Reframing the Academic Medical Center through Interprofessional Effectiveness: Toward Justice, Safety, and Kindness
In 2010, George Thibault invited Dr. Rita Charon of the Program in Narrative Medicine of Columbia University to consider the salience of its work to interprofessional health care team development. The core faculty of the Program had realized already the consequences of serious and creative narrative work for interprofessional teams of health care workers. Our projects in the pediatric oncology in-patient unit, the family medicine in-patient ward, the ob/gyn residency, and among graduate students from varying professional backgrounds had demonstrated the power of rigorous narrative work in developing shared goals, mutual respect, individual self-awareness, and deepening of trust among participants.
The prospect of launching narrative-based learning among faculty and students of the health professions schools at Columbia University Medical Center was both thrilling and daunting. Columbia is known for its strict hierarchical structure, its competitiveness, and its traditional lines of status and power. If improvement of the health care team is needed anywhere, it is in these intensive research institutions that both set the standards for science and health care nationally and can be deaf to movements toward equality and collaborative practice.
Emerging philosophy of IPE at Columbia:
Over the course of this project, Columbia diverged from the mainstream national currents in IPE. Through our involvement with IPEC and the National Center for Interprofessional Practice and Education at the University of Minnesota, we are well aware of the skills-based approaches often adopted elsewhere. Through a ten-year collaboration with colleague schools in a broad NIH-funded grant program in enhancing social science and behavioral science curricula in medical schools, we have worked closely with an IPE sub-group of health professionals at Oregon Health Sciences University, University of California at San Diego, UCLA, Indiana University, University of Texas at San Antonio, and Brown University. Some if not many of the programs at other institutions in the US emphasize joint learning of concrete interprofessional skills: learning each profession’s specific role in clinical situations, training for courtesy toward members of other professions, and check-listing approved behaviors in clinical simulations.
In contrast, the approach at Columbia is focused less on specific tasks completed by each role, and more on shared values and ways to work together to produce better healthcare for the patient. Our narrative approach results in individual-to-individual contact within the context of health care teams. We don’t gather to discuss operating room checklists or who does what at the cardiac arrest code. Instead, whether with faculty groups or student groups, we invite participants to grapple with fundamental issues of the human condition. Each of our courses and seminars devotes some time to intensive close reading and creative writing, in addition to more conventional seminar discussions. Through rigorous and guided examination of cultural works—literary texts, visual images, or performative arts—groups of participants can meet within a shared confrontation with powerful carriers of meaning. This is not as obscure as it sounds: together, a group will read a poem or a paragraph from a great novel or watch a clip of a movie or look slowly at a painting. They talk about it; they work at what it says or shows; they learn how diverse are their individual perspectives on the work. They are invited to write—spontaneously, in just a few minutes—about their trains of thought released by the work. When they read aloud or tell about what they’ve written, they achieve privileged views of their own and one another’s subjectivity. Within a half-hour, they’ve enjoyed intimate contact with their own and their colleagues’ deep ways of knowing of the world.
In ways that are still somewhat mysterious to us, such learning methods allow gradual, safe, reciprocal exposure of individual values, perspectives, and lived experiences. Over the course of as few as six sessions of such work, a group will cohere into a relationship of respect and safety. Participants become one another’s readers, able to see things in one member’s writing that the writer himself or herself cannot see. Paying attention to the form of the writing as well as its content, participants can sense underlying meanings and perceptions that, until summoned into expression, remain unexposed and therefore unknowable to the writer. Reading or looking at well-chosen works and writing to expansive and evocative writing prompts together enable each participant to have a creative experience—often being surprised into unbidden thoughts and memories. The powers of representation account for the benefits of this work: it is only when perceptions and thoughts are captured in some form of representation that we perceive them to begin with. When health care teams—or teams of students from different health care professions—undertake serious narrative work together, they are able to find common ground as individuals committed to the care of the sick.
