Introduction

Interprofessional education (IPE), as defined by the World Health Organization, is a process that “occurs when students from two or more professions learn about, from and with each other” [1]. It is assumed that a robust IPE in the training of health care provider learners will lead to enhanced interprofessional practice (IPC) and result in improved patient outcomes. Interprofessional education is required in essentially all health care curriculum [2]. The Liaison Committee on Medical Education (LCME) includes IPE in standard 7.9 [3]. This standard requires “the faculty of a medical school ensure that the core curriculum of the medical education program prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from the other health professions.” In addition, the Association of American Medical Colleges (AAMC) devotes one of 13 Core Entrustables to interprofessional teamwork in EPA 9: “Collaborate as a member of an interprofessional team” [4].

Although a required component, many health profession schools, including medicine, struggle to develop and implement curricula that provide robust and meaningful interprofessional learning experiences. Such factors as limited resources (time, financial, and human), logistics, rigid curriculum, and competing interests have been identified as barriers to implementing IPE [5]. In particular, we note that there is limited IPE in the clinical setting. We conducted a thorough electronic search of databases in PubMed, Google Scholar, and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and found no other mandatory fourth year IPE clerkship experiences in US medical schools. Although there are simulations in IPE and elective clinical experiences in IPE, to our knowledge, TCMC is the only medical school to require a fourth year IPE clerkship.

The mission of TCMC is to “educate aspiring physicians and scientists to serve society using a community-based, patient-centered, interprofessional, and evidence-based model of education that is committed to inclusion, promotes discovery, and utilizes innovative techniques” (emphasis added). TCMC is a private, free standing, medical school not affiliated with any major medical teaching center, which provides unique challenges and opportunities for IPE. TCMC has developed a number of different approaches to IPE in all levels of its curriculum by partnering with other colleges and universities in our 17 county regions [6].

Interprofessional education can and should be included in didactic, clinical laboratory, and simulation scenarios; however, we believe IPE is the most authentically experienced in the clinical (experiential) setting when learners interact with other health professionals (learners and practitioners) while caring for real patients. Ensuring that all learners get a robust and bonafide interprofessional experience is difficult to achieve and evaluate. The complex nature of medical schools’ organizational structure and curriculum in addition to a convoluted and fragmented health care system (at least in our area), pose significant obstacles to implementing IPE in the clinical setting. As such, we have developed and report on our successes using a novel approach to IPE—a fourth year required clerkship in an interprofessional environment.

Methods

TCMC developed and approved a 2-week selective clerkship in interprofessional practice (MD 915) during the 2012–2013 academic year. Students were first required to complete this rotation during the 2013–2014 academic year. The course was conceptualized and developed by a pharmacy faculty member (EF) while on sabbatical at TCMC with input from faculty at TCMC and other health professionals. During the first year of the course, MD 915 was co-coordinated by the pharmacy faculty and a TCMC medicine faculty member (KA). An Experts in education evaluation provided expertise in the assessment of the course (ES).

There are five course outcomes, the first four of which were based on the IPEC core competencies [7] (roles/responsibilities, teamwork, interprofessional communication, ethics/values), and a fifth, “Demonstrate professional integrity with awareness of and commitment to the principles and responsibilities of the health professions and a profound respect and unconditional regard for human dignity” was included to meet other curricular requirements. The IPE course is required but is “selective” in that it was developed so it could occur in a number of different settings allowing students to foster individual interests in medicine.

The course requires a number of activities and assignments. These requirements were developed such that they would allow the learner to achieve the stated outcomes. Additional responsibilities could be assigned or substituted by the preceptor as outlined in a syllabus addendum provided by the site. Assignments were reviewed by the preceptors but this feedback was not controlled our superficially measured by us. Course activities and assignments are presented in Table 1.

Table 1 Course activities and assignments
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Sites were identified by the course coordinators and were considered appropriate if they delivered care in a highly functional, interprofessional environment. One of the course coordinators visited the site to determine the overall appropriateness of the site and to provide training and guidance. A 1 h continuing education (CE) program was developed and delivered to the staff at each of the sites. The CE program “Precepting an Interprofessional Clerkship” provided an overview of IPE, course content and reviewed precepting and assessment skills. The program was accredited for physician and nursing.

The clerkship is graded on a Pass (P), or Fail (F) basis. The learner must have satisfactorily completed all activities and assignments to earn a passing grade.

At the end of each clerkship, learners were given a paper survey to provide feedback on the course. In addition to demographics (ethnicity, gender, site), learners were asked to identify which health professionals (professional or learner) they had “at least one meaningful interaction with” during the experience. Meaningful interaction was defined as one which “implies that you have learned from, about and/or with one of these individuals.” In addition, learners estimated the percentage of time they spent working with non-physicians. A series of Likert-based questions were used to assess learner perception of the site and course. Site questions were related to staff, organization, and preceptor effectiveness. These questions were site-specific and were used mostly for quality assurance and feedback to sites/preceptors and so are not presented here. The questions relating to overall course effectiveness and the activities are included in Table 2.

Table 2 Medical student perception of interprofessional clerkship (presented as % of respondents answering each question)
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We analyzed the quantitative data using standard descriptive statistics. We analyzed learner final reflections (assignment #4) qualitatively utilizing utilized NVivo 10 (QSR International, Doncaster, Victoria) to assist in data management and coding.

