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Suggested Citation:"5 Transdisciplinary Professionalism." 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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5

Transdisciplinary Professionalism

I personally believe that this social contract that you are trying to work out, transdisciplinary professionalism, could be the saving grace. It could be a rudder that guides change.

—Judith Miller Jones, caregiver and educator

INHERITING A SHARED SOCIAL CONTRACT IN THE NEXT GENERATION

As an M.D./Ph.D. student and a member of the workshop planning committee who assisted in developing the agenda, Sandeep Kishore was well positioned to lead the discussion on whether development of a social contract—as defined for the purposes of this workshop—will resonate with the next generation. He started his opening remarks by defining transdisciplinary professionalism as an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and the public. Such a professionalism would facilitate improved interprofessional teamwork and might synthesize and extend discipline-specific expertise to create new ways of thinking and acting. Kishore asked his panelists to focus their remarks on the basis of this definition of transdisciplinary professionalism.

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According to roundtable participant Dave Chokshi, who recently finished his residency in primary care, his starting point in terms of a shared

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

social contract is thinking about the health professions as service professions. Emanating from that, a shared social contract is about being held accountable both to the patients and to the communities served by health professionals. As a primary care doctor, Chokshi thought this meant integrating patients’ values into clinical decision making. For example, the patient’s beliefs should be considered in deciding whether to order a prostate-specific antigen test or some other diagnostic test. In terms of being held accountable to the communities that he and other health professionals serve, Chokshi thought the key concept is transparency. Transparency is essential with patients and with respect to governance boards reporting to the community at large. Health professionals must be transparent in gauging success of treatments, sharing metrics, and answering questions honestly.

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Through his perspective as a primary care doctor, Chokshi thought his work was particularly relevant to the discussion of establishing a contract with society primary care, he explained, sits at the nexus between the community and the health care system or between medicine and public health. He said he sees it as this fundamental crucible—not just for a discussion of ideas, but also as the operational reality of trying to deliver on a shared social contract.

His final point with respect to transdisciplinary collaboration involved a note of caution. He feared that transdisciplinary could at times come into conflict with patient centeredness. The example Chokshi provided involved his desire to lead very efficient patient rounds at the hospital where he was doing his residency. On this particular day, Chokshi was engaged with 18 different health professional learners in an active dialogue outside each patient’s room about the particular patient they were caring for. Not until later that day did he realize that although the discussions were spirited for each patient, the patient was not kept front and center during those discussions. In Chokshi’s view, a shared social contract involves accountability to the patient as well as to the communities that health professionals are called to serve.

In thinking about Kishore’s challenge to focus on the definition of transdisciplinary professionalism, roundtable participant Judith Miller Jones noted that she is a great devotee of interprofessional education (IPE). As the director of the National Health Policy Forum at George Washington University, she has experienced the value of IPE. Her remarks, however, were from the perspective of being the caretaker for her husband, who had late effects of polio. As a caretaker, Jones has firsthand experience in dealing with the health care system. The system, she said, lags behind other industries such as information technology and aviation. Jones had previously worked for

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

IBM and was an instrument-rated pilot, so she said she understands how much leaders in health and health care could learn from these other industries in terms of communication, teamwork, and safety.

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Another point Jones brought up related to her experience with uneven power relationships among the health professionals and how changes in health care are affecting these relationships. For example, changes in reimbursements for what health professionals can charge influence what individual health professionals do and the learning environment that gets created for health professional students. In her opinion, the social contract that the Forum is grappling with, defined as transdisciplinary professionalism, could guide positive changes in health care. Transdisciplinary professionalism (TDP) as defined by Kishore levels the hierarchical structure and engages individuals in determining the structure of their relationship with health professionals.

She said that as a patient and as a caregiver, she wants health professionals to help her make difficult decisions. She does not want decisions to be made without her input, and she does not want to make decisions alone; rather, she wants to be part of the team whose main interest is maintaining or improving the health of her as an individual and her husband as a patient.

As a cancer survivor, Seun Adebiyi also provided a patient perspective to the roundtable discussion. Adebiyi is a lawyer from Nigeria who grew up in the United States. In 2009 he was diagnosed with leukemia and lymphoma and needed to find a compatible bone marrow donor. He learned that African Americans have less than a 17 percent chance of finding a compatible donor partly because of the lack of black donors on the registry and partly because of the greater genetic diversity within the African diaspora.

