Interprofessional Education in Patient Centered Medical
Homes Implications from Complex Adaptive Systems Theory
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C. Scott Smith, MD Winslow G. Gerrish, PhD
Professor of Medicine Clinical Assistant Professor
Adjunct Professor of Behavioral Informatics Psychiatry and Behavioral Sciences
and Medical Education/Evaluation University of Washington
Division Seattle, WA, USA
University of Washington
Director of Behavioral Sciences,
Seattle, WA, USA
Research and Grants
Physician Consultant Family Medicine Residency of Idaho
Centers of Excellence in Primary Care Boise, ID, USA
Education
VA Office of Academic Affiliations
Boise, ID, USA
William G. Weppner, MD, MPH
Assistant Professor of Medicine
University of Washington
Seattle, WA, USA
Associate Director, Clinical Outcomes
Center of Excellence in Primary Care
Education
Boise VA Medical Center
Boise, ID, USA
ISBN 978-3-319-20157-3 ISBN 978-3-319-20158-0 (eBook)
DOI 10.1007/978-3-319-20158-0
Library of Congress Control Number: 2015944538
Springer Cham Heidelberg New York Dordrecht London
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Foreword
Healthcare is undergoing a radical transformation and it is a difficult time to be
managing or working in the outpatient clinic. The Affordable Care Act will alter the
management of chronic disease and prevention in unpredictable ways. Reward and
payment systems are also changing. Medicare has announced plans to significantly
link quality to payment, and private insurers are likely to follow suit. Meaningful
use criteria are prodding the electronic health record (EHR) market toward new
functionalities such as panel management, clinical quality measures, decision
support systems, and interoperability between EHRs. New care modalities, such as
telehealth and group visits, are becoming more accepted. Geographic Information
System (GIS) mapping is emerging as a public health tool. As the role of the care
team in the healthcare system changes, it can seem overwhelming to decide how to
focus our energies. The patient-centered medical home is receiving greater atten-
tion as an ambulatory care model. However, it seems to work well in some settings
and not at all in others, and it is not obvious why this is so.
Education in the health disciplines is trying to adapt. The Institute of Medicine
has endorsed interprofessional education, and many national accrediting bodies are
encouraging adoption. New campaigns such as “Choosing Wisely” and “High
Value Care,” designed to train providers to be good stewards of limited health
resources, are becoming the norm. The location of education is shifting from the
classroom to the workplace. Clinic redesign and new models of healthcare training
are inseparable, and are occurring simultaneously in many institutions. With all of
this dynamism, it can sometimes seem that we need a template, algorithm, or expert
to guide us forward. And yet, we know that each situation is unique and these sys-
tems are too intricate for one-size-fits-all solutions to work.
The authors are part of regional and national efforts to convert healthcare training
environments into interprofessional education teams in a patient-centered medical
home. We have had successes and we have struggled. Through all of this, we have
found value in broadening our perspective; moving where appropriate from a “com-
mand and control” style of optimization and best practices toward a learning orga-
nization that is flexible and adaptive. Along the way, we found complex adaptive
systems theory to have great explanatory power. It helped us to understand how to
v
vi Foreword
design new initiatives. It guided us toward better expectations of evaluation and
assessment. It focused our attention on previously ignored data patterns that are
critical for stability as a team.
This book is a beginning. It will not reveal a recipe for universal success. It may,
however, provide new insights for how to deal with uncertainty. It may help you
identify when to attempt and when to avoid control.
A book like this is not created without significant support and assistance. We
would first like to thank our wives, Cathy Sandstrom, Marisa Weppner, and Sarah
Gerrish, for their support and patience during this project. We would also like to
thank several experts who reviewed various sections for their insightful feedback
and suggestions. These include Mark Friedberg, Stuart Gilman, Chris Knight, Eric
Larson, James Ralston, and Thomas Staiger. Finally, we acknowledge the institu-
tions whose support made this project possible: the VA Centers of Excellence in
Primary Care Education, the Boise VA Medical Center, the University of Washington
Boise Internal Medicine Residency, and the Family Medicine Residency of Idaho.