Here is an example: around 12 members of the Macy Core were present at a recent meeting. Before starting the business of the meeting, we read together a page-and-a-half excerpt from Wallace Stegner’s novel Angle of Repose that described an elderly man, an amputee, being given a bath by his housekeeper/attendant. (See Appendix B for the excerpt.) The writing emphasized the “habitual motions” of care between these two old people, the housekeeper almost as frail as the patient. In the descriptions of these two, we all could appreciate the choreography of care, the efforts they both went through to maintain privacy despite the intimacy, and the gliding from identity as “patient” to identity as “person” that occurred. After talking about the scene for about 10 minutes, we were invited to write to a prompt: “Write about the habits of care.” In four minutes, one basic science researcher on the nursing school faculty wrote about her regrets that, in giving her young children their baths, she often absented herself into rote motion without attending to the nature of the care involved. “Why did I need to fulfill the physical motions and not the emotional ones?” A midwife described her ritual after a birth: “What I do is birth cleansing. My offering to the woman is to pass warm hands and soft gauze over her inner thighs, buttocks, and bruised vulva.” A physician in the group was reminded by this description of the biblical scene of Mary Magdalene preparing Jesus for the tomb, adding a dimension of the sacred to our work. One of the very senior adult nurse practitioners described her utter delight in caring for a new grandchild, “In contrast to my kids, when I was sometimes unappreciative of the gifts of care, here I was experiencing the missing joy of intimacy and closeness.”
I hope you can see, with this example, how the 20 minutes of reading and writing made us visible to one another, made our lives of care explicit, and plunged our professional lives straight into our lives of meaning and self. Our writing brought us in touch with quite deep levels of awareness in ourselves and in others, creating a clearing of trust in the midst of discovery. We were now present to one another as ourselves and not as representatives of our respective health care professions.
IPE for Faculty:
Our path toward interprofessional parity began with intensive outreach to the four professional schools –dentistry, medicine, nursing, and public health—on the CUMC campus. With a hard-won conviction that students will not learn what their teachers do not believe, Dr. Charon recruited senior leaders from all four schools, upon recommendations from their deans, as my original Core Faculty on the Macy Foundation Project for Interprofessional Education. I wanted to develop a cadre of deeply committed, powerful leaders at CUMC who could withstand the battering that comes to bearers of unpopular ideas through the very force of that unpopular idea: that effective health care teams nourish one another, support one another, protect one another, and do what no profession alone can do.
These Deans of Admissions and Senior Vice Presidents set to work they had never done—creating partnerships with the schools they typically competed against for resources, putting aside assumptions and biases, exposing private aspects of themselves that influenced their practice as health professionals. Many of us had grown up in Columbia and had been burned by its aggressively stratified power structure. The Macy project gave us a chance to break from negative stereotypes and to meet one another—authentically, humbly, with great curiosity. Taking turns in chairing our sessions, we adopted narrative methods of teaching and learning—reading and writing together, exposing deeply held values by virtue of shared creative work, and providing a context for sharing perspectives. By starting with topics that had nothing to do with clinical practice, we dove underneath the distinctions that separate us from one another as doctor and dentist and nurse and public health professional. Within months, we had accomplished what decades of well-meaning conventional efforts for combining professional students had failed to do: we reached the ground of authentic contact as professionals deeply committed to effective humanistic health care.
IPE for Students:
Once the Macy Core Faculty had achieved a level of trust and collaborative respect, we felt ready to share what we had learned with our students. After robust study of our context, we executed a multi-pronged approach to increase opportunities for IPE for all our students.
The combined CUMC undergraduate student body approaches 4,000 and is segregated by schedules and location. Among the four schools, there are three different winter holidays! No wonder there has been so little overlap in learning and teaching. Our strategy for achieving interprofessional education had to include five simultaneous goals:
- Increase in interprofessional teaching in all schools of CUMC.
- Selective and intensive credit-bearing interprofessional seminars for small groups of students chosen for their commitment to IPE.
- Opening up of credit-bearing courses in one school to students of other schools.
- Break-through combination of student bodies from two or more schools for all or part of required courses.
- Ultimately, enrollment in an interprofessional course as graduation requirement for all students.
We have achieved successes in all but the final ultimate goal. Interprofessional teaching in courses within individual schools is now commonplace, and professors often turn to us for help in finding colleagues to join them in their teaching. Credit-bearing interprofessional courses, the “Macy IPE Seminars” that we created and offered during the 4 years of the grant, are now well-recognized, desirable, and over-subscribed learning experiences for students of all schools and programs. We are looking forward to increasing enrollment for the coming year. Opening up of credit-bearing courses across schools is underway: Columbia Commons now generates lists of courses within each of our schools that are open for enrollment to students from other schools. This material will be available to all students once the Columbia Commons website is installed. Until then, it will be broadcast to students from each school by their Commons faculty. Combined required courses have increased for several of the schools; designing the nursing/medical school required course merging is now our most urgent task.
The ultimate goal is to install a graduation requirement in each school for in interprofessional education course. One of our Core members, Deepthiman Gowda, installed a requirement for a cultural diversity course for all undergraduates at the University of North Carolina. He and his colleagues started the effort when they were freshmen; by the time they graduated, the requirement was in place. We will follow Deepu’s model to aim high and to try for what is now unlikely but will, we are convinced, become more and more possible as our work matures.
