Abstract
Thirty-nine volunteer students from 3 health science colleges at Touro University California participated in an exercise designed to promote interprofessional collaboration. In the event, thirteen 3-person multidisciplinary teams of students identified potential medical errors in a series of case-based scenarios. In an immediate postevent survey, 33 of 39 respondents (85%) indicated that the exercise marked the first time that they had worked on clinical problems with students from other health professions. All respondents agreed that interprofessional education was useful and necessary. A 6-month follow-up survey had 24 respondents, 9 of whom (38%) indicated that the experience helped them in interprofessional communications in their clinical rotations. Twenty-two respondents (92%) recalled that all team members were involved in the selection of answers. Respondents reported that team answer selections were made by consensus (12 [50%]), by accepting the opinion of an “expert” on the team (9 [38%]), or by majority vote (3 [13%]). Since this exercise, there has been a surge of interprofessional activities at Touro University California, including steps toward the implementation of campus-wide interprofessional education.
The goal of interprofessional education (IPE) in the health professions is to prepare students for collaboration with healthcare providers from various professions, such as physicians, pharmacists, nurses, and social workers. In 2010, a report by the Study Group on Interprofessional Education and Collaborative Practice of the World Health Organization (WHO), affirmed collaborative health education and practice as an effective and necessary approach to strengthening healthcare systems, both locally and globally.
1 The WHO's conclusion was based on a series of studies that demonstrated the benefits of IPE. The Institute of Medicine identifies the ability “to work in interdisciplinary teams—cooperate, collaborate, communicate and integrate care in teams to ensure that care is continuous and reliable“as 1 of 3 core competencies needed by healthcare professions.
2 Early introduction of medical students to interdisciplinary collaboration has been recommended as part of the preparation for the changing healthcare environment in the United States.
3
Accreditation standards for pharmacy education programs mandate “a stated commitment to a culture... that promotes development of interprofessional learning and collaborative practice.”
4 Similarly, the accreditation standards for physician assistant education assert that the “curriculum
must include instruction to prepare students to work collaboratively in interprofessional patient-centered teams.”
5
No similar requirement has yet been included in the accreditation standards for osteopathic medical education,
6 though the tenets of osteopathic medicine underscore key attributes of IPE, and, conversely, IPE reinforces many of the core competencies of the osteopathic medical profession.
7 While the Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Pomona, California, has been leading the way in IPE facilitation,
7 other osteopathic medical schools, including the Midwestern University/Arizona College of Osteopathic Medicine in Glendale
8 and the A.T. Still University-Kirksville College of Osteopathic Medicine in Missouri,
9 are at various stages of developing IPE.
Patient safety is inextricably linked to interprofessional communication. Failures of communication in a complex healthcare environment contribute to medical mishaps.
10 Therefore, searching for medical errors was a logical choice as the task for the interprofessional exercise described in the present article.
Touro University California has 3 colleges of health professions: the College of Osteopathic Medicine (COM), the College of Pharmacy (COP), and the College of Health Sciences (COHS), which trains physician assistants. The presence of students from different disciplines on the same campus provides an opportunity for their early exposure to future healthcare providers from disciplines other than their own.
As an introductory endeavor in IPE, an on-campus event was organized in which students of the COM, COP, and COHS worked together in teams. The event was dubbed the Touro Interprofessional Teams Clinical Competition (TIPTCC). The primary goal of this event was to stimulate students' interest in interprofessional collaboration. Interdisciplinary teams of students were asked to review several management charts of fictitious patients and to identify potential medical errors on the charts. This task was meant to emphasize patient safety through the recognition and avoidance of such errors.
Success in collaborative identification of the medical errors required the team members to share information quickly, to rely on the specific expertise of their partners, and to commit to a group decision. Subsequently, the participants were surveyed regarding their previous interprofessional contacts (or the lack thereof) and their views of the TIPTCC experience.