C. Scott Smith, MD
Winslow G. Gerrish, PhD
William G. Weppner, MD, MPH
Contents
1 The Argument for Interprofessional Education..................................... 1
Complexity and Interprofessional Education in Healthcare ....................... 1
A Wicked Problem ...................................................................................... 2
Modes of Collaborations ............................................................................. 3
Developmental Growth Across Collaborative Modes ................................ 5
Wisdom of the Crowd ............................................................................. 6
Homogeneity of Error ............................................................................. 6
Emergence............................................................................................... 7
Putting It All Together................................................................................. 8
References ................................................................................................... 9
2 The Argument for the Patient-Centered Medical Home:
Replicating Good Primary Care .............................................................. 11
A Brief History of Primary Care ................................................................. 11
Principles of Good Primary Care ................................................................ 13
Why Primary Care Works: Evidence for Efficiency, Quality,
and Satisfaction ........................................................................................... 14
What Is the Patient-Centered Medical Home?............................................ 15
Where Are We with Primary Care?............................................................. 16
Making Sense of Mixed Evidence in the Patient-Centered
Medical Home............................................................................................. 18
Evidence from the Veterans Affairs Patient Aligned Care
Team Transformation .................................................................................. 19
Where We Need to Go: Reinforcing Primary Care
with the Patient-Centered Medical Home ................................................... 21
Identifying Attractors that Facilitate Patient-Centered Medical
Home Transformation ................................................................................. 21
References ................................................................................................... 24
3 A Brief Introduction to Systems .............................................................. 27
Identifying and Understanding Systems ..................................................... 27
Simple Systems ........................................................................................... 28
vii
viii Contents
Complicated Systems .................................................................................. 29
Complex Adaptive Systems ........................................................................ 30
Diversity.................................................................................................. 31
Connectedness......................................................................................... 31
Interdependence ...................................................................................... 32
Coadaptation ........................................................................................... 32
Self-Organized Criticality ....................................................................... 34
Structural Coupling ................................................................................. 34
Emergence............................................................................................... 36
Differences Between Types of Systems ...................................................... 36
Consequences of Mixing Systems Up ........................................................ 38
References ................................................................................................... 39
4 The Training Clinic as a System .............................................................. 41
What Does a Systems Approach Mean for the Training Clinic? ................ 41
Continuity Clinic as Nested Complex Adaptive Systems ........................... 42
The Individual-Group Interface .................................................................. 43
The Group Dynamic ................................................................................... 46
The Group-Environment Interface .............................................................. 51
References ................................................................................................... 52
5 SHED: Four Important Sub-theories That Help Us to “Bracket” ....... 53
Situated Learning Theory............................................................................ 53
Historical Theories ...................................................................................... 56
Ecological Psychology ................................................................................ 57
Dual-Processing Theory.............................................................................. 59
References ................................................................................................... 63
6 Implications for Design............................................................................. 65
Systems ....................................................................................................... 66
Designing for a Complicated System ..................................................... 66
Designing for a Complex System ........................................................... 68
Design ......................................................................................................... 70
Structural Design Considerations ........................................................... 70
Process Design Considerations ............................................................... 73
Cultural Design Considerations .............................................................. 76
Implementation Science Considerations ................................................. 80
References ................................................................................................... 80
7 Implications for Evaluation...................................................................... 83
Evaluation Philosophies .............................................................................. 83
Logical Positivism .................................................................................. 84
Constructivism ........................................................................................ 85
Realism ................................................................................................... 87
Specific Evaluation Methods ...................................................................... 88
Exploratory Methods .............................................................................. 88
Naturalistic Methods ............................................................................... 90
Contents ix
Methods for Testing Variables ................................................................ 92
Predictive Mathematical Modeling ......................................................... 94