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Through a personal appeal to Nigerian students, Adebiyi did finally locate a compatible bone marrow donor, who saved his life. That experience left him with a strong desire to start a bone marrow registry in Nigeria. He also approached stakeholders in the United States with the same idea, but they realistically said that establishing such a registry would take several years, if not decades, to institute. Working with Kishore and his colleagues within the Global Health Network, he was able to get a fully operational and accredited registry in Nigeria functioning within 2 years.

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

According to Adebiyi, the most valuable lesson he drew from this experience was the importance of stepping outside the trap of silo thinking. All the people he talked to before launching the registry and before meeting Kishore and his colleagues looked at the complications with starting a registry from the standpoint of their own discipline. The bone marrow transplant doctors looked at the development of a registry from their point of view, and the radiologists had another viewpoint. Few people within the medical community looked at developing a registry from the perspective of patients, the ultimate end-users of the system.

Adebiyi believed this experience serves as a case study for discussions for developing a new framework for thinking and collaborating among the different disciplines and professions. The end goal of this orientation should be designed with the user, the patient, in mind, he said. Patients should have an important voice in developing this framework for collaboration. But when speaking as a lawyer, Adebiyi also described the basic foundation of a contract whereby each party gives something and gets something in return for a contract to be judged valid. When considering a social contract, he said, there must be consideration of what would persuade health professionals to want to enter into the contract.

Eric Cohen spent 14 years as a hematology/oncology nurse before going back to school for a master’s degree in nutrition and integrative health at the Maryland University of Integrative Health. His remarks reflected perspectives as a health care provider and a student.

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One key point Cohen mentioned was the issue of “territory” and professional boundaries. In his work in oncology, Cohen said, he was reminded of his collaborative relationship with a social worker and the tensions that both he and his colleague felt when either talked about something that was in the other’s realm of expertise. In his opinion, much of the tensions arise out of ego. Being able to truly work together in creating a shared vision for a social contract will require letting go of the ego. Educating in a way that takes the ego out of the equation will better ensure that the next generation is equipped to work across disciplines and professions.

Another point Cohen raised was health care literacy. He believed that through educating people, the public will be empowered to know where to go to get answers to health-related questions. In his opinion, the social contract must address health care literacy and provide people with the tools to understand the system. It is no coincidence that navigators are being hired

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

in the United States to coordinate aspects of a patient’s health care and wellness. According to Cohen, navigators are prevalent in oncology because the system for cancer treatment is so complex that it has to be navigated by a third party. Educating patients to understand the health care system is something Cohen thinks should be addressed as part of the social contract.

In making his remarks, Himanshu Negandhi, a professor of public health from India, reported that consumerism is on the rise in India, which impacts how students select their fields of specialization. Indian students can end their medical education at the graduate level and receive an M.B.B.S. degree. Graduates often choose to specialize in internal medicine, cardiology, or radiology, however, because the private sector in India has grown so rapidly that doctors who enter these specialty areas have the potential of making a lot of money.

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Jones echoed Negandhi’s comment and endorsed a vision of what a reconfigured health care system could be that would empower young physicians and nurses to practice together so that health professionals would be driving the system as opposed to entrepreneurs. Although it may be appropriate for physicians who run big hospital systems to have a high salary, she said, she fears that to a certain degree the money has taken over. She sees professionalism as an empowerment tool for starting this conversation. Chokshi agreed that the United States is at a special point in time; in this period after the passage of the Patient Protection and Affordable Care Act (ACA), the health system is changing rapidly. New models of care, such as the Accountable Care Organization and the Patient-Centered Medical Home are being tested. In his opinion, health professions and education have not kept pace with these rapid transformations. The Department of Veterans Affairs’ (VA’s) Centers of Excellence and Primary Care Education is one exception, he pointed out. In this demonstration across five medical centers, the VA is providing interprofessional education and aligning curricula and schedules of the medical and nursing schools within a particular specialty.

