well as the general public are often unsure about what public health is, exactly. Clinicians have been heard to define public health as “not (clinical) medicine.” Public health has been viewed by some as government-funded health care—that is, Medicaid, Medicare, or so-called safety-net care. Schools of public health are concerned with public health in a pedagogical sense, as a discipline distinct from clinical fields such as medicine, nursing, and allied health. In considering transdisciplinary professionalism, it may be useful to think of public health not as a discipline per se, but as a concept or a unifying idiom that spans health care delivery, disease prevention, health promotion, and health policy. Transdisciplinary thinking, then, would imply attention to the connections and dynamic relationships among clinical care, measures to prevent disease and promote health, and policies that direct and support the health of the public.

Our tendency in the United States, however, is not to focus on such connections and relationships. More commonly, debates have involved whether public health is part of medicine or whether medicine is part of a broader notion of public health. For many decades, thinking about public health has implicitly or explicitly involved a divide between medicine and public health (Lasker et al., 2001; McGinnis, 2006). In the early days of medicine, when infectious diseases were rampant and scientific knowledge

Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
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was limited, public health measures were essential in keeping populations healthy. But as infections became controlled and clinical knowledge advanced, the focus on public health faded as a more powerful and prestigious clinical medicine assumed the dominant meaning of health care in society (Starr, 1982). The 9/11 terrorist attacks, rapid advances in medicine and information technology, and broad socioeconomic changes in health care led to renewed interest in public health processes and modes of thinking and recognition of a need for collaboration and cooperation across medicine and public health (McGinnis, 2006). In a sense, medicine is also public health: the successful or unsuccessful delivery of health care in a clinical setting affects the public’s health, just as public health processes and policies can influence care provided in the clinical arena. In working toward a transdisciplinary professionalism, then, it is critical that students understand “public health” as a concept encompassing all aspects of health care—delivery, prevention, promotion, and policy. With such understanding, similarities and differences in ethical and professional duties and obligations of clinicians and public health professionals and the relationships among these duties and obligations can be further scrutinized.

Standards for professionalism in clinical fields such as medicine, nursing, and allied health are generally found in the ethical code for a particular profession. Compared with medical and nursing codes, an explicit code of ethics for public health is relatively new. The public health code, Principles of the Ethical Practice of Public Health, was developed by the Public Health Leadership Society in conjunction with the Centers for Disease Control and Prevention in 2002 (Public Health Leadership Society, 2002). This document states values and beliefs underlying 12 ethical principles of public health, provides interpretive notes for each principle, and operationalizes each principle by linking it to essential public health services. The Principles differ from other clinical codes in their focus on the community as well as individuals and on the obligations of public health institutions, programs, and policies. At the same time, the Principles share qualities of other codes; for example, the notion of beneficence or “doing good” is expressed in an aim to “prevent adverse health outcomes” (Principle 1), and a duty to respect others is conveyed in the principle that community health should be achieved by respecting the rights of individuals (Principle 2) (Public Health Leadership Society, 2002).

In addition to the public health code of ethics, the Association of Schools and Programs of Public Health (ASPPH) has developed competencies in public health professionalism and ethics for both the master of public health (ASPPH, 2006) and doctor of public health (ASPPH, 2009) graduate training levels. At the master’s level, professionalism is considered a “cross-cutting” competency, that is, one that is essential in all five core areas of public health. For the master’s level, basic competencies such as promoting

Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
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high standards of personal integrity and respect for individuals are identified, while advanced competencies (e.g., managing conflicts of interest) are formulated for students at the doctoral level (ASPPH, 2006, 2009).

Strategies for Teaching Transdisciplinary Professionalism in Public Health

One aspect of teaching transdisciplinary professionalism to public health students is engaging them in the critical examination of a “medicine–public health divide” and encouraging evaluation of an alternative perspective of “public health” as a holistic system encompassing all of health care—the public’s health. Students can then identify the commonalities and interrelationships among values and ethical obligations that transcend individual professional groups. Public health students who enter a program of study at the graduate level often already hold a professional degree, for example, in medicine, nursing, social work, or law. Students can begin by reflecting on professionalism and ethics as defined by their own professional codes and compare and contrast values, duties, and obligations stated in these codes with those included in the public health principles and competencies. One contrast, for example, is that in clinical settings, students in medicine and nursing become socialized into patient-focused care during their training, in which the locus of professionalism is a professional–individual patient relationship. Public health professionals, on the other hand, often train in community settings, with advocacy or social justice as a potential focus. The locus of professionalism for public health could be viewed as a professional–community relationship. Students then can be encouraged to explore these relationships further and identify their implications—for example, when a professional’s duty to the individual might “trump” his or her duty to the wider community/society, and vice versa, and how professionals can work together to uphold values of both individuals and communities.