Faculty from all 3 colleges (COM, COP, and COHS) volunteered to design and organize the TIPTCC event. Descriptions of the medical histories and management of the fictitious patients were written by a COM faculty member (I.C.L.). These materials were then reviewed by faculty from each of the 3 colleges, who ensured that the difficulty of the medical error identification tasks would be commensurate with the knowledge of their students. Attention was paid to include types of medical errors in the management charts that could most likely be recognized by osteopathic medical, pharmacy, or physician assistant students. The effort to create the TIPTCC exercise, which was comparable to preparing a midterm examination, was completed within a 9-week timeframe. The Touro University California Institutional Review Board approved the present study, and participant informed consent was obtained.
Volunteer students were recruited by announcements sent to appropriate classes with the goal of forming several 3-person teams of students—each team consisting of an osteopathic medical student (in the second year of education), a pharmacy student (in the second year of education) and a physician assistant student (in the first or third year of education). The students were randomly assigned to the teams. The number of teams was determined by the number of registrants.
The TIPTCC was held on campus in March 2010. The rationale for choosing this time for the event and for including this particular student population in the exercise was that by the spring of their last academic semester (for all COM and COP participants and for most COHS participants), these students had acquired substantial clinical knowledge and they were still present on the campus. In addition, participation in the exercise appeared to be a good opportunity to direct the students' attention to interprofessional collaboration before they headed out to their experiential sites.
Two days before the TIPTCC, each participating student received descriptions of the preadmission histories and physical examinations of 5 fictitious patients, along with the patients' laboratory results. The students were asked in instructions included with this material to familiarize themselves with the patient histories before the event. The students met their teammates for the first time when they assembled in a lecture hall for the start of the exercise. The teams were seated at some distance from each other in the lecture hall.
After introductory remarks delivered by the event organizers, the teams were shown slides describing various steps in the management of the 5 fictitious patients following admission. Each slide included a brief introduction followed by 4 numbered management steps (1 of which could be a potential error) and a fifth choice, that there was no error in the listed steps. Examples of 2 slides used in the event are shown in
Figure 1 and
Figure 2. Three slides were shown for each patient, for a total of 15 slides (ie, 15 decisions on medical errors were required of the teams).
The teams were asked to identify the potential medical error among the consecutive steps of patient management shown on each slide. While viewing the slide, the members of each team discussed the appropriateness of the patient management steps to reach a decision regarding the answer chosen by the team. Each team had an audience response device (ie, a “clicker”), with which they clicked the number of the item on the slide that they considered to be a medical error (or the choice for no error). After all the teams submitted their answers for a slide, the results of all team responses were displayed on the left side of the screen as the percentage of answers given for each selection, with an arrow pointing to the correct selection (as shown in
Figure 1 and
Figure 2). These results were obtained by using TurningPoint audience response software (Turning Technologies LLC, Youngstown, Ohio).
After results for each slide were shown, an expert panel (consisting of faculty from each college) commented on the teams' choices and explained the nature, relevance, and consequences of the medical errors.
The viewing, error selection, and discussion for all slides took about 90 minutes to complete. Upon completion, the results (ie, the number of correct selections) of the highest-scoring teams were calculated and displayed using the TurningPoint summary report program.
Immediately after the TIPTCC exercise, the student teams were asked to respond to an 11-item survey using a 5-point Likert scale. They responded to the 11 items anonymously using the clickers. The items covered the pre-TIPTCC interdisciplinary experience of the students, their feelings and opinions about the TIPTCC, and their views on interprofessional education in general.
Six months after the TIPTCC, the participants—who were in clinical rotations by that time—were invited by e-mail to respond to a 3-question Web-based survey. The questions asked the participants whether their TIPTCC experience helped them interact with healthcare providers from other professions in their rotations, whether all members of their team actively participated in the TIPTCC exercise, and what method was used by their team to select the medical errors on the slides. Respondents could also add their own comments to the survey.
Thirty-nine volunteer students were recruited to participate in the TIPTCC. (Initially, somewhat fewer than 39 students volunteered. A few additional students had to be recruited to complete the predetermined makeup of the teams as previously described, with 1 student from each college on each team.) These students were divided into thirteen 3-person teams. The participants were mostly students who had cocurricular experiences.
All of these students participated in the 11-item survey administered immediately after the exercise. Their responses to this survey are shown in
Table 1. The responses to items 1, 2, and 3 showed that there had been little interprofessional contact and collaboration among the students of the 3 colleges prior to the competition. All 39 students indicated that they were glad they had participated in the TIPTCC—with 29 students (74%) “strongly” agreeing with that statement and 10 students (26%) agreeing with it. All 39 students also reported that they enjoyed working with students from colleges other than their own—with 33 students (85%) strongly agreeing and 6 students (15%) agreeing.