Evaluation in Simple Systems .................................................................... 94
Evaluation in Complicated Systems ........................................................... 94
Evaluation in Complex Adaptive Systems.................................................. 95
Identifying Complex Systems ................................................................. 95
Signs of Critical State Transition ............................................................ 96
Creating an Evaluation Plan........................................................................ 97
References ................................................................................................... 98
8 Implications for Institutions..................................................................... 101
Implications of Complex Systems .............................................................. 101
Accrediting Bodies...................................................................................... 102
Structural Implications ............................................................................ 102
Process Implications ............................................................................... 103
Policy Implications ................................................................................. 104
Payers .......................................................................................................... 105
Structural Implications ............................................................................ 105
Process Implications ............................................................................... 105
Policy Implications ................................................................................. 106
Sponsors ...................................................................................................... 106
Structural Implications ............................................................................ 106
Process Implications ............................................................................... 108
Policy Implications ................................................................................. 109
Professional Schools ................................................................................... 111
Structural Implications ............................................................................ 111
Process Implications ............................................................................... 112
Policy Implications ................................................................................. 112
Institutional Review Boards and Quality Councils..................................... 113
Policy Implications ................................................................................. 113
Summary ..................................................................................................... 113
References ................................................................................................... 114
Index ................................................................................................................. 115
Chapter 1
The Argument for Interprofessional Education
As part of the Department of Veterans Affairs (VA) system-wide redesign to improve
primary care, the Boise VAMC undertook an effort to integrate psychology, medi-
cine, pharmacy, and nurse practitioner postgraduate training programs. Despite a
shared goal in supporting interprofessional education (IPE), initial efforts to focus
on curriculum development, implementation, and evaluation quickly became stalled
due to a lack of understanding, differences in academic experience, and tension
between disciplines. We found that we lacked the necessary theoretical underpin-
nings and coordinated direction for this effort. To move forward, we rededicated
ourselves to the shared goal of IPE and suspended judgment of each other. Beginning
with small projects that required minimal trust and coordination, we gradually
increased the scope and complexity of our projects with each new success and even-
tually gelled as a team.
Complexity and Interprofessional Education in Healthcare
All aspects of modern healthcare are increasing in complexity. Technological and
pharmaceutical advances, an aging population, shifts from acute to chronic care,
and new models of care delivery and payment put ever increasing demands on mul-
tiple health and social professions. Providing coordinated, comprehensive, and
effective care has never been as needed nor as difficult as it is now. While these
demands have resulted in increased needs for improved communication and col-
laboration among allied health professions, most clinicians come out of uniprofes-
sional training programs and function in operational environments that are constantly
subject to volatile market forces and rapidly adapting systems of care. Additionally,
market forces and systems of care typically exert only an indirect influence on edu-
cational programs, which therefore often fail to see the need to retool in response.
All of these forces and feedback loops among health, healthcare, and training create
© Springer International Publishing Switzerland 2015 1
C.S. Smith et al., Interprofessional Education in Patient-Centered
Medical Homes, DOI 10.1007/978-3-319-20158-0_1
2 1 The Argument for Interprofessional Education
a frustratingly complex landscape to those tasked with preparing the next generation
of healthcare workforce to function as effectively as possible in team-based inter-
professional care (Brienza et al. 2014).
Studies have demonstrated that effective interprofessional collaboration is under-
mined by “boundary infringements, a lack of understanding of others’ roles, limited
communication and poorly coordinated teamwork efforts” (Zwarenstein et al.
2009). Awareness of frustrations around this kind of experience may explain why
pursuits to include interprofessional experiences earlier in healthcare education and
training are beginning to take place in academic and teaching health centers through-
out the USA. Yet, at this point, these developments are in nascent stages. There is
significant variability in implementation and little guidance in how to address or
structure programs to optimize learning and collaboration across traditional bound-
aries (Abu-Rish et al. 2012).
In order to better link training with the evolving practice landscape, and to begin
addressing the challenges of how to think about optimal interprofessional healthcare
education (IPE), we need to identify the unique characteristics inherent in interpro-
fessional work environments that make team-based care difficult to implement con-
sistently and effectively. Understanding these challenges will help us design IPE
that yields graduates able to work together in teams seamlessly and effortlessly.
A Wicked Problem
Many aspects of modern healthcare have been conceived of as being “wicked prob-
lems.” Nowhere is this more apropos than in the question of how to train the next
generation of providers to function in modern interprofessional environments
(Westbrook et al. 2007). Wicked problems are often described as situations that
“cannot be understood in the context that gives rise to them” (p. 141). We will delve
into how coordinating and improving interprofessional training is a particularly
wicked problem, but in general, such problems are defined as having a particular set
of characteristics, as seen in Side Bar 1.1.
