Multiprofessional working: learning from experience

In March this year, the Standing Committee on Postgraduate Medical Education (SCOPME) in the UK published a document entitled Equity and Interchange: multiprofessional working & learning.1 The report draws on the contents of several government documents whose key concept is ‘partnership’. Described also as a way of achieving ‘clinical governance’, partnership is translated as ‘…efficient and effective working in teams across organisational boundaries’ and ‘…between individuals and the organisations in which they work and between the NHS, patients and the public’. Benefits are described in terms of ‘…improved patient care, financial savings and a better working environment’. The reorganization of the National Health Service has called into question the meaning of health care and what it means to be a physician. The roles of the doctor, related health care professionals and the contexts in which they work, are being rewritten and adapted to reflect the needs of different communities and organizational arrangements. The labels are the same, but of necessity, practitioners, managers and policy makers are being forced to rethink their values and how these changed values affect clinical practice. Broadly, our main objective remains the same, that is, the provision of the best possible care for patients, but how to achieve this objective is always a contentious issue. Today, the buzzwords in both Europe and North America are ‘multiprofessional’ and ‘teamwork’.2, 3 Previously at the base of a hierarchical pyramid and subjected to conveyor belt medicine, the patient should now be placed at the ‘hub’ of the multiprofessional health care ‘wheel’. Doctors and their colleagues – the spokes of the wheel –work in teams, communicate and collaborate with colleagues, involve families and ‘turn’ together to reach their goal. A tantalizing observation in the report is that ‘a skills training approach in team-working is neither necessary nor appropriate. If individuals are provided with autonomy, and a climate of equity and mutual respect between different professionals is created, then a multiprofessional group will develop its own way of working and learning effectively together’. Whilst commending most aspects of the report’s approach and findings, many medical teachers will be intrigued by the view that skills in multiprofessional working can be serendipitously acquired through work-based experience. What are the preconditions necessary for such effective group learning and what role does education play in developing the appropriate milieu for learning? Of course, some practitioners do have the skills and share similar values, but many others do not and may be unwilling or unable to become effective team members. Is it possible to provide autonomy and a climate of equity and mutual respect? Many practitioners believe that autonomy is already theirs by virtue of their training and final qualifications. Whilst equity and mutual respect are both desirable and necessary, professional education and practice neither encourage nor provide opportunities to reduce inequity, or influence stereotyped views, or foster positive attitudes between different professionals. We cannot assume that by simply putting people together, ‘effective’ learning will occur. We know from experience at undergraduate level that this is not so.4 The ‘culture’ of each professional group, mentioned frequently in the report, is so powerful, that multiprofessional learning cannot simply be left to chance. The report also recommends that ‘if information and expertise is required on the principles and practises underpinning multiprofessional working and learning’, it is most likely to be found in ‘…organisational democracy and democratic education’. Unfortunately, this is not a reflection of the real world of health care. The NHS is an organization that remains hierarchical despite extensive recent reforms, and is unevenly resourced in both financial and manpower terms. Information and expertise on the principles that underpin multiprofessional working and learning are not, therefore, likely to be readily acquired through example. Multiprofessional postgraduate learning should not be separated from undergraduate medical education and the report advocates that working and learning at postgraduate level should begin with the needs of patients and communities, and involve relevant professionals who are able to function as a democratic decision-making team. The educational principles at both levels are the same and a seamless continuation of these principles should be the aim. Multiprofessional learning should begin with undergraduates so that doctors and other professionals can start to understand the equally valuable contributions each can make to patient well being, although there is little evidence that this is happening. Such planned education, undertaken with sensitivity at the right time, will help to generate the mutual trust and respect that is so essential for multiprofessional working and learning to achieve its goals. Acquisition of the necessary knowledge, skills and attitudes required for effective interprofessional behaviour is conditional upon a large number of variables, over many of which practitioners may have little control. Planned educational and organizational strategies, research and evaluation are needed to answer the considerable number of questions and issues raised by the report.