Increasing Faculty Collaboration:
We cannot teach students to adopt a collaborative model of practice without continuing to train faculty to adopt it for themselves and to model it for students. Our opening of the Core to four clinical programs in addition to the four schools was a major development in our maturation, increasing the breadth and number of colleagues with whom to learn and teach. We have consistently sought to open up teaching and learning opportunities to faculty from all professional schools. Here are some recent examples and works-in-progress:
- Qualitative Research Methods course: although this intensive 6-week seminar was hosted in a medical school faculty development seminar, Macy Core Faculty were invited and asked to relay the invitation to members of their faculties.
- Seminar and lecture by Dr. Kelley Skeff: When international expert on faculty development for clinical education Kelley Skeff was visiting professor at Columbia, Macy Core Faculty members were the first and only invitees to the small-group intensive seminar on small group teaching and giving feedback. A wider invitation to attend Dr. Skeff’s lecture on redesigning the HPI was tendered to clinical educators in all professional schools and programs. This may lead to an invitation to Dr. Skeff to hold a larger program of interprofessional faculty teacher training at Columbia.
- Three-part intensive seminar on Motivational Interviewing: Co-taught by a psychologist and a pediatrician, this seminar is hosted by a P&S faculty development NIH grant but is open to clinical educators from all Macy programs.
- Teaching Academies: There are currently four faculty Teaching Academies on campus, one for each school. Of late, pedagogic programs for one school have been attended by more and more faculty from other schools. We are striving to open these learning experiences across the board to one another.
- Faculty Research Seminars: There has been a sudden rise in on-going faculty seminars in research methods, especially educational research. Currently, the department of medicine hosts a monthly seminar, while the teaching academy for P&S hosts another one. The nursing school offers an advanced qualitative research methods course at the doctoral level. We are working to democratize these learning opportunities.
- Experiential Learning Story-Telling Workshop: The Macy Core invited Lance Weiler, Director of the Center for Experiential Learning at Columbia University, to partner with us to develop a city-wide interactive, narratively-based exploration of interprofessional conflicts and opportunities. We foresee that these workshops could become not only locally available but widely disseminated through networks of local partners.
Guiding Principles for IPE at CUMC:
In the solidification of IPE into the institutional structures and culture of CUMC, we have developed overall guiding principles to direct our actions. The following list outlines our multi-pronged approach to build toward a healthy interprofessional climate:
- Establishment of Columbia Commons: Collaboration Across Professions: With the close of Macy Foundation funding, the Macy Core continues to function with funding support from the deans of the four schools. The Commons is the campus-wide network and inventory for IPE courses, events, activities, and organizations. Our major shared work is the designing and teaching of CUMC-wide IPE seminars, the “Macy Seminars,” and the on-going vigorous initiation of innovative IPE opportunities as described above. In addition, we host public events welcoming students and faculty from all schools and programs to take up questions that are urgent for us all. We publicize courses in each school that are open to students from other schools. We assist faculty members to find members of sister-school faculties who can join them in their own teaching and research. We identify content material that is best taught interprofessionally—for example, qualitative research methods and palliative care—as best-practices development of new IPE courses. We anticipate being able to offer modest curriculum-development grants for teams who produce IPE courses open to all students. We await decisions by the four deans regarding organizational placement of the Commons so as to appropriately locate its website and to structure its on-going leadership and reporting expectations.
- Inquiry into professional role conflicts: In addition to training in task-specific IPP skills, we recognize the need to examine the underlying values and beliefs of our clinical professions. We have begun the process with a probe into nurse/physician roles and role conflicts. The mainstay of clinical care, the nursing and medical professions have both undergone tectonic shifts in their training, clinical domains, and self-images. The Columbia Commons faculty has initiated a high-stakes joint exploration of the changing and conflicting roles of doctors and nurses. The traditional “doctors cure, nurses care” no longer (if it ever did) accurately portrays the reality. From autonomous advance-practice nurses to relationship-centered physicians, the stereotypes are defied. We are committed to intensive sociological, historical, psychological, and personal narrative study of the antecedents and current status of role interplay between these two powerful components of the clinical workforce. We recognize that, historically, the nurse/doctor relationship can be considered as a site of bias and microaggression, replete with humiliation of the one and the arrogance of the other. We believe that adopting this framework for our inquiry will keep us honest and give us useful conceptual and practical templates from other sites of bias and microaggression. This project, recently underway, will seek external funding in the coming year, for we believe this conceptual work is an urgent and unmet need in IPE/IPP. It is the prelude, we believe, to additional such inquiry groups to examine other professional role conflicts, e.g., physical therapy and orthopaedics/neurology or social work psychotherapists and psychiatry.