Side Bar 1.1 Characteristics of “Wicked Problems” (Westbrook et al. 2007)
1. Competing stakeholders.
2. Interdependent components.
3. Dynamic boundaries.
4. “Unwinnable” solutions, i.e., no globally true/false solutions, only better/
worse alternatives at any given time point.
5. No single outcome identifies an overall solution.
6. Every attempted solution impacts the system and cannot be rerun.
7. No enumerable set of operations needed to achieve an end point
8. Defies complete definition.
9. No defined end point.
Modes of Collaborations 3
Conceived in the healthcare training environment, these elements would begin
with the many institutions and individuals with vested interest in IPE (competing
stakeholders), such as training directors, faculty, medical center administrators,
national accrediting bodies, universities, insurers, trainees, patients, and staff. Each
of these representative groups is continually forming and reforming relationships as
needed to both identify and pursue goals (dynamic boundaries). Pursuit of identified
goals, such as improving patient care, lower costs, or advancing learning, forces
each involved party into interdependent collaborative networks, where efforts to
resolve one problem are likely to create or uncover entirely new sets of problems in
the system (one-time trials, “unwinnable” solutions). Additionally, it is unlikely that
any group or individual will completely agree on an overall set of goals at any given
time (no single outcome), and perceived attainment of goals would also vary (no
end point).
It has also been noted that “it is often the social complexity of wicked problems,
as much as their technical difficulties, that make them tough to manage” (Camillus
2008). One of the critical elements found in interprofessional healthcare training
environments is the unique cultural and social factors that lie outside of the mana-
gement strategies typically necessary in uniprofessional programs. Sociocultural
ideals, including but not limited to professional exceptionalism, differences in pro-
fessional and educational developmental models, varied approaches to supervision,
or attitudes toward hierarchy, add both depth and confusion to collaborative efforts.
For each professional group included in an interprofessional endeavor, layers of
complexity seem to grow exponentially. If each group’s own series of “wicked prob-
lems” is the intricate arrangement of petals making up a flower, as a bouquet, they
must be put together in such a way that a functional aesthetic can emerge from the
overall arrangement. This outcome, like the beauty of a bouquet, is ideally the clas-
sic “whole that is greater than the sum of its parts.” Yet, for IPE, these social and
cultural clashes among stakeholders pose significant barriers in attempts at colla-
boration. Additionally, perceived constraints on resources and constant changes of
physical (clinic space) and logistical (electronic health record system, reimburse-
ment structure, institutional policy) boundaries further complicate efforts to learn
collaboratively.
Modes of Collaborations
Along with the “wicked” nature of interprofessional collaboration and training, mod-
ern healthcare demands access to highly specialized areas of knowledge. Over time,
this has become compartmentalized, both in knowledge, culture, and divisions of
responsibility. Current strategies to blend expertise often entail relatively pragmatic
approaches of collocating different providers in the same physical space
or identifying them as a “team” who are encouraged to work toward shared goals. In
this context, the terms “multidisciplinary” and “interdisciplinary” are often used,
sometimes as loosely interchangeable, to describe perceived levels of integration
4 1 The Argument for Interprofessional Education
within healthcare teams and clinics. Along the same lines, a third category of collabo-
ration called “transdiciplinary” has been identified (Bruder 1994; Brown et al. 2010).
Side Bar 1.2 Modes of Collaboration
1. Multidisciplinary
(a) Knowledge is profession specific: learning about own discipline, but
not others.
(b) Behavior: provides opinions from one perspective. Each discipline
“expert” provides recommendations from their singular perspective.
2. Interdisciplinary
(a) Knowledge is profession bounded: learning about own discipline within
the context and influenced by awareness of other expert perspectives.
(b) Behavior: develops shared opinions. Each discipline affects the others,
working toward consensual goals.
3. Transdisciplinary
(a) Knowledge is professionally unbounded: an intuitive understanding of
all perspectives and an instinctive understanding of how this applies to
the group’s goals.
(b) Behavior: focus is shifted away from specific disciplines and indivi-
duals and toward successful group behaviors around heterogeneous
domains.
