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Research

The Extent of Interprofessional Education in the Clinical Training of Integrated Health and Medicine Students: A Survey of Educational Institutions

Beth Rosenthal, MPH, MBA, PhD1, Anthony J. Lisi, DC2 Address: 1Assistant Director, Academic Consortium for Complementary and Alternative Heath Care, Chicago, IL, USA, 2Associate Professor, University of Bridgeport College of Chiropractic, Bridgeport, CT, USA. E-mail: Beth Rosenthal, MPH, MBA, PhD – brosenthal@accahc.org *Corresponding author Topics in Integrative Health Care 2015, Vol. 6(1) ID: 6.1004 Published on March 31, 2015 | Link to Document on the Web

Abstract

Today’s healthcare environment requires collaboration and cooperation among healthcare professions, whether working in a ‘virtual’ team or in an integrated clinical setting. Patients are best served when healthcare providers understand and respect each other’s professions and are able to work well together. The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) conducted a survey to assess the extent and characteristics of interprofessional education (IPE) in the clinical training of students at accredited programs, colleges and universities of the licensed integrative health and medicine disciplines (chiropractic, acupuncture and Oriental medicine, naturopathic medicine, massage therapy, direct-entry midwifery). The survey was sent to 134 clinical training administrators, and we received responses from 88 for an overall response rate of 66%. There was much variation in the reported amount of IPE and the particular disciplines engaged in IPE activities with other disciplines during clinical training. Chiropractic institutions reported the most IPE, whereas direct-entry midwifery reported the least. Across all disciplines, multidisciplinary institutions generally reported more IPE in clinical training than single discipline institutions. Further work assessing the quality of such training, and its effect on subsequent practice, may help inform future educational strategies for the integrative health and medicine disciplines.

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Introduction

Today’s healthcare environment requires collaboration and cooperation among healthcare professions, whether working in a ‘virtual’ team or in an integrated clinical setting. Interprofessional collaboration (IPC), the efforts of different professions working together to positively impact healthcare1 has been shown to improve healthcare processes and outcomes.2 Patients are best served when healthcare providers understand and respect each other’s professions, and are able to work well together.3,4 IPC is of particular relevance to the integrative health and medicine (IHM) disciplines (also known as complementary medicine, complementary and alternative medicine, or complementary and integrative medicine). Since these professions have historically functioned separately from mainstream healthcare – and separately from each other – the extent to which they now engage in IPC can have important ramifications for their future roles in team-based clinical, academic and research activities. There is evidence that the most common antecedent to interprofessional collaboration is interprofessional education (IPE),5 defined as “occasions when members (or students) of 2 or more professions learn with, from and about one another to improve collaboration in the quality of care.”1 Moreover, IPE itself has been linked to improved teamwork and enhanced quality of care.1 Although in some cases educational accreditation standards of the licensed IHM disciplines require that students know how to communicate, refer to, co-manage, and collaborate with practitioners in professions different from their own, there are not yet firm, specific requirements about how this is to be achieved.3,4 Since educational standards among the IHM disciplines have few, if any, specific requirements addressing IPC and/or IPE, it is not known how – or even if – students are being educated and trained to practice with providers from different disciplines. A baseline understanding of the current IPE status at licensed IHM educational institutions can be an important step in assessing educational quality and effectiveness with regard to IPC. The purpose of this study is to assess the extent to which students in licensed IHM disciplines are receiving clinical training from providers of disciplines other than their own.

Methods

This study was a descriptive survey of administrators at accredited academic institutions of five licensed IHM disciplines with US Department of Education recognized accrediting agencies: acupuncture and Oriental medicine (AOM), chiropractic medicine (DC), direct entry midwifery (DEM), massage therapy (MT), and naturopathic medicine (ND).3 These disciplines comprise the core membership of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

Operational definition

For the purposes of this work we focused on the person-to-person aspect of IPE, that is, we sought to identify the frequency with which students in a given discipline, during the course of their clinical training, are likely to have in-person interactions with providers from other disciplines.