- Cultivation of Interprofessional faculty culture: Not only faculty development, which typically means teaching teachers how to teach, we strive toward developing bonds among faculty of different schools, to make it common for nurses to consult with dentists or doctors with physical therapists. We want them to be in the same world together, not as antagonists or in hierarchies but as necessary and sought-after partners.
- Shared learning opportunities in matters of pedagogy, research, and scholarship.
- Aggressive drive toward joint teaching in one another’s’ schools.
- Collaboration on invitations of visiting professors, speakers for endowed lectures and sharing their presence CUMC-wide.
- Develop links or mergers among school-specific Teaching Academies.
- Cultivation of interprofessional student culture: In addition to the many concrete achievements in developing opportunities for IPE at CUMC outlined in this report, the Commons seeks further symbolic and real ways to emphasize the dividends and necessity of team-based education and practice. Here are a few of our dreams:
- One “White Coat Ceremony” for all students at CUMC.
- A graduation requirement for a credit-bearing Interprofessional Education Course.
- Joint school approach to shared problems: diversity issues; microaggression and bias on race, sex, gender identity, and profession grounds; addiction and impairment; relationship to Washington Heights community.
- Joint clubs and organizations for cultural, athletic, and intellectual interests.
- Joint school health care activism: student-run clinics for uninsured patients; support for primary care training at Columbia; global health initiatives for students, human rights activism; quality of health care for marginalized patient populations, including LGBTQ patients, non-citizens, patients with stigmatized illnesses (mental health illnesses, illnesses related to IV drug use, etc.).
We feel a sense of nostalgia and regret in signing off on our final report. We members of the Executive Core, the Deans and Education Deans of CUMC health professions schools and programs, and the students who participate in the Macy IPE seminars and other Commons activities have been emboldened by the support of the Josiah Macy, Jr. Foundation and grateful to them for awakening in us a commitment to interprofessional education. You have allowed us to dream beyond our realities.
Some of our dreams have become reality. And achieving some of our dreams makes us hungry to achieve more. Here is the future we can envision and taste:
CUMC is home for students and faculty who need and delight in partnership across professions and specialties. The admissions committees of all the schools highlight opportunities for IPE in their recruitment materials. Gone are the days when nursing students did not talk with medical students or when dental students were assigned to separate tables from medical students in their shared Gross Anatomy course. There are enough historically-named “Macy IPE Seminars” to accommodate all first-year CUMC students.
Students commonly access the course catalogues of one another’s’ schools and know they may enroll in IPE courses for credit toward their own diplomas. Clinical teachers on the wards and in the out-patient settings synchronize students’ rotations so that interprofessional groups of students can become longitudinal learning partners. Students maintain their “rolodex” of students from the other professions as their own network of consultants as clinical need arises.
Researchers in the 8 schools and programs have ready access to all faculty members’ CV’s and research specialties for ease in including one another in research projects and grant applications. Because intensive and high-stakes interprofessional study groups have probed and examined the underlying sources of conflict between professions, faculty are able to design equitable and mutually supportive roles for one another in shared projects. We don’t keep making the same mistakes.
Groups of teachers and learners from across campus join for shared events and rituals. The Annual Endowed Lectureship in Interprofessional Education and Practice brings internationally known leaders in IPE to campus for several-days-long Visiting Professorships. Endowed Chairs in Interprofessional Education and Practice are funded with a requirement that the chairs’ occupants eventually include faculty from each school and program.
We are not wacky dreamers. We are much too practical and cynical to waste our time on the impossible. And yet, our work with the Macy Project has unleashed a common desire that no one knew we shared. Having “come out” as an institution who values IPE, even if we are a small fraction of the faculty and students, we can envision and work toward ever-more-egalitarian lives together, sharing ideals, sharing the care of patients, sharing our dreams of a just and kind world.
Grant Duration: July 2012 – June 2016
In anticipation of the close of the Macy Foundation funding, the deans of the four professional schools contributed toward an amount equal to our annual budget. Both symbolic and actual, this commitment installs IPE into the goals and missions of CUMC schools and guarantees a future and growth for what we have accomplished. Since we can no longer call ourselves “The Macy Project,” we have chosen a new name for our work:
The Commons, as it is already being called, will continue to be the site for education, scholarship, and practice spanning the professions, improving the work of each one.