This denotes a mode of cross-disciplinary functioning that comes out of
environments whose constituents have themselves trained in an interdisciplinary
culture and who are therefore able to transcend traditional bounds of profession-
specific cultures of knowledge, communication, and responsibility (see Side Bar 1.2).
The distinctions between multidisciplinarity, interdisciplinarity, and transdisciplinarity
are exemplified in the following example.
Example 1.1 Children in a Sandbox
The analogy of putting children together in a sandbox is one way to better
understand modes of collaboration.
Multidisciplinary: Simple collocation may result in parallel play akin to
multidisciplinary functioning. In this, children are “experts” in their particular
sandbox tool, be it a shovel, rake, action figure, or bucket, and are engrossed
in their toy function. Thus, while one child’s road construction may get used
(continued)
Developmental Growth Across Collaborative Modes 5
Example 1.1 (continued)
for another’s action figure, there is no specific coordination between the two.
Even if children are seemingly working together toward building inter-
connected sandcastles, this kind of parallel play does little to work toward
addressing the kinds of complex “wicked” problems discussed above.
Interdisciplinary: When the children begin to understand the other chil-
dren’s tools and “expert” skills, they move into sharing knowledge and bring-
ing others in a bit more collaboratively and systematically to utilize their
unique knowledge, skills, and tools toward an identified goal, something akin
to interdisciplinary functioning on a healthcare team. Thus, the child with a
toy airplane may recognize that the children with a rake and shovel can help
construct a landing strip and airport. The child with the shovel may not under-
stand this identified goal, but is happy to work toward building a “road” for
the airplane, and the group of children in the sandbox begin interacting and
utilizing each others’ skills and tools in coordinated task-specific functions.
Transdisciplinary: Ultimately, a group of children may join together in
both task and imagination of a shared vision, akin to transdisciplinary func-
tioning. In a sandbox, this is where a unified imaginary world begins to form
among the children, and each child’s “expert” functioning melds seamlessly
into creating this shared vision of sandcastles, airports, and superheroes. Like
jazz musicians improvising and riffing off each other’s rhythms and melodies,
each child’s “expertise” is effortlessly folded into a larger dynamic world,
where imagination and meaning take precedence over individual function and
expertise.
Developmental Growth Across Collaborative Modes
With interprofessional and team-based care as the current dominant goal and the
need to develop effective IPE environments posing significant challenges, it may be
helpful to step back and look at some of the basic processes at play in group and
team development. Newly formed groups can take advantage of the independent
nature of their diverse perspectives, and leveraging something social psychologists
call the “wisdom of the crowd,” they can generate novel creative strategies to address
the unique demand characteristics of their setting (Surowiecki 2005).
In time, as collaboration, trust, and shared knowledge begin to blossom in the
group, the positive benefits of group “wisdom” can change into “group think,”
another more pernicious social psychological phenomena that is best avoided
(Edmundson 2012, p. 119). At this stage, where knowledge, culture, and divisions
of responsibility are becoming more blended, the growing lack of independent
thought among team members needs to be managed to prevent systematic error.
Careful consideration to understand and avoid what applied psychologist James
Reason has termed “Swiss cheese” errors that occur in medical systems can assist
6 1 The Argument for Interprofessional Education
planning across all levels of group and team functioning (Reason 2000). Finally, in
the latter developmental stages of group and team functioning, in a process of tilling
the collaborative soil to allow for the growth of transdisciplinary functioning, an
understanding of emergent social phenomena is helpful. Rand et al.’s (2014) recent
work building on a long-standing sociological concept called social network theory
has shown how advanced and stable group functioning can lead to high levels of
cooperation that consistently emerge as self-organizing and globally coherent com-
plex patterns. Following these models, teams that foster an environment where
transdisciplinary functioning can emerge open the door to the kind of improvisa-
tional synergy and accurate anticipation that makes workflow automatic and efficient.
IPE teams, then, initially have useful independent opinions, then develop situational
awareness and backup behaviors, and finally have interdependent opinions.
