6

Building the Bridge Forward

In the closing session, held on May 25, 2021, forum members and workshop participants highlighted key messages and lessons learned from

the previous activities, and reflected on how to leverage these findings to improve health professions education (HPE) moving forward.

LESSONS LEARNED

Workshop 1

At the first workshop, said Talib, “we were in the thick of it with COVID” and the workshop brought to light the long-standing fragilities of the HPE system. While many issues were identified (see Box 6-1), she said, they were “arguably nothing new.” D’Agostino noted how these issues were brought to light and exacerbated not just by the pandemic but by a “syndemic” of multiple interacting biological and social factors. COVID-19

was added to a world already struggling with racism, overcrowding, loneliness, poor nutrition, lack of access to health care, environmental damage, and political turmoil, creating a “perfect storm.” Together, these factors created a crisis that highlighted the instability of HPE and other systems, said D’Agostino. The nature of the virus and the associated syndemic, said Bondy, meant our “old playbooks” that worked for other disease epidemics did not work for COVID-19. Instead, we had to “zoom out” to take a population health approach while at the same time meeting the immediate needs of individuals afflicted. Many of us “were just unprepared for the significant challenges we faced all at one time,” she said. One significant lesson learned, Bondy observed, was that systems with preexisting emergency planning, institutional support, and infrastructure in place were more easily able to pivot to online learning and telehealth. Given this recognition, now is the time to begin assessing and planning ahead for the next crisis, she said. D’Agostino concurred with the need to plan ahead, but emphasized the criticality of real-time evaluation. In the midst of a crisis, it is essential that HPE be agile, flexible, and responsive so rapid changes and innovations can occur. He added one additional point as we move forward, “we can never go back wholly to the status quo.” Being prepared means being innovative and agile. During a crisis, we have to challenge ourselves to do things differently; in doing so, “we have to give up some of those things that have been very comfortable,” and arguably too comfortable when dealing with crisis level challenges.

Frost identified one way in which HPE must operate differently in the future: “We need to be much more collaborative, interrelated, and systems-based.” Talib concurred and noted with a traditional siloed approach, actions in one part of the system may have unintended negative consequences in the system as a whole. Particularly during a time of crisis, said Frost, it is critical that the actions of all parts of the system be aligned with the overall objectives. During the pandemic, said D’Agostino, many changes were made; for example, education shifted online, telehealth expanded, and regulations were relaxed. While these innovations were necessary and commendable, “we are obligated … to think down the line” about what the unintended consequences of these changes might be.

Scenario Planning

The scenario planning session was “an opportunity to tackle the bigger challenges” and to prepare for the next crisis, regardless of what the crisis may be, said Talib. She commented on what was interesting about this session was although each group worked from a different set of assumptions, there were common elements proposed across all the solutions. In their hypothetical future scenarios, said Talib, many participants described a need for:

• interprofessional communities of practice for sharing ideas and research;
• education research to gather data and identify platforms for sharing findings;
• communication among leadership, faculty, and students, between education and practice, and between education and community members;
• community-engaged education for reaching underserved populations and to build public trust; and
• policy and advocacy to ensure that accreditation and licensure are appropriate.

Talib asked participants whether creating a “playbook” would be a good way to capture the lessons learned from COVID-19 and prepare for the next crisis. D’Agostino responded that playbooks can give comfort but also create a false sense of security. Because it is impossible to predict every potential scenario that might occur, having a pre-defined list of boxes to check off can create chaos if the next crisis is significantly different than the scenarios imagined in the playbook. Instead of a playbook, he said, it might be more useful to ensure that relationships and systems are in place so people can quickly connect and share information, collaborate, and take action. During the first workshop, several participants commented on one of the biggest challenges during the pandemic, which was connecting with leadership who “held the controls for solutions they needed,” said D’Agostino. Bringing together organizations and individuals before a crisis occurs can help ensure the response is coordinated, agile, and robust. D’Agostino expressed his support for universities as organizations primed to bring people together to create solutions. While acknowledging the university culture often reinforces siloes, the nature of how universities are designed, he noted, makes them the ideal “interprofessional thinktank.”

