Published on

Published in: Health & Medicine, Education
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. Multiprofessional learning Interdisciplinary education and teamwork: a long and winding road Pippa Hall & Lynda Weaver Purpose This article examines literature on interdisciplinary education and teamwork in health care, to discover the major issues and best practices. Methods A literature review of mainly North American articles using search terms such as interdisciplinary, interprofessional, multidisciplinary with medical education. Main ®ndings Two issues are emerging in health care as clinicians face the complexities of current patient care: the need for specialized health professionals, and the need for these professionals to collaborate. Interdisciplinary health care teams with members from many professions answer the call by working together, collaborating and communicating closely to optimize patient care. Education on how to function within a team is Introduction The aging population, the rising incidence and prevalence of cancer and other chronic diseases are shifting the focus of medicine from the model of `cure' to one of controlling symptoms, maximizing patients' level of functioning and quality of life, as well as helping patients and families cope with a long-term illness. The increasing complexity of knowledge and skills required to provide comprehensive care to these patients has resulted in increasing specialization within the health professions.1 Although this specialization allows for in-depth exploration of issues by a speci®c discipline, it means that no one health care professional can meet all the complex needs of these patients.2 With increasing specialization, there is less opportunity for interdisciplinary exchange. It is more comfortable to remain within one's own discipline where communication is facilitated by specialized Correspondence: P Hall, Assistant Professor, Department of Family Medicine, University of Ottawa Institute of Palliative Care, 43 Á Bruyere St, Ottawa, Ontario, K1N 5C8, Canada essential if the endeavour is to succeed. Two main categories of issues emerged: those related to the medical education system and those related to the content of the education. Conclusions Much of the literature pertained to programme evaluations of academic activities, and did not compare interdisciplinary education with traditional methods. Many questions about when to educate, who to educate and how to educate remain unanswered and open to future research. Keywords Education, medical, *methods; interdisciplinary communication; patient care teams; quality of health care; teaching. Medical Education 2001;35:867±875 vocabulary, similar approaches to problem solving, common interests and understanding of issues. This discipline-speci®c view of the world is taught and reinforced through the socialization processes of educational experiences.3,4 Members of each specialty and discipline have a theoretical basis through which they interpret and address issues which arise in their work. Petrie refers to this as the professional's `cognitive map', i.e. the whole cognitive and perceptual approach embraced by the discipline.5±7 As these maps become entrenched through repeated use, communication with other disciplines can become increasingly challenging. Petrie states that `¼quite literally, two opposing disciplinarians can look at the same thing and not see the same thing'.5 The patient with complex health problems, and his/her family, must interact with a battery of specialists who may experience dif®culty establishing effective communication among themselves. This communication becomes even more problematic as the socioeconomic pressures move care out of institutions and into the community where health care professionals are usually not in the same geographic location at the same time. Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:867±875 867
  2. 2. 868 Interdisciplinary education and teamwork · P Hall & L Weaver Key learning points Education on how to function within a team is essential if the endeavour is to succeed. Interdisciplinary education must address role blurring, group skills, communication skills, con¯ict resolution skills for team members and leadership skills for faculty. Many questions about the effectiveness of teamwork and best practices in teaching are yet unanswered. In summary, a dilemma emerges as clinicians face the complexities of patient care: an increase in specialization of health professionals and an increase in challenges to collaboration between specialists. In many facilities, the response to complex patient care is to group different professionals together as health care teams. Health care teams In practice, health care teams function somewhere along a continuum of degrees of interaction among team members and their degrees of responsibility for patient care. Different points on this continuum are represented by the multidisciplinary team, the interdisciplinary team and the transdisciplinary team. The multidisciplinary team allows for each discipline to independently contribute its particular expertise to an individual patient's care. Traditionally, it has been the physician who is responsible for prescribing the contribution other disciplines could make and for coordination of services.8 Team members work in