Paul B. Batalden, MD, Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA

This piece by Dr. Paul Batalden is a concise description of what has been learned by educators in the health professions about weaknesses in the curricula and settings for the improvement of care and offers a formula for change.

Health care could be better than it is — everywhere.  If that is to become so, many reports, commissions and knowledgeable experts have pointed to the need for differently prepared health professionals.  Each profession has begun to respond and to integrate these ideas into its own “mainstream” of work.  Taking action for change and improvement in these educational settings is slow and costly.  Resources and methods to support, foster changes are limited.  Creativity and pride in professional work is great.  Students are bright and willing to learn.  How best to proceed?

Background Assessment

1. The living system of professional formation — where the professional identity is taking shape — adapts to stimuli more than follows directions for change.  Learning by the smart people who are faculty and leaders works best from curiosity and invitation rather than from intention and control.  Examples provoke local responses.  Enabling the personal action that newly makes sense to faculty is a key skill of formal professional educator-leaders.

2. The formal curricula are overstuffed with geometrically increasing knowledge content.  Faculty have adapted in many different ways.  Certification of a “fully prepared” professional is the “ever-green” task of evaluators who must balance what has been true and helpful in the past with what seems to be necessary for present and future work in a changing society.  New, stable courses on the improvement of health care seem to face enormous resistance before they are born.

3. Good care is increasingly recognized as work that requires a small group of interdependent people prepared in different disciplines and specialties who gather for the common purpose of limiting the burden of illness and injury for individuals who arrive one at a time, but who together form small subsets of larger populations.  These systems include patients and providers, people and technology, settings and communication across settings.  Like all systems they are in relation to other systems — larger and smaller.

4. Increasingly transparent results of the work of health care liberates new energies for change as well-meaning professionals learn that continuing to do what they are doing will not allow the better results they seek in the future.  Getting the data about the results of your own patient care performance is a new activity for most health professional educators.  Doing something systematically differently in your own clinical context to improve those results is even more unusual.  Teaching someone how to do both and to enjoy the experience requires attracting real faculty to personal change — learning and unlearning.  These smart individuals do not usually have blocks of uncommitted time.  So, finding the time to help them acquire these skills and this knowledge is dependent upon a wide variety of local factors — both opportunities and constraints.

5. The students are bright and want to learn what it takes to become masters of their chosen work.  They form emergent profession-specific identities early and continue to shape them by their learning from experience in their professional school/course of study.  Attractive role-model faculty capable of improving the quality, safety and value of patient care are simply the fundamental point of leverage.

Working Within and Across Existing Professional Disciplines

1. While theoretically possible to “blend” the learning across profession and discipline, it is most likely that students entering medical education do so with the expectation of becoming a physician and so on for nursing, pharmacy, etc.  Hence, it will be necessary to change the learning within the basic preparation of a physician to become a differently prepared physician.  Further, the content of the learning about commonly named subjects — e.g., pharmacology — must honor the unique requirements of each professional discipline within which the subject matter learning fits.

2. Part of this learning involves new subjects that it will be important for all health professionals to learn — methods, measures, skills, concepts — about the quality, safety and value of health care.  Some of that learning can and should occur simultaneously across disciplines.  Some of the learning even involves learning how to work better with persons professionally prepared in other disciplines.  Learning about collaborative health care work becomes vivid and personally real when students of differing professions are together and in relation to actual patients and communities.  This preparation for interprofessional practice can be guided by the common aim of the improvement of patient care.

3. Each professional discipline can identify its “within profession” and “across professions” learning intentions.  Collaborative efforts can occur within professions and across professions.  One profession working on “within profession” learning can learn from the work of another profession doing the same for its constituency. 

4. Educational leaders and these change ideas can be stratified in three groups.  Group 1 consists of those actively engaged in making the new learning take shape locally.  They are involved in planning and executing the intent to change.  They are adapting their “best laid plans” to the daily reality of “what works — here and now.”  Group 2 consists of those curious leaders trying to “scope out” what needs to happen and they are prepared to formulate and take action locally when the path seems sensible.  They are filled with questions about content and process.  Group 3 consists of leaders wanting to “stay current” with the new ideas and trends, in part because they think that eventually it will make sense for them to consider, take action locally.  Their questions are often more basic — about the assumptions underlying it all.  Planning collaboratives that honor the needs of each group and allow each group to benefit from their peers is challenging, but fundamental if progress is to be made.  Lumping all the groups together invites regression to the least well-developed efforts and drives the leaders out of the collaborative efforts.

5. Different professional disciplines have developed different supportive histories for these changes.  The words and frames of one professional discipline’s history have sometimes been categorized as “their way” by members of another discipline, rather than to examine the relevant truth for all health professions.  So, our use of words should be taken for what they signify — not for their loyalty to a particular profession’s vocabulary.  Each discipline will need to develop its unique connections between the work and the rationale for it within the discipline.

General Aim

To prepare health professionals — as part of their usual professional formation — to lead the continual improvement of the quality, safety and value of health care:

• to know how to identify good care from the scientific evidence
• to know the actual measured performance in the context where the health professional is learning, and the nature of the gaps — if any — between good care and actual local care, and
• to know what activities are necessary — if any — to close the gap(s).

To achieve the knowledge, skill, and behavioral objectives will require changing the learning.  To do that will require the development of faculty capable of modeling the new learning and modifying the context for learning and patient care to support these new ways.

Each of the professions doing this work will need to take action.  These actions are grounded in a set of assumptions that are shared within a particular profession, but frequently these assumptions and the words used are not shared equally across professions.  Hence, our common and similar actions invite us to work together, whereas attempts at enforcing common agreement about assumptions can divide and speciate our efforts.  Conversations to make sense of the work across and within individual professions can enable the development of a new set of assumptions, shared by all health professions as together and individually we work to unlearn what now prevents better health care and better health professional formation.