Workshop 2

At the beginning of the second workshop, forum members reported on the previous day’s discussions about the impact of COVID-19 on different aspects of HPE: experiential learning, testing, communication, and faculty development. Participants discussed the challenges in each of these areas, the innovations and changes that were implemented, and what opportunities were presented for improving HPE in the future. Frost remarked that while specific issues discussed in each of the breakout groups differed, five main opportunities could be identified including:

• Using virtual platforms for learning and collaborating
• Re-thinking high-stakes tests
• Focusing on stress and burnout among faculty and students
• Focusing on diversity, equity, inclusion, and creating safe learning environments
• Incorporating social determinants into HPE

For these opportunities for improving HPE to be realized, said Frost, several items require consideration. First, polices may need to be changed at the state and federal level regarding licensure, reimbursement, scope-of-practice, and other issues. Second, we need to evaluate the impact of the different learning strategies and educational models used during the pandemic. Third, there is a need to develop and assess new modalities that use virtual or hybrid models across the education to practice continuum. Fourth, we need to design nimble, flexible, and anticipatory solutions, rather than retroactive solutions to “plug the dike.” Fifth, faculty need education and training on all models of instruction, including virtual, in-person, hybrid, and those yet to be formalized emerging technologies such as artificial intelligence. Critical to all of these changes, said Frost, is the need to empower leadership to prioritize these critical areas for integration into institutional culture.

IMPLEMENTING THE LESSONS LEARNED

This workshop series, said D’Agostino, revealed how “we have many more questions than we do answers.” It is a “great place to be,” he asserted, because once the questions are identified, then health professionals can begin the process of addressing them and developing solutions. The key questions raised by the workshops include:

• Where does public health fit within all health professions training?
• What is the evidence for doing what we are doing?
• Are HPE students and trainees “essential workers in the health systems or observers?”
• Does HPE need to shift to a competency-based model?
• Is HPE attending to the mental health stressors of learners, faculty, and leadership?
• What is the role of interprofessional and cross-sector collaboration during a crisis?
• How can faculty and leaders model the importance of diversity, equity, and inclusion?
• Can HPE be more community-engaged?

• Is there room in the curriculum to address health promotion? Or should that be the foundational training model for all the health professions?
• Is there a need to create and fund a permanent national coordinating organization to prepare in advance for future Health System and HPE disasters and crises?

Addressing these questions requires sifting through the “chaos,” managing complexity, and analyzing information in real time in order to make decisions, said D’Agostino (see Figure 6-1). Because we cannot predict the type of crisis we will face next, we need to have strategies in place that will allow HPE to respond, innovate, evaluate, and take action in real time. Implementation science is a strategy that can provide a framework for this type of rapid transformation. D’Agostino then introduced Toby Brooks from the Texas Tech University Health Sciences Center who gave a brief presentation to participants on the basics of implementation science.

Brooks began by defining implementation science as the systematic analysis of how evidence-based practices become accepted clinical practice. More precisely, he said, it is an approach to combat the resilience or “stickiness” of deeply held beliefs that can stifle the adoption of proven practices. Recent work indicates that it can take 17 years, on average, for established evidence-based practices to become standard, accepted practice. This is an “entire generation of health care providers,” said Brooks, and this slow pace and resistance to change stifles innovation and negatively impacts patient outcomes. Implementation science can help bridge the gap between what we know (evidence-based practices) and what we do (standard practices), he explained. HPE tends to focus on what health care providers know, rather than what they believe. However, knowledge is malleable and

can be transient, whereas beliefs are resistant to change and long-lasting. In our efforts to reform health care, he said, we must identify and address the barriers and facilitators to the uptake of evidence-based clinical practices. Implementation science can help to alter beliefs by conveying information with speed, efficiency, and a critical eye toward its relevance to people’s existing knowledge base and structures.

CLOSING THOUGHTS

To close out the last session of the workshop series, Talib asked for final reflections. Frost responded for the group saying, in any conversation about HPE, we will want to keep the needs of our patients and their families front and center. “Our ability to advocate and provide a collective voice” for patients is essential in any future crisis, she said, and we need to be comfortable and skilled within interprofessional advocacy. “Rather than getting stuck on the minutiae,” we need to address what is critical to our patients and their communities and make a “lasting difference in the lives … for whom we provide care.” Talib added that the pandemic highlighted inequities and fragilities in the system affecting students and patients, and that “it’s clear we cannot be unprepared for the next crisis.” As we look ahead, she said, we need to embrace systems thinking and bring together stakeholders, technologies, and innovations to guide the way forward.

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