parallel to each other, and direct interdisciplinary communication is minimal except through the physician in charge.9 Members of the team may be of the same discipline/profession (e.g. a team of surgeons and internists involved in the care of a patient with complex health problems) or from different disciplines/professions (e.g. an orthopaedic surgeon, physiotherapist and occupational therapist working with a patient who is recovering from a fracture). The interdisciplinary team refers to a team whose members work together closely and communicate frequently to optimize care for the patient. The team is organized around solving a common set of problems9 (as opposed to being organized around a single physician) and meets frequently to consult. Each member of the team contributes his/her knowledge and skill set to augment and support the others' contributions.10 Each member's assessment must take into account the others' contributions to allow for holistic management of the patients' complex health problems.5 Team members preserve specialized functions while maintaining continuous lines of communication with each other,7 placing themselves somewhere in the centre of the continuum of interactions and responsibilities. Examples of this type of teamwork are often seen in complex patient care areas exempli®ed by palliative care,10,11 geriatrics9,12 and mental health.13 This type of work in clinical practice is also referred to as `interprofessional'.14 In transdisciplinary work, the team is operating at the opposite end of the continuum from multidisciplinary teams. Roles of the individual team members are blurred as their professional functions overlap. Each team member must become suf®ciently familiar with the concepts and approaches of his/her colleagues to be able to assume signi®cant portions of the others' roles.14 This discussion will only focus on what is known about interdisciplinary education and teamwork in the health care ®eld and will identify some of the many questions raised along the long and winding road towards excellence in patient care. Review of the literature: interdisciplinary education of the health care team In the health care literature there appears to be a lack of evidence addressing professionals' ability to learn interdisciplinary team skills while working, without formal education. The majority of publications were from academic centres where educational programmemes were the focus of study. The literature search was complicated by the inconsistent and myriad terminologies used to describe health care professionals working in team settings. Most literature reviewed was from North America. Interdisciplinary teamwork and education is a recurring issue in the health care literature, a fact well documented in the review article of Giardino et al.15 Between 1971 and 1981, there was a ¯urry of activity on interdisciplinary work, as the American Nursing Association and the American Medical Association worked on a National Joint Practice Association. This effort collapsed due to con¯icts, particularly concerning issues of nurses' role expansion and salaries.16 Two main categories of issues emerge from the literature: one pertaining to the system of education and training of health care professionals and the other to the content of interdisciplinary education. Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2001;35:867±875
  3. 3. Interdisciplinary education and teamwork · P Hall & L Weaver 1 System issues Availability of interdisciplinary education In 1976, Bloom & Parad found only 36% of mental health training programmes had any interdisciplinary training component, although interdisciplinary functioning at work was the rule rather than the exception.13 In 1982, McPherson & Sachs reported the results of a survey to determine the extent to which interdisciplinary health team concepts were being taught in US and Canadian medical schools.17 Less than 30% of the 105 responding schools had a formal undergraduate programme or component for interdisciplinary teamwork. Only half of these were compulsory. In 1992, the Centre for the Advancement of Interprofessional Education in the United Kingdom reported the ®ndings of their May 1987±April 1988 national survey of professional groups involved in education (undergraduate, postgraduate and continuing education).18 Only 7% of the participants in the interprofessional educational activities were physicians (general practitioners), the rest being nurses and allied health care professionals. The report notes that interprofessional educational endeavours are increasing in general. Despite this apparent lack of opportunities, examples of university-based interdisciplinary health-related education programmes were found in the literature. Topics taught in this interdisciplinary manner ranged from oncology, health promotion, orthopaedics, and geriatrics, to information and appraisal skill building. Teams were made up of various combinations of undergraduate and graduate students from medicine, nursing, social work, psychology, pharmacy, dietary sciences, library sciences, and health or public administration. Timing of the interdisciplinary education intervention Several studies suggest that learning to work in an interdisciplinary milieu should occur early in the education of the health care professional (e.g. within the ®rst 2 years). Horak et al. suggest that the experience of shared learning at an early stage may better facilitate interdisciplinary collaboration (considered by Horak to be crucial to satisfactory patient outcomes) among future health care professionals.19 Arnvaripour et al. describe an interdisciplinary programme for second-year medical students, but recommend an even earlier introduction to the topic.20 Headrick et al., in two articles, recommend involving medical residents in interdisciplinary projects which are relevant to their needs, scheduled as part of their core programme and begun early in their education to optimize the learning experience.21,22 869 Petrie, however, says that the individual embarking on interdisciplinary teamwork must ®rst of all be secure in his/her competency in his/her discipline.5 Mariano also states that a thorough knowledge of one's own discipline is essential to understand contributions to the team effort, and freedom to be truly interdisciplinary only comes with security in one's own discipline.2 This would suggest that early interventions in undergraduate education would not be appropriate and programmes should only be started at the senior student23 or postgraduate level. Wahlstrom and colleagues describe an educational proÈ gramme which integrates multiprofessional education throughout the medical undergraduate curriculum.24 Obviously, the debate is unresolved. Non-traditional teaching methods Methods to teach interdisciplinary practice differ greatly from traditional didactic lectures. Interdisciplinary problem-based learning (PBL) and the service/learning models are examples of two team approaches to education.1,9,25 PBL, done in small-group format, offers a means of integrating theory with clinical components and demands knowledge acquisition, attitudinal and psychomotor skills from the learners.25 PBL is a structured educational activity, usually employing case presentations as the stimulus to learning. This approach helps students learn to listen to each other and to collaborate as they work to resolve the problems.26 The service/learner model uses a clinical setting to challenge the learners to work together effectively to address real clinical problems,23 patient education or health dilemmas of under-serviced populations.9 Both these teaching methods support Petrie's recommendation for `idea dominance' if an interdisciplinary team is to succeed.5 `Idea dominance' means that a clear and recognizable idea must serve as a focus for teamwork, rather than the traditional focus of each member's domain of care. This would place the patient at the centre of the team's focus. In addition, `idea dominance' emphasizes that the team members must be able to recognize their success and achievements in pursuing their goals. Not only must the project/idea succeed, but each team member must perceive that he/ she is personally achieving something. Teaching methods, such as critical appraisal and the highly re¯ective or questioning techniques proposed by some poststructuralists, including Cherryholmes,27 Lincoln,28 Tierney29 and Purdy,30 and by feminists such as Bryson,31 Hoodfar32 and Manicom,33 can confront traditional approaches, facilitate working across professional and cultural differences and could make signi®cant contributions to interdisciplinary Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:867±875
  4. 4. 870 Interdisciplinary education and teamwork · P Hall & L Weaver communication. These methods are unfamiliar to most faculty, particularly those in the health care professions. Introducing these concepts to faculty in practical and useful ways will be a challenge. MacDonald suggests physicians are reluctant to participate in certain educational activities, such as role play, small-group problem-based learning and practicum experiences, which have been shown to have an impact on their behaviour.34 Without these interactive learning tools, practising interdisciplinary work would be dif®cult. Need for faculty development In addition to non-traditional teaching methods, faculty face other educational concepts and issues which require new knowledge, attitudes and skills when facilitating interdisciplinary education.35 McPherson and Sachs examined programmes which used concepts from behavioural and management sciences to teach group process skills, team roles and functions, and health care content.17 They emphasized the need to prepare students for the interpersonal dynamics required in the integrated approach to health care planning and management. However, the physician educators were not familiar with the concepts used in the behaviour sciences and management. The interdisciplinary undergraduate programme reported by Horak, O'Leary and Carlson at George Washington University and George Mason University (known as the George Team) illustrates the extensive amount of time, dedication and skill required by the faculty to successfully implement this type of programme.19 Motivating faculty to become interested in new programmes and approaches to education is an ongoing challenge, requiring change-implementation strategies, such as those facilitated by tools and management approaches used by continuous quality improvement (CQI) programmes.36±38 As Bruhn25 says, ¼no change will occur unless members of a system feel it is safe to give up