Workshop planning committee member Sally Okun from PatientsLikeMe commented on the discussions of the roundtable. She agreed with the importance of using the social contract to engage the deliverers of care in more effective and productive conversations. But she saw a gap in engaging the receivers of care in the discussion of the social contract. They also have something to give and to get. If there is to be a contract between patients and providers, both deliverers and receivers must be involved. She added that patients are already engaged through social media. For example, 220,000 people are networking through her online website, sharing treatment and disease experi-

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

ences. In her opinion, receivers of care are not being given the tools they need in order to work effectively with deliverers of care on the social contract. As a result, patients are finding their own mechanisms for networking.

Jones observed that in her work in West Virginia, this motivated online group is not representative of the entire public. She described what has been labeled “Appalachian apathy,” which is not unique to Appalachia. People for generations have very low expectations of what they can do for themselves and lack the ability to talk candidly to a nurse and definitely not a doctor. They go along to get along, she said. It is very hard to motivate them to pay attention to their drug regimens, to exercise, or to eat more nutritiously because their families have done fine for generations without such interventions. Jones pointed out that these patients are not interested in going to a Center of Excellence and would not know what one is. They do not know good provider care from bad provider care. The apathy is pervasive, and doctors do not offer options to apathetic patients because they anticipate a negative response. This is unethical, according to Jones. A health provider should, at a minimum, describe the options of care to the patient and explain the risk and benefit of each choice. If the giver just assumes that the receiver will not use the information, then it becomes a self-fulfilling prophecy.

Forum member Madeline Schmitt commented about the flip side of Appalachian apathy, which is “cultural humility.” Cultural humility involves a provider’s commitment to balancing the power between patients and providers and extends to developing positive partnerships with communities, as well as a desire for self-evaluation and self-critique throughout one’s career (Tervalon and Murray-Garcia, 1998). According to Schmitt, the spectrum of apathy to humility demonstrates a lack of a common language. There needs to be a language so that the public understands what transdisciplinary professionalism is and so that health professionals better understand the needs of these populations.

In a similar regard, Jones expressed a need to go beyond the standard academic health training model to include community organizations such as Alcoholics Anonymous and Narcotics Anonymous, as well as families and caregivers. Such an inclusive approach to forming teams would be very empowering to patients at different times in their lives. Okun said this point resonated with her. Giving patients the opportunity to express what they need in ways they are comfortable with will improve the literacy of health providers in working with special populations.

Jones thought that goal-oriented care plans could be created for use in practice environments and for training health professionals that might inspire students to think and act in new ways. Kishore agreed that young people are a potential oasis of inspiration and energy, particularly given all their virtual connections. But he cautioned that many of his colleagues

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

talk about losing their idealism as they transition from students to young professionals. As a second-degree student, Cohen agreed with Kishore, saying that he has felt the frustration and exhaustion from some of his fellow students. But, he added, a very positive movement is also under way, focusing on prevention-oriented actions that inspire students and create hope for the future.

REFLECTIONS

Patient Perspective

Barbara Kornblau is currently the executive director for the Society for Participatory Medicine. She is an occupational therapist and an attorney by training, although the perspective she provided in her reflective comments came from her experiences as a patient and a caregiver of six children with disabilities and multiple chronic conditions (her comments are shared more extensively in a paper in Part II of this report). She began by describing participatory medicine. In participatory medicine, patients are encouraged to shift from being passive recipients of care to being active members of their health team, all of whom are equal partners on the team. In Kornblau’s view, being the driver of one’s own care carries with it a responsibility, a responsibility she terms being an “e-patient.” “E-patients” are equipped, enabled, empowered, and engaged in their health care and their health care decisions. It is an equal partnership between the e-patient and the health providers and systems that support them (Society for Participatory Medicine, 2013). According to Kornblau, this concept of e-patients needs to be integrated into health professional education.

Looking more closely at the area of patient engagement, Kornblau referred to the Center for Advancing Health, which defines patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them” (Center for Advancing Health, 2010). She also described the importance of patient engagement, which, according to the World Health Organization and others, can improve patients’ experiences and satisfaction and can provide clinical and economical benefits to patients, providers, and the health system (Coulter et al., 2008; Coulter, 2012; Hibbard and Greene, 2013).