Table 1.
Results of Survey of Participants Immediately After Touro Interprofessional Teams Clinical Competition (N=39) *
|
Responses†
| | | | | |
|---|
Survey Item
| Strongly Agree
| Agree
| Neutral
| Disagree
| Strongly Disagree
| Mean Score‡
|
|---|
| 1. I know the students of other TUCA colleges very well. | 3 (7.7) | 3 (7.7) | 6 (15.3) | 24 (61.5) | 3 (7.7) | 2.5 |
| 2. I frequently study together with students of other TUCA colleges. | 0 | 0 | 0 | 12 (30.8) | 27 (69.2) | 1.3 |
| 3. This is the first time that I worked on clinical problems with students of other professions. | 27 (69.2) | 6 (15.4) | 0 | 6 (15.4) | 0 | 4.4 |
| 4. I am glad that I participated in TIPTCC. | 29 (74.4) | 10 (25.6) | 0 | 0 | 0 | 4.7 |
| 5. I enjoyed working with students from other colleges at TIPTCC. | 33 (84.6) | 6 (15.4) | 0 | 0 | 0 | 4.8 |
| 6. The format of TIPTCC was good. | 12 (30.8) | 12 (30.8) | 9 (23.1) | 3 (7.7) | 3 (7.7) | 3.7 |
| 7. I learned something new at TIPTCC. | 39 (100) | 0 | 0 | 0 | 0 | 5.0 |
| 8. I am looking forward to working together with colleagues from other professions in my rotations. | 33 (84.6) | 3 (7.7) | 3 (7.7) | 0 | 0 | 4.7 |
| 9. I heard a lot about interprofessional education before TIPTCC. | 0 | 0 | 12 (30.8) | 12 (30.8) | 15 (38.5) | 1.9 |
| 10. Interprofessional education is useful. | 33 (84.6) | 6 (15.4) | 0 | 0 | 0 | 4.8 |
11. Interprofessional education is necessary.
| 33 (84.6)
| 6 (15.4)
| 0
| 0
| 0
| 4.8
|
Table 1.
Results of Survey of Participants Immediately After Touro Interprofessional Teams Clinical Competition (N=39) *
|
Responses†
| | | | | |
|---|
Survey Item
| Strongly Agree
| Agree
| Neutral
| Disagree
| Strongly Disagree
| Mean Score‡
|
|---|
| 1. I know the students of other TUCA colleges very well. | 3 (7.7) | 3 (7.7) | 6 (15.3) | 24 (61.5) | 3 (7.7) | 2.5 |
| 2. I frequently study together with students of other TUCA colleges. | 0 | 0 | 0 | 12 (30.8) | 27 (69.2) | 1.3 |
| 3. This is the first time that I worked on clinical problems with students of other professions. | 27 (69.2) | 6 (15.4) | 0 | 6 (15.4) | 0 | 4.4 |
| 4. I am glad that I participated in TIPTCC. | 29 (74.4) | 10 (25.6) | 0 | 0 | 0 | 4.7 |
| 5. I enjoyed working with students from other colleges at TIPTCC. | 33 (84.6) | 6 (15.4) | 0 | 0 | 0 | 4.8 |
| 6. The format of TIPTCC was good. | 12 (30.8) | 12 (30.8) | 9 (23.1) | 3 (7.7) | 3 (7.7) | 3.7 |
| 7. I learned something new at TIPTCC. | 39 (100) | 0 | 0 | 0 | 0 | 5.0 |
| 8. I am looking forward to working together with colleagues from other professions in my rotations. | 33 (84.6) | 3 (7.7) | 3 (7.7) | 0 | 0 | 4.7 |
| 9. I heard a lot about interprofessional education before TIPTCC. | 0 | 0 | 12 (30.8) | 12 (30.8) | 15 (38.5) | 1.9 |
| 10. Interprofessional education is useful. | 33 (84.6) | 6 (15.4) | 0 | 0 | 0 | 4.8 |
11. Interprofessional education is necessary.
| 33 (84.6)
| 6 (15.4)
| 0
| 0
| 0
| 4.8
|
×
Approximately two-thirds of students (24 [62%]) strongly agreed (12 [31%]) or agreed (12 [31%]) with the statement that the format of the TIPTCC was good. All 39 students strongly agreed that they had learned something new during the event. The answers to items 9, 10, and 11 showed that the participants had previously been mostly unfamiliar with the concept of IPE and that the TIPTCC event helped them to realize the importance of it (
Table 1).