old responses and learn new ones. The change must ®t the total learning environment and be integrated into the total system if it is to survive¼ Many of the innovative interdisciplinary service/ learner projects mentioned above are in preventive health and health maintenance in primary care, particularly for low socioeconomic groups, which may be considered low pro®le medical domains. McPherson & Sachs suggest that the lack of interest in developing interdisciplinary educational programmes is related to this, and to a general reluctance to embrace new ideas.17 The need exists, then, for more training and motivational incentives for physician educators to become involved in these programmes, as well as an increase in the use of non-physician educators to teach interdisciplinary skills. Institutional support If they are to succeed, interdisciplinary teams require support from the administration of the educational and clinical institutions involved5,26,35 and, as Petrie notes, from their peers.5 Mariano reinforces the need for institutional commitment to interdisciplinary collaboration, mentioning not only the time necessary for team process and development, but issues of space and physical proximity of team members,2 which are even greater dilemmas for health care professionals in the community. Administration's acknowledgement of the success of an interdisciplinary project, as well as the individual accomplishments of team members, provides important positive feedback for the team and can signi®cantly contribute to the project's success. Participants' characteristics Most of the educational projects reviewed involved learners who volunteered to participate in an interdisciplinary educational activity. Groups showed high participation rates by women, perhaps re¯ective of the higher proportion of women in disciplines such as nursing, physiotherapy, etc. The number of participants was small in most projects, although the group described by Horak et al. showed increasing rates of participation over the 2 years of the project.19 Latimer and colleagues, discussing McMaster University's daylong interdisciplinary palliative care course, reported high levels of both learner and faculty satisfaction;39 however, the participation rate of medical students had been decreasing over the previous few years. Those interested in, or with an appropriate skill base in, interdisciplinary work may self-select to participate. Positive evaluation results may indicate this bias, or the intensive supervision by and contact with faculty. Faculty members were given minimal dedicated time or ®nancial rewards for this work, indicating they were generally highly motivated and committed. Indeed, they may represent a very small proportion of faculty with a predisposition for acquiring the skills, knowledge and attitudes necessary for this type of programme. Petrie states that participants in interdisciplinary teamwork must have a taste for new adventure.5 To be an effective team, members must all be excellent within their disciplines, aware of the stringencies of their respective disciplines, yet ready to leave this Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2001;35:867±875
  5. 5. Interdisciplinary education and teamwork · P Hall & L Weaver safety to embark on the relatively uncharted course of interdisciplinary work. They must also be willing to pursue excellence in this new domain with similar rigour. 2 Content issues Professional role demarcation versus role blurring As previously discussed, each health care professional learns his/her traditional role through the education process of his/her profession and discipline. The role becomes an integral part of the individual's `cognitive map'.5 Agreeing with Petrie, Hill formulates that health professionals come to the health care team with preconceived maps of their roles based on their learned culture, beliefs and cognitive approaches in their speci®c disciplines.40 They have poor understanding of the other person's roles or maps, which causes anxiety, con¯ict and ineffectiveness as a team. In teamwork, members should possess areas of overlapping competencies and share responsibilities depending on the model of practice. Mariano describes this as `role blurring'.2 Several problems arise when role blurring is not handled well. Some team members may not realize the others' potential contribution to patient care, and will underutilize their expertise. Consequently, members are not engaged to their full potential and may feel resentful. Some members may even try to do all the physical, psychosocial and emotional care themselves, setting the stage for burnout, failure and team con¯ict. Hill found that nurses in particular experience role blurring as they struggle with con¯icts between being a clinical nurse specialist and traditional nurse, as well as with physicians' expectations of the nursing role.40 Mariano suggests exercises to assist team members to clarify each other's roles. These allow team members to: (a) clarify role perceptions and expectations; (b) identify their own professional competencies as well as the competencies of other team members; (c) explore overlapping responsibilities, and (d) renegotiate role assignments.2 Johnson et al. describe a programme which experientially introduces medical residents to the nurses' role.41 Working