In particular, evidence shows that engaged patients with chronic conditions are more likely to adhere to treatment regimens (Health Council of Canada, 2011). Kornblau urged educators to extract information for curricula development from the February 2013 issue of Health Affairs, which is entirely devoted to this topic. She emphasized that adding patient engagement to curricula does not have to increase the time burden on educators. For example, she says, using actual patients instead of paid actors and pro-

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

viding interprofessional education—that draws on true patient-interactive experiences from a variety of health professional learner perspectives—makes the teaching of history- and physical-taking very real. This benefits patients, who become part of the education of the next generation of health providers, and it benefits students, who receive more memorable educational experiences.

Kornblau also addressed what “transdisciplinary,” “a social contract,” “professionalism,” and “ethics” might mean to patients. With regard to the idea of transdisciplinary, she said, she believed it was premature to bring the concept to patients, given the current challenges around inter-provider communication for better continuity of care. Regarding the social contract, Kornblau questioned who the contract was being directed toward—society or individual patients. She was also not sure whether society had a contract with patients and who exactly makes up “society.” In the area of professionalism, Kornblau thought that patients viewed professionalism as behaviors, not beliefs, and she was uncertain about which comes first. Patients discuss professionals’ behaviors, she said, but those behaviors are formed by beliefs, so a case could be made for discussing “beliefs” in the way it was presented by speakers at the workshop. The issue of ethics, for Kornblau, is one that can have lasting effects on communities, such as in the Tuskegee Institute clinical study and the case regarding Henrietta Lacks, where members of a community become fearful of health systems because previous injustices and the lack of trust.

Although Kornblau had to speak for all patients in her remarks, she summarized her views by saying that what patients want is respect by being listened to. They also want information that is relevant to the social context in which they are living that considers a patient’s financial, physical, and neighborhood safety conditions. And, finally, patients want to be included. They want to be part of the decision-making process, which could include educating health professional students to understand the various key roles patients have, and could have, on teams and within health systems.

Educator Perspective

As chancellor of the University of the West Indies and director emeritus of the Pan American Health Organization, George Alleyne was well positioned to comment on the discussions and presentations that took place on the social contract for health. His remarks were framed within the context of innovation in health professional education and focused on whether it is possible to educate professions in a transdisciplinary manner and include the elements of a shared social contract. Before beginning, Alleyne admitted his skepticism, saying that he has seen many attempts to change the methods and content of medical education that have not been successful.

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

In terms of defining a profession, Alleyne was intrigued by the differentiation made by one of the speakers between vocation and occupation. He added that professionalism embraces the exercise of a profession. And almost by definition, health professionals have a formal relationship with three critical groups: patients, other health workers, and society at large. The organization of these relationships and the rules to order them in a formal sense go back about 150 years on both sides of the Atlantic.

Today the nature of the relationship among providers and between patients and providers has changed and continues to change for several reasons. First is the increased complexity. Alleyne posited that this increased complexity has resulted from the prodigious growth of science and an increased understanding of the basis of disease and illness. These advances in the basic sciences have made it impossible for any single discipline to have the knowledge and expertise to address the whole range of illnesses that exist. For that reason, specialty and subspecialty disciplines have developed that focus on a portion of the patient rather than the whole patient. A second reason involves changes in the world’s disease profile. Alleyne noted that the chronic noncommunicable diseases have now surpassed the acute communicable diseases as causes of death in most parts of the world. As a result, many societies are adopting models of continuous care that essentially involve the patient, the family, the community, and health care services at different levels. These patients require continuous care from a variety of health professionals over a long period of time. Such care necessitates that respect, understanding, and fluid communication exist among the professions; most important, said Alleyne, is the capacity to listen.

Another cause for changing relationships between providers and patients is the availability of information through a wide array of tools that also affect changes in population health. Alleyne cited the 1992 work of Geoffrey Rose that outlined population-wide interventions from a variety of perspectives, including social and political changes (Rose, 1992). There is now a better understanding and appreciation for social determinants of health at both the individual and the population level, he said. Alleyne also noted that greater expertise on the social determinants of health may reside within the fields of sociology and economics rather than with health professionals. This fact called into question whether such disciplines should be legitimately counted among the health professions. A more critical question, however, is whether the interventions needed for improving the health of populations should be part of the remit of individual health workers or whether it should be exclusively dealt with by the state. For example, in tobacco control the physician has the responsibility to set a good example by not smoking and by advising his or her patients not to smoke, while the state has the authority and the responsibility to raise taxes on tobacco as a deterrent to smoking. This example brings into question

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

the role of health professionals as advocates for change and whether such advocacy should be part of a health professional’s responsibility.