The research component of this report was reviewed and approved by the Institutional Review Board of The Commonwealth Medical College.

Results

Thirteen clinical sites were identified and utilized during 2013–2014 academic year. Sites included drug and alcohol rehabilitation (two sites), psychiatry, physical medicine and rehabilitation (PM&R) (two sites), geriatrics, developmental disabilities, primary care, HIV care, and global health. Individual sites had from one to six learners in the academic year.

Sixty-four learners completed the IPE rotation, and 51 surveys were completed (response rate 80 %). On average, learners had meaningful interactions with seven different health care professions and 42 (82 %) medical learners estimated that they spent more than 60 % of their time with non-physician health professionals. The most commonly engaged health professionals were registered nurses (88 % of respondents), social workers (86 % of respondents), nursing assistants (47 % of respondents), and nurse practitioners (43 % of respondents). The vast majority (80 %) of interactions were with professionals as opposed to other learners.

Overall course evaluations were positive (Table 2). For example, 86 % of the medical learners agreed or strongly agreed that the course was effective in enhancing understanding of interprofessional practice, and 94 % of the respondents would recommend their site to learner colleagues. As compared to the overall course and activities, it appeared learners were somewhat less enthused about the assignments. Quantitative data highlight the course’s effectiveness in meeting intended outcomes; 94 % agreed or strongly agreed that the experience created greater understanding about roles and responsibilities; 92 % reported its value in extending their understanding of teamwork; and 90 % felt they had learned about interprofessional communication.

High frequency themes, their incidence, and exemplar quotes can be found in Table 3. The qualitative data also illustrates the emphasis students placed on meaningful experiences. These data show that students found specific aspects of interactions with other health professional particularly meaningful, including new learning about patient care, a new-found appreciation of other health professionals, and the importance of interactions to student understanding of medical practice. Thus, the qualitative data highlight participants’ experiences related to an understanding of roles, appreciation for interprofessional teamwork, and communication between team members. Finally, the qualitative data extend our understanding of student learning to metacognition about their own practice.

Table 3 Final reflection: qualitative analysis high frequency themes and exemplar
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Discussion

There have already been some minor modifications to the course after the first year. Because our class size has increased, we expanded the number and geographic distributions of sites. In addition, we made changes to the assignments. Learner feedback was not particularly positive for the interview assignment. Many learners felt the assignment was remedial and that they should be able to learn about other professions more organically through the daily activities of the rotation and so it was not required for 2014–2015. Assignment #3 (clinical question/answer and presentation) was made recommended (not required) since it did not directly contribute to any course outcome.

We learned a great deal from this experience. We believe an IPE selective rotation is best suited as a fourth year rotation since it provides an opportunity for the learners to build on all areas of the curriculum (didactic and experiential) prior to graduation. In fact, most of our learners completed the rotation in the spring of the MD4 year. Learner feedback suggested that the IPE clerkship “pulls it all together” for them prior to graduation, potentially fulfilling the Core Entrustable Activity requirement. It is critically important to have strong relationships with sites. Most of our preceptors for this clerkship were non-physicians and all of them were volunteers. The coordinators of the course visited each site to make personal and professional connections with preceptors at the various sites and we believe this contributed to the success of the program. This very personalized attention may be difficult (but not impossible) to implement in larger and more complex medical schools. In all cases, we were met with a great deal of enthusiasm regarding the potential for both the clerkship and the medical learners. Although the clerkship is required, learners are able to choose their particular site (limited somewhat by availability and schedule) thereby allowing learners to take experiences in areas that they have an interest or seek additional training. Certain areas of health care lend themselves more readily to IPE experiences than others, including addiction, PM&R, and hospice. While hospitals would provide a meaningful clerkship site, it has proven difficult to place students in area hospitals for the purpose of this course.

There are some limitations to our study. While an 80 % response rate is reasonable, we hoped for a higher response rate. The paper survey was intended to be distributed on the last day of the rotation, some preceptors failed to provide the survey, thereby decreasing our participation rate. As with all survey research, it is possible that non-responders would have answered differently. This study reports perceptions of participants in the IPE rotation; further research is needed to make clearer links between experience and measurable outcomes. Feedback from sites has been positive, but we have not collected the data in a manner such to quantitate it.

Our next steps will be challenging. As noted above, most of our sites are in the outpatient setting—we hope to add some acute-care IPE elective rotations. We need to develop an effective and efficient method to document more meaningful clinical outcomes in learners and patients. With that said, we do not want to devalue the perception-data that we have collected. We believe that how learners feel about interprofessional practice is really important. Most of the interprofessional interactions were with professionals, as opposed to other learners so a long range goal is to schedule teams of IPE learners (medicine, pharmacy, nursing, and others) on rotation. Unfortunately, we currently do not have the resources to coordinate such a complicated undertaking.

Conclusion

This study demonstrates a required selective fourth year clerkship in interprofessional practice has significant potential for promoting interprofessional team-based care. Through quantitative and qualitative analysis, learners perceived that the course met its intended outcomes. Further study is required to investigate how and if our approach correlates to changes in behavior of future physicians and, most importantly, the care of patients. We believe that this novel approach to interprofessional education can be adopted successfully at any school of medicine.