for one day alongside a nurse preceptor, the residents gained an appreciation for nursing tasks, skills and knowledge. There was evidence that communication skills of the participating residents improved. At the opposite end of the spectrum, Giardino et al. report on a 1985 study of medical students who did not receive interdisciplinary education. Students' attitudes towards nursing became negative after their 4 years of schooling, and only 20% realized 871 that `nurses had legitimate roles independent of physician orders and expectations'.15 Hall et al. report that both the physicians and allied health care professionals in interdisciplinary palliative care educational workshops indicated that the interdisciplinary experience was the most valuable aspect of the programmes, and it would have an important effect on improving care of the terminally ill in their communities.42 By working on case studies and clinical issues in small groups, these participants gained insight into the importance of understanding each other's roles. Wilson points out that this appreciation can only become truly evident by working with problems in the real world.43 Resistance to giving up clearly de®ned roles and boundaries is fairly well documented. Critics such as Ivan Illich, as discussed by Schon, de®ne a profession È as an inappropriate manipulation of knowledge which disregards social injustices and mysti®es expertise.44 Professions tend to implement both procedures which separate other disciplines from their own and measures to restrict access to the discipline. Witz has called this external and internal closure.45 The concept of boundary work discussed by Gieryn actually contributes to the construction of the cognitive maps discussed earlier by forcing professionals to develop a framework or paradigm with which to view the world.46 Interdisciplinary education and practice propose to collapse the walls separating professionals. Group skills Weber & Karman describe the use of the Tuckman model of group development with students to develop their interdisciplinary team skills.47 The educator leads students through different stages of `forming, storming, norming and performing'. `Forming' refers to the forming of task-oriented behaviour as the goals and objectives for the team are de®ned. `Storming' is the stage where the individuals and group react affectively to the requirements of the task and to interpersonal con¯icts. The `norming' stage is achieved when effective cooperation between the team members occurs through communication of ideas, opinions and information. In the ®nal stage, `performing', collaboration between the team members for task achievement is evident through interdependence of relationships and contribution of resources. As the individual learners develop their group skills, the group matures to the performing level, requiring little direction from the educator. The group is then able to take on a task and independently carry it through to completion. As the group matures, so do the members' abilities to resolve con¯icts and remove barriers to goal achievement. This also illustrates the Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:867±875
  6. 6. 872 Interdisciplinary education and teamwork · P Hall & L Weaver importance of the leadership skills of the educator or team leader (see Leadership skills below). Communication skills As health care professionals face their patients' multidimensional problems, they can experience stress and high emotions, and this can introduce tension between team members.7,10 Elliott-Miller et al. discuss how open, honest and clear communication among team members can alleviate some of the stress.10 Others have shown that communication skills can be learned.48 Mariano identi®es poor communication skills between members of different disciplines as one of the major factors preventing effective interdisciplinary teamwork.2 Universities and other educational programmes have spent little time educating students on these skills. Con¯ict resolution skills Con¯ict resolution is an essential skill for all team members to master at an early stage. Bloom & Parad note that interdisciplinary practice does not necessarily mean all members come with equal attitudes towards tasks or take on equitable or reciprocal responsibilities.13 These value differences can cause con¯icts between members.2 Con¯ict can also arise from differing goals of team members. This reinforces the importance of Petrie's concept of `idea dominance' in reducing goal con¯ict (see section above on Nontraditional teaching methods).5 Mishandled con¯icts can make the team ineffective and dysfunctional. McKenna used `role negotiation' methods to alleviate serious con¯icts that developed in a team as a direct result of role blurring, and suggests that these techniques be taught early in the development of a team.8 Well-managed con¯ict resolution will facilitate team growth and maturation. Clark et al.,9 Fagin16 and Makaram26 point out that the perceived status of individual team members can potentially disrupt team harmony with issues of authority, power and autonomy, as can members' personal characteristics. Con¯ict resolution skills can assist in minimizing this problem, as can good communication skills. Leadership skills Leadership skills are particularly signi®cant for team leaders