Side Bar 1.3 Developmental Processes of Group Function
and Cooperation
1. Wisdom of the crowd
2. Homogeneity of error and the “Swiss cheese” example
3. Emergence: tilling the soil of synergy and improvisation
Wisdom of the Crowd
The wisdom of the crowd assumes that each individual knows something important,
but not everything, about the situation being evaluated. Their input then has two
components, the thing they uniquely know and randomly distributed error. With
enough diversity and as long as the amount of error in these guesses remains inde-
pendent, the things known are additive and the random guesses cancel.
Side Bar 1.4 Elements of “Wisdom of Crowds”
1. Diversity of opinion
2. Independent choice
3. No cross talk
4. Good method for aggregation
Homogeneity of Error
A systems approach to medical error emphasizes the fact that each individual
has different blind spots that could lead to a mistake. One person’s blind spot is
another person’s focus. In a well-functioning team, these blind spots would have
to line up like the holes in slices of Swiss cheese in order to affect the patient.
Developmental Growth Across Collaborative Modes 7
As Reason states (2000), “We cannot change the human condition, but we can
change the conditions under which humans work.” Thus, one argument for high-
functioning interprofessional teams is to cover each other’s blind spots.
Emergence
Emergence is a property of individual agents interacting efficiently in highly com-
plex systems (see Chap. 3). This is the process by which the “whole becomes greater
than the sum of the parts.” Emergent behavior cannot be predicted or controlled from
outside the group; its presence at any given time comes from having cultivated an
environment from which it can grow. And, as will be shown, it is responsible for the
powerful benefits gained from interprofessional teams. Dr. Atul Gawande captured
this well in his Harvard Medical School commencement address titled “Cowboys
and Pit Crews.” He stated: “The public’s experience is that we have amazing clini-
cians and technologies but little consistent sense that they come together to provide
an actual system of care, from start to finish, for people. We train, hire, and pay doc-
tors to be cowboys. But it’s pit crews people need.” He goes on to describe basic
elements necessary in these systems, “By a system I mean that the diverse people [on
a healthcare team] actually work together to direct their specialized capabilities
toward common goals for patients. They are coordinated by design. They are pit
crews. To function this way, however, you must cultivate certain skills which are
uncommon in practice and not often taught…[these] include humility, an under-
standing that no matter who you are, how experienced or smart, you will fail. They
include discipline, the belief that standardization, doing certain things the same way
every time, can reduce your failures. And they include teamwork, the recognition
that others can save you from failure, no matter who they are in the hierarchy.”
The need for effective interprofessional collaboration in healthcare at this point
in history is great, and to achieve this, IPE is a necessity. To make modern care
delivery models—such as the patient-centered medical home—work, it is going to
take much more than technology and logistics. It is going to take figuring out the
most effective ways to bring very different people, with different skills and cultures
and rules, together onto teams that can function with single-minded direction in
complex and ever-changing environments. Ideally, these emergent characteristics
will allow groups to move beyond “disciplinary confinement,” minimize fragmenta-
tion of knowledge, accept local context and uncertainty, and function as highly
trained and coordinated pit crews.
Example 1.2 Checklists or Real Teams?
In one patient-centered medical home (PCMH) training environment, all of
the required logistical and content-expert “checklists” were in place together,
yet there were no incentives for these different team members to “play”
together beyond simple parallel play. Schedules conflicted, cultural missteps
(continued)
8 1 The Argument for Interprofessional Education
Example 1.2 (continued)
were frequent, and communication was stymied. All of the “players” in this
clinical training environment desired to achieve high levels of collaboration,
ideally something akin to transdisciplinarity, yet were frustrated by the lack of
progress and the persistent barriers of traditional training and professional
silos. This example points to the fact that structures are necessary, but not suf-
ficient, to create functional interprofessional teams. The structure must be
supported by processes and organizational culture.
One challenge in the above illustration is that most leaders in healthcare training
programs have themselves not trained in true interdisciplinary environments.
To create interdisciplinary training, they must first be able to join as faculty and
educators into collaborative cross-discipline relationships. And even with that, the
best that can likely be achieved at first is the growth of interdisciplinary training, as
their vision will be limited beyond this horizon. The goal, of course, is that those
who then train in truly interdisciplinary environments, who learn to function from
the beginning of their careers in highly collaborative cross-disciplinary teams, may
eventually move beyond historic professional bounds, and transdisciplinarity might
emerge.