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Study Population

The study population was administrators responsible for clinical training (i.e. clinic directors / deans of clinics) at the accredited IHM academic institutions. We identified the institutions through websites and other public information of the Councils of Colleges and/or Accrediting Agencies for the five fields in question. Institutions with accredited programs in more than one discipline were defined as a Multi-Disciplinary Institutions (MDI). Institutions with accredited programs in only one discipline were defined as Single-Discipline Institutions (SDI). We identified the person(s) responsible for overseeing clinical training at each of the institutions by public website information and telephone contact with institutions as necessary. At the time of study preparation in the fall of 2013, we identified a total of 161 potential subjects from the respective disciplines as follows: 58 AOM, 19 DC, 67 MT, 9 DEM, and 8 ND. Potential subjects were contacted by email and invited to participate. The survey was launched March 10, 2014. Email reminders were sent on days 7, 14 and 20 after study commencement to those who had not completed the survey.

Survey design

The survey was modeled off of prior studies assessing characteristics, experiences and educational

needs of providers in various integrated settings.6-8 Questions were developed by the investigators

through an iterative process including input from subject matter experts in the five target disciplines.

Questions assessed features of interprofessional education at each school including 1) the venues in

which the majority of clinical training is provided; 2) the various provider types involved in clinical

training at these venues; and 3) the clinical training activities in which these provider types participate.

MDI sites received a survey version with two slightly modified questions to account for the multiple

disciplines being trained. The survey was pilot tested among a convenience sample of clinician educators

who were not subsequent subjects, and found to be clear and able to be completed in 10-15 minutes.

The full text of the survey is available at

http://accahc.org/images/stories/ipe_clinical_training_survey_instrument_sdi.

The survey was administered electronically via SurveyMonkey (www.surveymonkey.com) software. Responses were collected by the online system in an anonymous, confidential, and secure method. The investigators did not know the IP address or email address of individual respondents. The data were exported into a spreadsheet (Microsoft Excel) for tabulation and analysis with descriptive statistics. All respondents provided informed consent before participating. The study was approved by the Institutional Review Board of the University of Bridgeport.

Results

We identified an initial group of 161 accredited IHM schools. When there were multiple campuses for the same school, with the same person overseeing the clinical training of students, this was collapsed into one program and only one survey was sent. This was the case for 5 AOM schools and 19 MT schools. Additionally 2 AOM and 1 MT school had previously opted out of ACCAHC surveys and were excluded. This yielded a final population of 134 participants that were invited, and we received responses from 88 for an overall response rate of 66% (Table 1). Between disciplines, the highest

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response rate was from ND (100%) and the lowest was from AOM (57%). Across all disciplines, the response rate for MDIs (100%) was greater than that of SDIs (59%).

Table 1: Population and response rate.

Discipline Accredited schools

Opted out

Total invited

Overall response rate

Response rate of SDI

Response rate of MDI

AOM 58 2 51* 57% (29/51) 50% (22/44) 100% (7/7)

DC 19 0 19 89% (17/19) 83% (10/12) 100% (7/7)

MT 67 1 47* 60% (28/47) 56% (24/43) 100% (4/4)

DEM 9 0 9 67% (6/9) 63% (5/8) 100% (1/1)

ND 8 0 8 100% (8/8) 100% (4/4) 100% (4/4)

Total 161 3 134 66% (88/134) 59% (65/111) 100% (23/23)