and faculty who manage or facilitate interdisciplinary group work.47 The leader must be able to identify different stages of the team's development and implement appropriate leadership approaches. Early stages require highly directive leadership, with high emphasis on task and low emphasis on relationship behaviour. As the team matures, the leader facilitates the group's increasing ability to undertake tasks by encouraging the team's sense of ownership and responsibility. The next stage requires the leader to delegate more, with low task direction and less socioemotional support. Finally, the group will mature, become autonomous and assume full responsibility for tasks and relationships within the team. Leadership for different tasks may rotate among team members as the needs and focus change. In clinical settings, team membership is constantly changing as members leave for various reasons and are replaced. The changing membership challenges team dynamics. Although there is no clear discussion of this issue in the reviewed articles, the team leader must be prepared to adopt the appropriate leadership style necessary to lead the team to a new level of maturity. Discussion Problems of health care are major and complex, both on a clinical level and a management level. In Canada, it is only over the past decade that serious attempts to control health care costs have resulted in structural changes that force health care professionals to examine their practices.49 The complexity of patient care has contributed to the increasing awareness that effective interdisciplinary teams may help reduce costs by reducing service duplication and minimizing unnecessary interventions. Regardless of cost, the interdependence and synergy of the team may also improve patient outcomes and team members' individual job satisfaction and performance.9,10 The key points from the current literature can be interpreted as assumptions until further research tests the theories. The assumptions suggested by this literature are as follows. · There appears to be a consensus in the published literature on the need for an interdisciplinary component in health care professionals' education. · There is no clear consensus on the ideal timing of an interdisciplinary educational intervention. · Faculty development must be provided to address motivation to participate. This includes: opportunities for faculty to learn how to facilitate interdisciplinary education sessions, and learning skills from management and behavioural sciences as well as leadership skills. · Teaching methods are non-traditional, and include interdisciplinary problem-based learning (PBL), the service/learning model, and teaching strategies from feminist and poststructural theories. Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2001;35:867±875
  7. 7. Interdisciplinary education and teamwork · P Hall & L Weaver · `Role blurring' is necessary for function as an interdisciplinary team, though there is much resistance and confusion associated with rede®ning roles. · Certain non-clinical skills must be learned by team members: group skills, communication skills and con¯ict resolution skills. There appears to be little in the health care literature which discusses the outcomes of learning from one another in an interdisciplinary setting, although Fagin notes that many physicians state that, during their training, they learned from experienced nurses.16 Most of the results presented here were from programme evaluation (e.g. learner satisfaction), or indicated increased knowledge in programme participants without a control or comparison group to determine whether the intervention was the best practice (or just one of possible best practices). The majority of the participants in the reported interdisciplinary programme evaluations were volunteers. There was no information on the classmates who did not volunteer to take the programmes, which could have further illuminated some barriers. Issues which relate to cognitive learning theory are not addressed in this literature. Each profession and discipline may have a predominance of individuals with a particular set of cognitive learning skills and styles. Their educational process will reinforce these skills. Interdisciplinary education must therefore address not only these different cognitive styles, but also teach participants not to judge those with different styles as being inherently superior or inferior. The concept of interdisciplinary teamwork did not originate in the university health sciences programmes, but was formulated by front-line practitioners facing the complexities of patient care. As it is increasingly the responsibility of the university to educate health care professionals, it is proposed by both graduates and the community that students be better prepared for the work they will be expected to do. These external pressures on the university system demand ¯exibility and responsiveness from the educational process. The university in western society is now a diverse educational community, with different colleges and specialized schools and, within each, there are increasing numbers of departments and areas of special studies. Kerr refers to this as `the multiversity' of modern academic life,50 which portrays the multiple silos under one governance. Wilson suggests that this fragmentation