Putting It All Together
We have identified the unique challenges faced in modern healthcare and defined
these as wicked problems. We have suggested that robust interprofessional training
is a necessary requisite for addressing these problems and that achieving transdisci-
plinary competence will be critical to addressing wicked problems in healthcare.
What is the evidence for these assertions?
As has been described by others, reform of wicked problems is often best
approached initially as a problem of theory and design, which requires an initial
creative process of challenging existing practices and rebuilding (Brown et al. 2010).
With ill-defined goals, multiple stakeholders, no “right” solution, and no “known”
or “standard” methods, traditional linear and sequential problem-solving approaches
are insufficient (Roberts 2010). We are decidedly not alone in this opinion. An inter-
national commission presented similar recommendations in their report where they
concluded that systematic and practice-based teamwork must be integrated into
healthcare training (Frenk et al. 2010). Additionally, the Institute of Medicine
recently convened a global workshop entitled “Establishing Transdisciplinary
Professionalism for Improving Health Outcomes” (Cuff 2014), which concluded
that transdisciplinary professionalism is a critical competency for the future of
healthcare.
References 9
Outside of healthcare, other areas where interprofessional education (IPE) and
practice are felt to be critical to addressing wicked problems and multivariate
complexity are urban planning (design educators, architects, and public health
officials—Bore and Wright 2009), management of fisheries (marine biology, envi-
ronmental science, public policy—Jentoft and Chuenpagdee 2009), and doctoral
studies in science (Cumming 2010). What these papers share is the recognition that
these areas are dynamic and “unwinnable,” that a unidisciplinary attempt at a solu-
tion is too narrow and can be destructive, and that training with multiple disciplines
provides the more “generalist” skills and point of view required to address wicked
problems.
As you will see in the following chapters, this process might even best be con-
sidered a “super-wicked” problem, where not only are “wicked problem” criteria
met, but multiple wicked problems are layered together into levels of interdepen-
dent systems where leadership and communication are decentralized, future irratio-
nalities are both completely unknowable and inevitable, and urgency of time-critical
function is constantly present. Thus, it is critical to begin the discussion of how a
deeper theoretical understanding of complexity may help to structure healthcare
education systems to function at peak performance given these characteristics and
challenges.
References
Abu-Rish E, Kim S, Choe L, Varpio L, Malik E, White A, et al. Current trends in interprofessional
education of health sciences students: a literature review. J Interprof Care. 2012;26(6):444–51.
doi:10.3109/13561820.2012.715604:1-8.
Bore A, Wright N. The wicked and complex in education: developing a transdisciplinary perspec-
tive for policy formation, implementation, and professional practice. J Educ Teach Int Res
Pedagogy. 2009;35(3):241–56.
Brienza RS, Zapatka S, Meyer EM. The case for interprofessional learning and collaborative prac-
tice in graduate medical education. Acad Med. 2014;89(11):1438–9.
Brown V, Harris J, Russell J. Tackling wicked problems. London: Earthscan; 2010. p. 312.
Bruder MB. Working with members of other disciplines: collaboration for success. In: Wolery M,
Wilber JS, editors. Including children with special needs in early childhood programs.
Washington, DC: National Association for the Education of Young Children; 1994. p. 45–70.
Camillus JC. Strategy as a wicked problem. Harv Bus Rev. 2008;86:98–106. PPG Industries, Inc.
Cuff P. Establishing transdisciplinary professionalism for improving health outcomes. Washington,
DC: The National Academies Press; 2014.
Cumming J. Doctoral enterprise: a holistic conception of evolving practices and arrangements.
Stud High Educ. 2010;35(1):25–39.
Edmundson A. Teaming. How organizations learn, innovate, and compete in the knowledge econ-
omy. San Francisco: Jossey-Bass; 2012. p. 334.
Frenk J, Chen L, Bhutta Z, Cohen J, Crisp N, Evans T, et al. Health professionals for a new cen-
tury: transforming education to strengthen health systems in an interdependent world. Lancet.
2010;376(9756):1923–58.
Gawande A. Cowboys and pit crews. The New Yorker. Cond Nast Digital. 2011. Accessed 20 Jan
2015.