Alleyne then focused on the relationship between medicine and society. This relationship, he said, is where a social contract is needed such as the one described by the Cruesses. Such a contract would embrace the expectations and the contributions of both providers and patients. It would contain societal expectations of the provider and the provider’s expectation of society. For physicians, that means expecting trust, a monopoly on practice, and a reasonable measure of status and compensation, and it would mean the expectation of a health system that enables medicine to be practiced efficiently. In return, there is an understanding that physicians will be altruistic, trustworthy, and appropriately self-regulating and that they will address the concerns of society.

Alleyne then posed the following question: “Is it possible to envision a contract, perhaps not a social contract but a contract that is transdisciplinary in the sense that it cuts across all health disciplines?” He noted that a great degree of similarity already exists in the codes of conduct of various health professions, which, he suggested, all contain three essential elements. These elements are a corpus of standards and ethics, a system of registration, and a system of education and instruction. In this way, the relationship between a physician and a patient is not fundamentally different from that between a pharmacist and a patient or a dentist and a patient. These core elements might form the basis of a common approach for all disciplines to come together to form a contract with society. Most likely, such a social contract would be complemented by discipline-specific contracts that take into consideration unique features of individual disciplines and professions.

Considering the pedagogy for teaching a transdisciplinary approach to professionalism, Alleyne cited the Lancet Commission report. In this report, the commissioners stress the nature and the evolution of instructional reform that has moved from informational learning to formative learning and is now shifting toward transformational learning (Frenk et al., 2010). Although the report emphasizes transformational learning through leadership, Alleyne commented that he views it through a slightly wider lens. In his opinion, transformational learning is about acquiring the knowledge and skills beyond those traditionally given in health and instilling in students the importance of health as instrumental for human development. In addition, innovations in learning would be driven by new technologies as well as formal mentoring and role modeling. Such experiential learning does the most to engender relationships with the patients, with other health workers, and with society that must, according to Alleyne, be the bedrock of good health care. In his summative assessment of transdisciplinary professionalism, Alleyne suggested that innovative transdisciplinary pedagogy

Suggested Citation:"5 Transdisciplinary Professionalism." Institute of Medicine. 2014. Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18398.
×

can contribute to the formulation of a contract that is transdisciplinary and that a contract with society can exist that embraces all health disciplines.

REFERENCES

Center for Advancing Health. 2010. A new definition of patient engagement: What is engagement and why is it important? http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf (accessed September 14, 2013).

Coulter, A. 2012. Patient engagement—what works? Journal of Ambulatory Care Management 35(2):80–89.

Coulter, A., S. Parsons, and J. Askham. 2008. Where are the patients in decision-making about their own care? Copenhagen: World Health Organization.

Frenk, J., L. Chen, Z. A. Bhutta, J. Cohen, N. Crisp, T. Evans, H. Fineberg, P. Garcia, Y. Ke, P. Kelley, B. Kistnasamy, A. Meleis, D. Naylor, A. Pablos-Mendez, S. Reddy, S. Scrimshaw, J. Sepulveda, D. Serwadda, and H. Zurayk. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923–1958.

Health Council of Canada. 2011. How engaged are Canadians in their primary care? Results from the 2010 Commonwealth Fund international health policy survey. Canadian Health Care Matters, Bulletin 5.

Hibbard, J. H., and J. Greene. 2013. What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs 32(2):207–214.

Rose, G. 1992. The strategy of preventive medicine. Oxford: Oxford University Press.

Society for Participatory Medicine. 2013. Website home page. http://participatorymedicine.org (accessed July 1, 2013).

Tervalon, M., and J. Murray-Garcia. 1998. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved 9(2):117–125.

Suggested Citation:"5 Transdisciplinary Professionalism." 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 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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