Robert L. Jesse, MD PhD, is a strong proponent of interprofessional clinical and research collaboration and leads the VA Office of Academic Affiliations, the Nation’s largest provider of graduate medical education and a major contributor to health professions education and research. “Health care is a team sport,” said Dr. Jesse. “It is very important that multidisciplinary learners train together so that they can effectively work together to provide the highest quality care to all patients and their families.”

Approved in early 2002, the VA Interprofessional Fellowship Program is located at six sites across the country, with Palo Alto serving as the hub site.

“We currently have about 40 fellows nationwide: trainees in psychology, chaplaincy, nursing, and pharmacy who train side by side with medicine fellows,” said Dr. Periyakoil. “The intent of the program is to ensure that people don’t train in silos. Fellows or trainees learn to train together and have interprofessional, respectful dialogue so that later on [in their careers], it makes working together much easier. Moreover, the best way to provide quality patient care is to have multiple experts from various disciplines working together.”

Program Features
“Our faculty members—doctors, nurses, psychologists, social workers, and chaplains—meet on a regular basis to talk about what they need for all of our fellows. We are very deliberate in creating the training curriculum for this competency-based program. Together, our fellows and faculty meet for educational didactics and in-depth discussion.

“We also meet daily to discuss all the patients on service, with the physician fellow providing medical diagnoses and the psychology fellow assessing grief and depression and how it affects health. The social worker may point out the patient is homeless, and the chaplaincy fellow may assess how a patient feels about his or her faith. When you get multidisciplinary perspectives of patients, suddenly things come to life. [A picture emerges of] this full, living, breathing patient as a person who is a member of a family and of society.

“In addition to learning and working together, the IPE fellows conduct joint projects. For example, every Winter Quarterly, our IPE fellows collaboratively teach the Stanford undergraduates about the multiple facets of palliative care. We learn from our fellows, and the fellows learn from a multidisciplinary faculty. It becomes a gold standard of how we can practice much more collaboratively in the future.”

Challenges
“First, we know very little about how to train together. As a physician, if I’m left alone with several social work trainees, I have no idea how to train them other than with medical aspects. This area is really ripe for discovery and new innovation.

“Second, there is no dedicated funding to look at how to best train various disciplines together. We know how to provide interdisciplinary care, but we haven’t systematically studied how to teach interprofessional trainees concurrently without catering to the least common denominator.

“For example, we do a didactic on bereavement support, which is a topic that physicians know very little about. During the session, the social work fellows may be bored because they know it too well. How do you teach didactics and structure the curriculum in a way that we’re teaching to the highest, aspirational level for trainees of all disciplines? Likewise, to what extent do I need to teach psychologists, social workers, and chaplaincy fellows about opioids and pain management? Does it matter? If it becomes too deeply medical, it’s not really relevant, and if it is too superficial, a lot can get missed in terms of how to improve patient care.

“A gold standard is when all IPE fellows are taught at a level that is challenging to all of them in every single session. Once we figure out how to do that, the next step is to conduct research together so that we can advance quality of care.”

Beyond Palliative Care
“We practice palliative care within teams and groups; that’s not optional. How do we [share] that with other fields, such as cardiology and gastroenterology, where patients face similar challenges with fragmented care? If we systemically study what we are doing and talk in a standardized manner, other subspecialties will be eager to adopt and learn from palliative care. We have an opportunity to lead other medical subspecialties.

“Beyond that, we have a collective responsibility to mentor trainees in other disciplines. Just as team members in psychology, chaplaincy, social worker, occupational therapy, massage therapy, and music therapy are obligated to mentor the young physician trainee, an MD must support and mentor those trainees as well. By training fellows from all disciplines who practice palliative care, we can grow and innovate, and conduct research together.”

Future Plans
“There’s been a lot of interest recently within the VA to figure out what we need to do next. To me, the next natural step is for trainees to conduct research together. Right now this is a clinical fellowship, but interdisciplinary cross-pollination will open up opportunities for fascinating research in areas such as grief and depression and existential angst and pain.

“Beyond research, it’s important for the sake of all patients and families that we commit to a lifelong practice of working together.”

by Jane Martinsons, AAHPM senior writer