*Multiple campuses for the same school were collapsed

Across all disciplines, the most common reported clinical training venue was a clinic owned and operated by the school, located on the school’s campus. This was the case for 82% of the SDIs and 55% of the MDIs. The second most common clinical training setting at SDIs was again a clinic owned and operated by the school, located on the school’s campus (28%), followed closely by partnerships with one or more hospitals/medical centers (25%). For MDIs, the second most common clinical training setting was a clinic owned and operated by their school, located off site from the school’s campus (42%). Among SDIs 72.9% of respondents reported that their institution did not operate under any policies that required IPE in clinical training, whereas 18.6% reported that theirs did. Among MDIs 77.3% of respondents reported that their institution did not operate under any policies that required IPE in clinical training, whereas 22.7% reported that theirs did. For each of the five IHM disciplines, we asked which provider types other than the school’s own discipline were involved in student clinical training. We also queried as to the roles played by these other providers. For each discipline we report 4 categories of responses regarding other disciplines’ engagement: not involved in clinical training; involved in communication, student observation, and other activities; involved in shared case management decision making; or directly overseeing students in delivering care. The results are shown in Tables 2 through Tables 6. We created a rating scheme to compare the frequency of IPE-related activities reported between each discipline. We defined low as 0-24% reported involvement of the given other discipline; moderate as 25-74% involvement; and high as 75-100% involvement. To facilitate comparison, we then graphically depicted these ratings on a chart as shaded boxes (Figure 1). In situations where results were inconsistent between the first and second most common clinical settings the respective boxes are split.

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Figure 1: Rating of reported frequency of interaction among different disciplines

Table 2: Roles of other disciplines in the clinical training of students in AOM programs

Single Discipline, Most Common Setting (n= 18) Multi-Discipline, Most Common Setting (n= 6)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

CHIRO 100% 0% 0% 0% 0% 33% 33% 33%

NATURO 75% 25% 0% 0% 13% 38% 25% 25%

MT 47% 33% 0% 20% 50% 50% 0% 0%

MIDWIF 100% 0% 0% 0% 100% 0% 0% 0%

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E

OTHER CAM

82% 18% 0% 0% 100% 0% 0% 0%

MD/DO 67% 33% 0% 0% 50% 50% 0% 0%

NURSES 100% 0% 0% 0% 50% 50% 0% 0%

ALLIED HEALTH

90% 10% 0% 0% 67% 0% 0% 33%

Single Discipline, 2nd most common setting (n= 16) Multi-Discipline, 2nd most common setting (n= 6)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

CHIRO 78% 11% 11% 0% 0% 40% 40% 20%

NATURO 54% 23% 15% 8% 14% 43% 29% 14%

MT 45% 36% 9% 9% 100% 0% 0% 0%

MIDWIFE 100% 0% 0% 0%

100% 0% 0% 0%

OTHER CAM 89% 0% 11% 0%

33% 33% 33% 0%

MD/DO 55% 27% 18% 0% 0% 100% 0% 0%

NURSES 78% 11% 11% 0% 0% 100% 0% 0%

ALLIED HEALTH 70% 20% 10% 0%

0% 75% 25% 0%

Table 3: Roles of other disciplines in the clinical training of students in DC programs

Single Discipline, Most Common Setting (n= 10)

Multi-Discipline, Most Common Setting (n= 7)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

43% 29% 14% 14% 11% 56% 22% 11%

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NATURO 63% 25% 13% 0% 43% 29% 29% 0%

MT 100% 0% 0% 0% 17% 33% 33% 17%

MIDWIFE

70% 20% 10% 0% 100% 0% 0% 0%

OTHER CAM

67% 22% 11% 0% 60% 20% 0% 20%

MD/DO 60% 30% 10% 0% 20% 50% 30% 0%

NURSES 67% 22% 11% 0% 25% 25% 50% 0%

ALLIED HEALTH

36% 45% 18% 0% 50% 25% 25% 0%

Single Discipline, 2nd most common setting (n= 10)

Multi-Discipline, 2nd most common setting (n= 7)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

56% 22% 11% 11% 25% 38% 13% 25%

NATURO 100% 0% 0% 0% 50% 50% 0% 0%

MT 75% 25% 0% 0% 40% 40% 0% 20%

MIDWIFE

100% 0% 0% 0% 100% 0% 0% 0%

OTHER CAM

100% 0% 0% 0% 75% 0% 0% 25%

MD/DO 44% 33% 11% 11% 0% 70% 20% 10%

NURSES 44% 33% 11% 11% 33% 33% 33% 0%

ALLIED HEALTH

13% 63% 25% 0% 67% 33% 0% 0%

Table 4: Roles of other disciplines in the clinical training of students in ND programs