An examination of sources of language and discourse used in ethics and professionalism across professions could also lead to recognition of common values and obligations. In medicine and nursing, for example, language and concepts of professionalism are derived from philosophy-based bioethics, while public health language and concepts of professionalism are often found in the ethical practice of public health and human rights and social justice perspectives (Slomka et al., 2008). Another resource for discussing transdisciplinary professionalism is the IPEC Expert Panel’s proposed interprofessional values/ethics competencies. These 10 statements focus on values, primarily mutual respect and trust, which underlie relationships and communication among professionals, patients, health care service delivery, and policy (IPEC Expert Panel et al., 2011). These competencies, involving both individual patients and populations, could promote discus-

Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

sions of the implications of “interprofessional professionalism” in contrast to “transdisciplinary professionalism.”

In addition to more theoretically-oriented discussions around transdisciplinary professionalism, public health students can engage in practice-oriented experiences to identify, critique, and learn professionalism in collaborative relationships across professions. One such experience is a “Professionalism in Practice” assignment, in which students have the opportunity to observe and critique over time an interprofessional team in practice. Ideally, such teams would include those that are required to make decisions in which differing viewpoints, values, and professional responsibilities must be negotiated. For example, institutional review boards may have to decide research questions when the law is silent about a particular issue. Or a hospital ethics committee or interdisciplinary intensive care team may face end-of-life care issues. Students can reflect on the communication, cooperative relationships, and underlying values they observe as a basis for group discussion.

Creative literature related to health care has often been used in teaching medical humanities, ethics, and professionalism, and it can be a useful resource in teaching transdisciplinary professionalism to public health students. In addition to books and short stories, television programs (fictional and nonfictional), social media, current events, and film are sources for discussion topics. Cases from students’ and faculty’s clinical experiences and from the scientific literature are readily available, and “paradigm” cases with multiple and complex elements can be identified as models for dealing with future cases. For example, a case on the topic of global HIV-prevention research would involve issues of cross-cultural communication, differing values of multiple stakeholders, implications for leadership and respectful interaction, accountability, and reciprocity in the “social contract” between professionals, patients, and the public.

Teaching transdisciplinary professionalism as part of the public health curriculum involves a number of challenges. Time constraints due to a full curriculum are inevitable, but can be managed by incorporating transdisciplinary professionalism topics into individual classes if a full-length course is not feasible. Skilled faculty can support and share their knowledge with educators who may interested in teaching professionalism but are reluctant due to lack of confidence in their abilities. Students who enter public health graduate programs without another professional degree may find clinical aspects of health care discussions intimidating. These students may not be attuned to issues such as “fiduciary relationships” or relationships of trust between health professionals and patients and may need additional experience in the clinical aspects related to transdisciplinary professionalism.

Finally, an innovation such as the teaching of transdisciplinary profes-

Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

sionalism should be studied in view of its potential for improving patient/public health outcomes. An additional challenge will be to identify desirable outcomes and decide how best to measure them. The incorporation of transdisciplinary professionalism into public health will require changes in thinking by health professionals and the public. Attitudes and behaviors may be difficult, but not impossible, to change, especially in a health care system in which change is constant and inevitable.

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Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
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Suggested Citation:"II.7 Toward Transdisciplinary Professionalism in the Teaching of Public Health--Jacquelyn Slomka." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
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Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary Get This Book
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Establishing Transdisciplinary Professionalism for Improving Health Outcomes is a summary of a workshop convened by the Institute of Medicine Global Forum on Innovation in Health Professional Education to explore the possibility of whether different professions can come together and whether a dialogue with society on professionalism is possible. Most of the 59 members making up the Global Forum were present at the workshop and engaged with outside participants in active dialogue around issues related to professionalism and how the different professions might work effectively together and with society in creating a social contract. The structure of the workshop involved large plenary discussions, facilitated table conversations, and small-group breakout sessions. In this way, the members - representing multiple sectors, countries, health professions, and educational associations - had numerous opportunities to share their own perspectives on transdisciplinary professionalism as well as hear the opinions of subject matter experts and the general public.

Efforts to improve patient care and population health are traditional tenets of all the health professions, as is a focus on professionalism. But in a time of rapidly changing environments and evolving technologies, health professionals and those who train them are being challenged to work beyond their traditional comfort zones, often in teams. A new professionalism might be a mechanism for achieving improved health outcomes by applying a transdisciplinary professionalism throughout health care and wellness that emphasizes crossdisciplinary responsibilities and accountability. Establishing Transdisciplinary Professionalism for Improving Health Outcomes discusses how shared understanding can be integrated into education and practice, ethical implications of and barriers to transdisciplinary professionalism, and the impact of an evolving professional context on patients, students, and others working within the health care system.

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