Twenty-four of the 39 participants (62%) responded to the 6-month follow-up Web survey. Responses to this survey are shown in
Table 2. When asked whether the TIPTCC experience helped them to better communicate and interact with healthcare providers from other professions during their clinical rotations, 9 of the 24 respondents (38%) answered in the affirmative. One of these students added the comment, “[I] Gained a working knowledge of the types of questions that the PharmDs and Physician Assistant's [sic] were really on top of.” Eleven respondents (46%) answered “possibly” to this question, with 1 student commenting, “It [the TIPTCC] showed me that we actually know, understand, and can talk about the same things even though we are learning it through different disciplines.”
Table 2.
Results of Survey of Participants 6 Months After Touro Interprofessional Teams Clinical Competition* (N=24)†
Survey Item and Response Choices
|
Responses, No. (%)‡
|
|---|
| 1. Do you agree with the following statement? “The experience of TIPTCC helped me in my rotations to interact and communicate better with health workers from other professions.“ | |
| □ I strongly agree | 3 (12.5) |
| □ I agree | 6 (25.0) |
| □ Possibly | 11 (45.8) |
| □ Not at all | 2 (8.3) |
| □ I don't know | 2 (8.3) |
| 2. Were all the members of your interdisciplinary group active and engaged during TIPTCC? | |
| □ All group members were actively participating | 22 (91.7) |
| □ Only two members were active | 1 (4.2) |
| □ Only one member was active | 0 |
| □ Some members were “tuning out“ from time to time | 1 (4.2) |
| □ I don't remember | 0 |
| 3. Typically, how did your interprofessional group decide which answer to “click“ for the slides in TIPTCC? | |
| □ A group leader decided | 0 |
| □ By majority vote | 3 (12.5) |
| □ By accepting the opinion of an “expert“ (ie, the pharmacy, COM, or PA student) knowledgeable about the problem at hand | 9 (37.5) |
| □ By discussion until consensus was reached | 12 (50.0) |
□ I don't remember
| 0
|
Table 2.
Results of Survey of Participants 6 Months After Touro Interprofessional Teams Clinical Competition* (N=24)†
Survey Item and Response Choices
|
Responses, No. (%)‡
|
|---|
| 1. Do you agree with the following statement? “The experience of TIPTCC helped me in my rotations to interact and communicate better with health workers from other professions.“ | |
| □ I strongly agree | 3 (12.5) |
| □ I agree | 6 (25.0) |
| □ Possibly | 11 (45.8) |
| □ Not at all | 2 (8.3) |
| □ I don't know | 2 (8.3) |
| 2. Were all the members of your interdisciplinary group active and engaged during TIPTCC? | |
| □ All group members were actively participating | 22 (91.7) |
| □ Only two members were active | 1 (4.2) |
| □ Only one member was active | 0 |
| □ Some members were “tuning out“ from time to time | 1 (4.2) |
| □ I don't remember | 0 |
| 3. Typically, how did your interprofessional group decide which answer to “click“ for the slides in TIPTCC? | |
| □ A group leader decided | 0 |
| □ By majority vote | 3 (12.5) |
| □ By accepting the opinion of an “expert“ (ie, the pharmacy, COM, or PA student) knowledgeable about the problem at hand | 9 (37.5) |
| □ By discussion until consensus was reached | 12 (50.0) |
□ I don't remember
| 0
|
×
Twenty-two of the 24 survey respondents (92%) indicated that all team members were active and engaged during the TIPTCC. When asked about the method(s) of decision-making, 12 respondents (50%) replied that their team discussed the problems until consensus was reached. According to 9 respondents (38%), the opinion of an “expert” student was adopted. One student answered the question by commenting, “Usually by consensus, [but] in cases where there was an expert then yes, we deferred to the expert,” indicating that alternate strategies of decision-making were used as needed by the teams. Only 3 respondents (13%) reported that team decisions were made by majority vote. No student chose the answer, “A group leader decided.”