Single Discipline, Most Common Setting (n= 4)

Multi-Discipline, Most Common Setting (n= 4)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation,

Shared case management decision

Directly oversee students

Not involved

Communication, student observation,

Shared case management decision

Directly oversee students

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and other making in delivering care

and other making in delivering care

ACUPUNC

50% 25% 0% 25% 25% 0% 25% 50%

CHIRO 50% 0% 0% 50% 0% 33% 0% 67%

MT 100% 0% 0% 0% 100% 0% 0% 0%

MIDWIFE

100% 0% 0% 0% 100% 0% 0% 0%

OTHER CAM

75% 0% 0% 25% 33% 0% 0% 67%

MD/DO 50% 50% 0% 0% 0% 50% 0% 50%

NURSES 100% 0% 0% 0% 100% 0% 0% 0%

ALLIED HEALTH

50% 25% 0% 25% 33% 0% 0% 67%

Single Discipline, 2nd most common setting (n= 4)

Multi-Discipline, 2nd most common setting (n= 4)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

75% 0% 0% 25% 0% 0% 0% 100%

CHIRO 75% 0% 0% 25% 33% 0% 33% 33%

MT 100% 0% 0% 0% 100% 0% 0% 0%

MIDWIFE

100% 0% 0% 0% 100% 0% 0% 0%

OTHER CAM

75% 25% 0% 0% 100% 0% 0% 0%

MD/DO 75% 25% 0% 0% 0% 67% 0% 33%

NURSES 75% 25% 0% 0% 67% 33% 0% 0%

ALLIED HEALTH

75% 25% 0% 0% 100% 0% 0% 0%

Table 5: Roles of other disciplines in the clinical training of students in MT programs

Single Discipline, Most Common Setting (n= Multi-Discipline, Most Common Setting (n= 4)

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20)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

80% 7% 7% 7%

50% 33% 0% 17%

CHIRO 79% 7% 14% 0% 9% 45% 27% 18%

NATURO 92% 0% 8% 0% 25% 25% 25% 25%

MIDWIFE

100% 0% 0% 0%

100% 0% 0% 0%

OTHER CAM

79% 14% 7% 0%

50% 25% 0% 25%

MD/DO 87% 7% 7% 0% 100% 0% 0% 0%

NURSES 87% 0% 13% 0% 100% 0% 0% 0%

ALLIED HEALTH

79% 7% 14% 0% 25% 50% 25% 0%

Single Discipline, 2nd most common setting (n= 15)

Multi-Discipline, 2nd most common setting (n= 4)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

80% 20% 0% 0% 100% 0% 0% 0%

CHIRO 80% 20% 0% 0% 20% 60% 0% 20%

NATURO 89% 11% 0% 0% 50% 50% 0% 0%

MIDWIFE

100% 0% 0% 0% 100% 0% 0% 0%

OTHER CAM

89% 11% 0% 0% 100% 0% 0% 0%

MD/DO 64% 36% 0% 0% 33% 67% 0% 0%

NURSES 55% 36% 0% 9% 50% 50% 0% 0%

ALLIED 56% 33% 0% 11% 50% 50% 0% 0%

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HEALTH

Table 6: Roles of other disciplines in the clinical training of students in DEM programs

Single Discipline, Most Common Setting (n= 4)

Multi-Discipline, Most Common Setting (n= 1)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

100% 0% 0% 0% 100% 0% 0% 0%

CHIRO 100% 0% 0% 0% 100% 0% 0% 0%

NATURO 17% 33% 17% 33% 0% 0% 0% 100%

MT 100% 0% 0% 0% 100% 0% 0% 0%

OTHER CAM

100% 0% 0% 0% 100% 0% 0% 0%

MD/DO 100% 0% 0% 0% 0% 100% 0% 0%

NURSES 0% 50% 0% 50% 0% 0% 100% 0%

ALLIED HEALTH

100% 0% 0% 0% 100% 0% 0% 0%

Single Discipline, 2nd most common setting (n= 4)

Multi-Discipline, 2nd most common setting (n= 0)

