|Sobering Robert Wood Johnson Project Illuminate the Challenges of Inter-Professional Integration|
Summary: The emerging field of inter-professional education (IPE) is viewed by many as a chief contributor to the kind of optimal integration needed to most enhance patient care. The integrative practice fields tend to embrace this trend as part of the necessary transformation of health care practice. Yet a report from a Robert Wood Johnson Foundation project that merely sought to create better team care between nurses and MDs is deeply sobering. What does it say about integrating medical doctors and nurses with chiropractors and naturopathic physicians, for instance? Are we up to taking on this transformational challenge? Or have we all been, as is sometimes wondered, smoking something?
Ten years ago, an advisory board member of a newsletter I wrote on the business of integration was a former nun who led a complementary and alternative medicine integration initiative in a large, faith-based, multi-hospital health system.
Her situation seemed perfect to make a huge difference in patient care. She was a former hospital CEO who was then a respected vice president of the system. Her initiative was backed by the system's mission-level commitment to a holistic, patient-centered care.
Yet within 4 years, she pulled the plug on the "CAM" initiative. Why? She responded: "There is no way complementary medicine integration can happen effectively in a system in which doctors don't respect nurses."
"There is no way CAM integration
can happen effectively in a system in
which doctors don't respect nurses."
- Former Catholic health system
This story came to mind recently while internet-researching experience data on
collaborative medicine and team care. My focus was interprofessional
education (IPE). Awareness has grown that discipline isolation and disrespect is harmful to patient care, especially in the context of complicated chronic conditions and aging populations. IPE has begun to emerge as a respected field of study with its own organizations, centers of excellence, funded scholars and journals.
The memory of my colleague's decision came via a Robert Wood Johnson
Foundation (RWJF)-funded project called Partnerships for Quality Education (PQE) and its Collaborative Inter-professional Team Education (CITE) program. Pilot projects were funded to develop better team care among medical doctors and nurses in a
clinical managed care environment. Here,
in blunt language, was the key result:
Sobering report for those interested in ehanci inter-professional teamwork and respect
CITE was unable to deliver an effective model of teamwork. This was due to
issues with how academic medicine and managed care work-their administrative
structures, academic schedules, attitudes of the disciplines toward each other
and prejudices about teamwork.
A post-factor analysis of the projects (1) underscored the systemic challenges:
What was happening was that people were trying to do what
was really a small initiative that went against the grain of the institution.
There was no structure for medicine and nursing to collaborate. Administrative
systems, such as scheduling of appointments, were not supportive of teamwork.
Few, if any, faculty practiced in teams, which meant that the trainees had no
models to emulate. Their academic years were different. Everything was working
I suspect that most integrative practitioners will quickly decide that managed care is the Mr. Green who performed the murder with the candlestick of poor payment practices. If so, you would have been partly right. The analysis notes: "There has to be a business case for team work." And: "The insurance business isn't really asking for teamwork."
"Since the first nurses and first doctors
began working in modern health
in 1900, nurses have felt that doctors
treated them as their
do the dirty work and take orders."
Yet to jab one more time at everyone's favorite punching bag misses implications controllable by the disciplines doing the jabbing. Listen:
Interdisciplinary teamwork is likely to bog down when hierarchical issues
are embedded in the process from the get go. Doctors feel superior and in
control. Nurses feel unvalued and angry. You have to take that into account and
find a mechanism to sidestep that ...
And then, even more to the point:
Since the first nurses and first doctors began working in modern health
care in 1900, nurses have felt that doctors treated them as their
handmaids to do the dirty work and take orders. As the nurses aspired to
do more, they took routes that encroached on what doctors considered to be
their territory. Doctors rejected this, nurses got angry. And that
conflict remains alive today."
The assessment by my health system colleague a decade ago, in abandoning all hope for holistic integration in a context of such MD-nurse animosity, would seem to be prescient. The references to historic animosities and to turf
have high resonance in the integrative practice realm. Fear of
MD-usurpation of complementary and alternative health therapies, and
disregard for distinctly trained practitioners, is both deep and widespread.
Yet recognition of the need to change relationships between the disciplines is embedded in the foundations of the integrative practice fields. The definition of integrative medicine from MD-led programs in academic health centers underscores the importance of integrating "health professionals and disciplines." The vision statement
from a consortium of educators representing acupuncture and Oriental medicine, chiropractic medicine, massage therapy, naturopathic medicine, direct-entry midwifery and some emerging fields "envisions a health care system that is multidisciplinary and enhances
competence, mutual respect and collaboration across all complementary
and alternative medicine and conventional health care disciplines." (2) Each
resounds as a profoundly inter-disciplinary commitment.
Yet recognition of the need to change
relationships between the disciplines
is embedded in the foundations
the integrative practice fields.
Integrative practice posits a new world order among disciplines. This report from these RWJF projects is both a sobering wake-up call and profoundly important guidance on the work ahead. Never mind that, to date, most of us who have been attempting to engage these challenges have been hampered by not having the support of significant foundations such as RWJF.
Are we up to it? Or have we all, as is sometimes wondered aloud, just been smoking something? I confess to an urge, on mulling the findings in this report, to return to my Central American sabbatical. My colleague's summary judgment from a decade ago is haunting.
(1) I originally accessed the full report summary from which these citations originated at http://www.rwjf.org/pr/product.jsp?id=59293
on June 8, 2010. It is not presently available there and I haven't found it elsewhere on the RWJF site. The best surrogate is http://www.rwjf.org/pr/product.jsp?id=17748. For a copy of the powerful 2-page document I repeatedly cite, please email me at
(2) Disclosure: I serve as executive director of the latter consortium.
About The Author
Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields of complementary, alternative and integrative medicine since 1983. Happily, I have learned some things. I was once called an "expert in alternative medicine" by......more