in academia has resulted in further fragmentation of knowledge.43 The physical layout and traditional academic approach of universities are not conducive to interdisciplinary concepts. Changing these structural 873 barriers will be challenging, and will probably only be achieved through formal research evidence. Despite the plethora of literature on interdisciplinary education and teamwork, many questions are still unanswered. Which patients truly bene®t from the care provided by an interdisciplinary team?51 Do interdisciplinary teams actually provide more holistic and effective care? Which health professionals should learn how to work in an interdisciplinary team? Are there certain cognitive skill sets which preclude learning and functioning in an interdisciplinary way? Does every health professional require all or some of the knowledge and skills? If everyone requires at least some, which ones are essential? How do the rigorous demands of traditional disciplines apply to the interdisciplinary setting? Are members of interdisciplinary teams more satis®ed with their work, and, if so, why? When should interdisciplinary education begin? Is there a continuum of complexity to this type of work which would allow for some educational interventions early in undergraduate training (e.g. communication skills, con¯ict resolution skills, exercises to encourage interpretation of a given situation with a new perspective), followed by more complex levels of interdisciplinary work when students are more competent and con®dent in their respective disciplines? What values are involved in interdisciplinary practice? What methods are most effective for teaching interdisciplinary teamwork? What is the best way of teaching nebulous but vital concepts, such as the necessity of sharing the burden of care, understanding equality in responsibilities and reciprocity, sharing a common goal, and trusting team members? Are there jurisdictional and medicolegal issues which need to be addressed before collaborative and effective teamwork can occur? Who should teach interdisciplinary concepts and teamwork? Further research is needed to answer these questions and to test assumptions, beginning with exploratory methods to determine the underlying concepts and epistemology of interdisciplinary teamwork. Through programmes such as those described at the undergraÈ duate level by Carpenter23 and Wahlstrom,24 at the postgraduate level by Leiba52 and Counsell et al.12 and at the continuing educational level by Hall et al.,42 answers to these and other emerging questions should begin to be provided. The long and winding road ahead is exciting and appears to have much to offer patient care. Funding The authors are grateful for the support they have received from the AMS Wilson Senior Fellowship which helped them complete this work. Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:867±875
  8. 8. 874 Interdisciplinary education and teamwork · P Hall & L Weaver Contributors Dr Hall's interest and experience in interdisciplinary teamwork and education led her to review the literature, assisted by Ms Weaver, who is the Evaluation and Education Project Coordinator for the Institute of Palliative Care. Together they developed the article, with equal contribution. References 1 Lary MJ, Lavigne SE, Muma RD, Jones SE, Hoeft HJ. Breaking down barriers: multidisciplinary education model. J Allied Health 1997 Spring; 26 (2):63±9. 2 Mariano C. The case for interdisciplinary collaboration. Nurs Outlook 1999;37 (6):285±8. 3 Loseke ID, Cahill SE. Actors in search of a character: student social workers' quest for professional identity. Symbolic Interact 1986;9 (2):245±58. 4 Shiva V. Biopiracy. The Plunder of Nature and Knowledge. Boston, Massachusetts: South End Press; 1997. 5 Petrie HG. Do you see what I see? The epistemology of interdisciplinary inquiry. J Aesthetic Educ 1976;10:29±43. 6 Itano JK, Williams J, Deaton MD. Impact of a student interdisciplinary oncology team project. J Cancer Educ 1991;6 (4):219±26. 7 Benierakis C. The function of the multidisciplinary team in child psychiatry ± clinical and educational aspects. Can J Psychiatr 1995;40:348±53. 8 McKenna PM. Role negotiation: a strategy for facilitating an interprofessional health care team. Nurs Leadership 1981;4 (4): 23±8. 9 Clark PG, Spence DL, Sheehan JL. A service/learning model for interdisciplinary teamwork in health and aging. Gerontol Geriatr Educ 1996;6 (4):3±16. Â 10 Elliott-Miller P, Hupe D, Seely J. The team in palliative care. In: Dunlop R, Portenoy R, Coyle N, Davis C eds. The Concise Oxford Textbook of Palliative Care. Oxford: Oxford University Press; In press. 11 Burge FI. Palliative care in medical education at McMaster University. J Palliat Care 1989;5 (1):16±20. 12 Counsell SR, Kennedy RD, Szwabo P, Wadsworth NS, Wohlgemuth C. Curriculum recommendations for resident training in geriatrics interdisciplinary team care. JAGS 1999;47:1145±8. 13 Bloom BL, Parad HJ. Interdisciplinary training and interdisciplinary functioning: a survey of attitudes and practices in community mental health. Am J Orthopsychiatr 1976;46 (4):669±77. 14 Hinton Walker P, Baldwin D, Fitzpatrick JJ, Ryan S, Bulgar R, Debasio N, et al. Building community: developing skills for interprofessional health. Nurs Outlook 1998;46 (2):88±9. 