Role in student clinical training Role in student clinical training

Other Discipline

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

Not involved

Communication, student observation, and other

Shared case management decision making

Directly oversee students in delivering care

ACUPUNC

100% 0% 0% 0% NA NA NA NA

CHIRO 100% 0% 0% 0% NA NA NA NA

NATURO 100% 0% 0% 0% NA NA NA NA

MT 100% 0% 0% 0% NA NA NA NA

OTHER CAM

100% 0% 0% 0% NA NA NA NA

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MD/DO 67% 33% 0% 0% NA NA NA NA

NURSES 67% 33% 0% 0% NA NA NA NA

ALLIED HEALTH

100% 0% 0% 0% NA NA NA NA

Discussion

This work presents an overview of the current status of IPE in the clinical training of IHM students in the US. Previous work assessing aspects of IPE in a sample of Canadian CAM schools found varying degrees of instructional time devoted to interprofessional collaboration.9 Our work adds to the literature by describing IPE at US IHM institutions, and by focusing on in-person interprofessional clinical training activities. Across and within each of the five disciplines, schools reported a varying range of IPE frequency from low to high. Across and within each discipline, the MDIs were more likely to report high frequency IPE than the SDIs. This finding suggests that inter-institutional collaboration may be important for single discipline schools in preparing students for collaborative practice in integrated settings. The AOM and DC disciplines had the most respondents reporting high IPE, and DC had the fewest respondents reporting low IPE. DEM was the discipline with the greatest instances of low IPE, and the fewest instances of high IPE. Overall, DC institutions reported the highest exposure to both other IHM disciplines and to conventional medical providers. AOM and ND institutions were similar to each other and both slightly higher than MT with respect to conventional and other IHM providers. DEM generally reported the least exposure to any other discipline. IPE is an underpinning for IPC and in itself may lead to improved clinical outcomes.1 In the education of healthcare professionals, the clinical training period is a formative time that influences future clinical practice.10,11Since clinical training typically entails mentorship and other one-on-one involvement between trainees and clinicians, the resultant collaboration and socialization exert influence on future provider behavior.12,13 Therefore, the scope of IPE occurring in clinical training at IHM institutions may have an impact on the future IPC capacity of graduates from those institutions. The results of this work provide an initial picture of the current IPE environment at licensed IHM academic institutions. Further research is needed to assess more detail of this IPE, including elements such as frequency and duration of IPE activities, effect on patient care, and student perception of quality.

Limitations

As with all surveys, this work is subject to respondent recall and reporting error. We asked respondents to report on the most common and second most common clinical training sites, therefore our results likely reflect the IPE that the majority of the student body at each school experiences, however we did not attempt to gather information on the number of students being exposed to any reported IPE at each

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school. It is possible that other clinical training sites deliver more IPE, however these would likely be available to smaller proportions of students. It was beyond the scope of this work to discriminate between IPE exposures to single-trained providers vs. dual-trained providers. Lastly, we did not attempt measure the duration or quality of any reported IPE, nor of the effect of any reported IPE on graduates’ practice patterns.

Conclusion

This work describes variation in the reported extent of IPE occurring in the clinical training of the 5 licensed IHM disciplines. DC institutions reported the most IPE, whereas DEM reported the least. Across all disciplines MDIs generally reported more IPE than SDIs. Further work assessing the quality of such training, and its effect on subsequent practice, may help inform future educational strategies for the IHM disciplines.

Acknowledgments

This study was supported by a grant from the Leo S. Guthman Fund.

Legend

ACCAHC -- Academic Consortium for Complementary and Alternative Health Care AOM -- acupuncture and Oriental medicine DC – Doctor of Chiropractic DEM -- direct entry midwifery IHM -- integrative health and medicine IPC -- interprofessional collaboration IPE -- interprofessional education MDI – Multi-Disciplinary Institutions: Institutions with accredited programs in more than one discipline MT -- massage therapy ND -- Naturopathic Doctor SDI -- Single-Discipline Institutions: Institutions with accredited programs in only one discipline

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