Responses to the 2 surveys indicated that the TIPTCC achieved its goal of introducing students to a collaborative, interprofessional environment. Survey responses further revealed that the TIPTCC directed students' attention to the collective responsibilities of healthcare teams in patient management, including the recognition and prevention of medical errors.
The TIPTCC took place close to the time when the students would begin their clinical rotations, and it served as a reminder of, and preparatory exercise for, interaction with other professions at clinical sites. The enthusiasm of the participating students—with 100% either strongly agreeing or agreeing with the statement, “I am glad that I participated in TIPTCC”—suggests that the exercise was effective in engaging students in discussions with colleagues from other disciplines for the first time. Importantly, the vast majority of students (92%) reported that all members of their teams had been active and involved in the decision-making process.
We believe that the quality and level of difficulty of the cases and related management problems used in the TIPTCC were crucial factors in the favorable reaction of students to the exercise. Very easy problems would have been uninspiring for the students, jeopardizing the whole concept of competition in the TIPTCC. Conversely, overly difficult questions could have led to frustration and disengagement among the students. The quality of cases used in the TIPTCC was reflected by the fact that none of the teams was able to correctly select the medical errors on all the slides, while each team correctly selected the medical errors for several slides.
Decision-making is a crucial function of interprofessional groups. The students participating in the TIPTCC received no instructions about how their teams should select answers. The 6-month follow-up survey (
Table 2) revealed that working toward a consensus was the most common decision-making approach, reported by 50% of respondents. Close behind was the strategy of deferring to the expertise of a certain team member, reported by 38% of respondents. These results are noteworthy because more than a few problems in the exercise had been designed to require the special knowledge of either an osteopathic medical, pharmacy, or physician assistant student. For example, correctly selecting the medical error in the problem represented by
Figure 2 likely required the knowledge of the team's COM student about high-velocity, low-amplitude treatment. Relatively few students (13%) reported that decisions were made by majority vote, and none reported having a group leader who made the decisions.
Thus, the teams apparently performed their tasks in a mature and collegial manner. Moreover, a modicum of long-term value of the TIPTCC exercise was indicated by the follow-up survey results showing that more than one-third (38%) of respondents deemed the experience useful in their rotations with regard to “real-life” interactions with healthcare workers from other professions.
The TIPTCC has proved to be a powerful catalyst for the development of IPE at Touro University California. Shortly after the event, a campus-wide steering committee was established to develop IPE courses (including a pilot course on patient safety) and other events (such as presentations from invited speakers). In addition, students have formed a club committed to the promotion of collaborative healthcare and have organized an interprofessional student-run free clinic (supervised by licensed faculty) that serves the local community. Osteopathic manipulative medicine, provided by COM students under DO supervision, is the most popular service offered at this clinic. Non-COM students readily refer patients to the clinic for OMM.
We plan to make the TIPTCC an annual event at Touro University California. Among the goals for the next TIPTCC are boosting student participation and designing a more extensive postevent survey.
Exercises such as the TIPTCC are promising as a means of stimulating interest in IPE. However, such activities cannot be a substitute for a systematic and didactic approach to IPE. Nevertheless, it is hardly a coincidence that planning and development of campus-wide IPE at Touro University California commenced soon after the first TIPTCC.
The TIPTCC demonstrated that, given the opportunity, osteopathic medical students work willingly and constructively with pharmacy and physician assistant students. This exercise helped the students to realize the importance and necessity of interdisciplinary collaboration. The TIPTCC approach can be used as an effective introduction to interdisciplinary education in the respective curricula of various health professions. The experience at Touro University California indicates that this approach may also jumpstart the development of systematic interprofessional education at universities.
Financial Disclosures: None reported.
We thank Janet M. Burns, DO; Greg Strebel, DO; Gregory Troll, MD; and Keith Yoshizuka, PharmD, MBA, JD, for their valuable contributions as members of the expert panel at the March 2010 TIPTCC.
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