15 Giardino AP, Giardino ER, Seigler EL. Teaching collaboration to nursing and medical undergraduates. In: Seigler EL, Whitney FW eds. Nurse±Physician Collaboration: Care of Adults and the Elderly. New York: Springer, 1994: pp. 127±57. 16 Fagin CM. Collaboration between nurses and physicians: no longer a choice. Acad Med 1992;67 (5):295±303. 17 McPherson C, Sachs LA. Health care team training in U.S. and Canadian medical schools. J Med Educ 1982;57:282±7. 18 Horder J. A national survey that needs to be repeated. Centre for the Advancement of Interprofessional Education. J Interprofessional Care 1992;6 (1):65±71. 19 Horak BJ, O'Leary KC, Carlson L. Preparing health care professionals for quality improvement: the George Washington University/George Mason University experience. Quality Management Health Care 1998;6 (2):21±30. 20 Anvaripour PL, Jacobson L, Schweiger J, Weissman GK. Physician±nurse collegiality in the medical curriculum: exploratory workshop and student questionnaire. Mount Sinai J Med 1991;58 (1):91±4. 21 Headrick LA, Neuhauser D, Schwab P, Stevens DP. Continuous quality improvement and the education of the generalist physician. Acad Med 1995;70 (1 Suppl):S104±S109. 22 Headrick LA, Richardson A, Priebe GP, Bergman D. Continuous improvement learning for residents. Pediatrics 1998;101 (4):768±73. 23 Carpenter J. Interprofessional education for medical and nursing students: evaluation of a programme. Med Educ 1995;29:265±72. Â 24 Wahlstrom O, Sanden I, Hammar M. Multiprofessional È education in the medical curriculum. Med Educ 1997;31:425±9. 25 Bruhn JG. Problem-based learning: an approach toward reforming allied health education. J Allied Health 1992 Summer;21 (3):161±73. 26 Makaram S. Interprofessional cooperation. Med Educ 1995;29 (1 Suppl):65S±69S. 27 Cherryholmes CH. Thinking about education poststructurally. In: C Cherryholmes, ed. Power and Criticism: Poststructural Investigations in Education. New York: Teachers College Press; 1988: pp. 31±48. 28 Lincoln YS. Advancing a critical agenda. In: W Tierney, ed. Culture and Ideology in Higher Education. New York: Praeger; 1991: pp. 17±32. 29 Tierney WG. Cultural citizenship and educational democracy. In: WG Tierney, ed. Building Communities of Difference: Higher Education in the Twenty-First Century. Westport, Connecticut: Bergin and Garvey; 1993; pp. 127±58. 30 Purdy LM. Politics and the college curriculum. In: R Simon, eds. Neutrality and the Academic Ethic. Lanham, Maryland: Rowman & Little®eld; 1994: pp. 236±64. 31 Bryson M, de Castell S. Queer pedagogy: praxis makes im/ perfect. Can J Educ 1993;18 (3):285±305. 32 Hoodfar H. Feminist anthropology and critical pedagogy: the anthropology of classrooms' excluded voices. Can J Educ 1992;17 (3):303±19. 33 Manicom A. Feminist pedagogy: transformations, standpoints, and politics. Can J Educ 1992;17 (3):365±89. 34 MacDonald N. Limits to multidisciplinary education. J Palliat Care 1996;12 (2):6. Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2001;35:867±875
  9. 9. Interdisciplinary education and teamwork · P Hall & L Weaver 35 Multidisciplinary education [editorial]. Med Educ 1995;29:329±31. 36 Batalden PB, Mohr JJ, Nelson EC, Plume SK. Improving health care, Part 4: concepts for improving any clinical process. J Qual Improvement 1996;22 (10):651±9. 37 Berwick DM. Cost improvement as an ideal in health care. N Engl J Med 1989;320 (1):53±6. 38 Berwick DM. A primer on leading the improvement of systems. BMJ 1996;312:619±22. 39 Latimer EJ, Deakin A, Ingram C, O'Brien L, Smoke M, Wishart L. An interdisciplinary approach to a day-long palliative care course for undergraduate students. Can Med Assoc J 1999;161 (6):729±31. 40 Hill A. Multiprofessional teamwork in hospital palliative care teams. Int J Palliat Nurs 1998;4 (5):214±21. 41 Johnson SB, Norton JC, Wilson EA. A program to foster residents' appreciation of the nurse's role. Acad Med 1992;67:439±40. Â 42 Hall P, Weaver L, Hupe D, Seely J. Community-based palliative care education: can it improve the care of the terminally ill? Acad Med 1999;74 (10 Suppl):S105±7. 43 Wilson EO. Consilience: The Unity of Knowledge. New York: AA Knopf; 1998. 44 Schon DA. Educating the Re¯ective Practitioner. San Francisco: È Jossey-Bass; 1987. 875 45 Witz A. Professions and Patriarchy. London: MacMillan; 1992. 46 Gieryn TF. Boundary-work and the demarcation of science from non-science: strains and interests in professional ideologies of scientists. Am Sociol Rev 1983;48:781±95. 47 Weber MD, Karman TA. Student group approach to teaching using Tuckman model of group development. Am J Physiol 1991;261 (6 Part 3):S12±16. 48 Buckman R.How to Break Bad News: a Guide for Health Professionals. Toronto: University of Toronto Press; 1992. 49 Lurie N. Preparing physicians for practice in managed care environments. Acad Med 1996;71 (10):1044±9. 50 Kerr C. The idea of a multiversity. In: The Uses of the University. 3rd edn. Cambridge, Massachusetts: Harvard University Press; 1982: pp. 1±45. 51 Fulmer T. Curriculum recommendations for resident training in geriatrics interdisciplinary team care. JAGS 1999;47:1149±50. 52 Leiba T. Current developments in interprofessional education. Br J Nurs 1993;2 (12):631±3. Received 14 March 2000; editorial comments to authors 1 August 2000; accepted for publication 19 September 2000 Ó Blackwell Science Ltd ME D I C AL ED U C AT I ON 2001;35:867±875