Anthony Sanfilippo

real-life-lessonsThe term “ivory tower” apparently has its origin in the Song of Solomon (7:4) where the writer describes the beauty of his beloved with a list of poetic terms, including “your neck is like a tower of ivory”.  The image found its way into descriptions of venerable figures, as depicted in “Hunt of the Unicorn Annunciation” (circa 1500).  For obscure reasons, the term has, over the centuries, come to be used to refer to “a world or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” (Wikipedia).

University faculty are often accused of such intellectual self-indulgence.  They can seem disconnected from the “real world” issues and challenges faced by practitioners of their respective disciplines.  Physicians engaged in both care delivery and medical education might think themselves somewhat protected from the “ivory tower” mentality.  I have certainly been of that opinion; at least until a recent “real life” experience has caused me to question that assumption as it relates to how we educate our learners with respect to interprofessional practice.

The development of educational processes that teach and promote Interprofessional Care and Practice has proven to be one of the biggest challenges faced by our school and faculty.  The largest obstacles, in my view, have been two-fold.  The first is purely pragmatic.  It is very difficult to bring together the complex and very full curricula of multiple educational programs.  Finding “space” in the packed schedules of our learners that coincide with compatible points in their separate learning continuums is a considerable logistic challenge, and will always be limited.  The second issue is more philosophical.  To be successful, any educational initiative must be directed toward clearly understood and mutually accepted objectives.  Both teachers and learners must have a common understanding of the desired outcome.  Simply put, they need to share a vision of the “final product”.  Although we, and most schools, have developed articulate vision statements, I believe we lack a practical and commonly accepted understanding of that “final product” of Interprofessional Education programs.  Our “ivory tower”, in this instance, has perhaps become a little too high to see what’s needed on the ground.

This brings me to my recent “real life” revelation.  My parents are now 91 and 86 years of age.  My father has increasing health issues that require regular supervision and assistance.  They have lived in the same small community all their 60+ years of marriage, and wish to remain in the home that they built for their retirement.  My siblings and I, as well as all involved in their care, agree this is the best option for them and, frankly, the desired option for all seniors wherever practical.  Achieving this is becoming increasingly complex.  They are blessed to have an absolutely incredible Family Physician with whom I communicate regularly.  On a recent visit to my parents, we agreed to meet while I was there to update on a few issues.  He took the opportunity to ask some other individuals involved in my parents care to join us.  So, on a weekday morning, in my parents’ living room in that small community, a Family Physician, visiting Home Care nurse and Personal Support Worker met with myself and one of my sisters with both my parents in attendance.  We were in telephone contact that morning with the Home Care supervisor, Respiratory Technician, Heart Failure Nurse Specialist, as well as the local Pharmacist who packages my father’s medications and is very familiar with recent changes.  The complexity and extent of care required to support my parents was not a surprise to me.  What I’ve had trouble imagining is how it could all possibly be coordinated in the home.

That morning, as I watched this process work so effectively, it became apparent that the single most essential key to success was that the contributions of each person were consistently centred on the welfare of their common patient.  People knew the technical aspects of their jobs, to be sure, but their focus never deviated from the patient.

The second key to success was in the listening.  Each individual was receptive to and respectful of the input of the other contributors, recognizing that the input of each was independently important to the central goal.  Interestingly, the input of the PSW was perhaps the most relevant and led the discussion, because that person was closest to and most familiar with the impact of everyone’s work on my parents themselves.  The Family Physician initiated the conversations, provided medical input a couple of times and, at the end, ensured everyone (including my parents themselves), had had the opportunity to get all their concerns and issues discussed.  There was no jockeying for dominance.  There was an openness and acceptance of each role that allowed everyone to make suggestions without fear of compromising their status.  There was, in short, a sense of trust and mutual respect that allowed full and effective collaborative effort.

Although this particular experience crystallized this issue in a personal way for me, I realize that these highly effective interprofessional interactions play out in our wards, clinics, offices, emergency departments and operating rooms every day.  They are becoming part and parcel of effective health care delivery, and provide a prime example of how our university based teaching programs must emulate and promote exemplary practice.

So what makes this work in the “real world”, and what lessons can we, ensconced in our Ivory Tower, take back to our educational programs that strive to teach and model optimal IP practice?  Based on our real world exemplars, I would suggest five principles that may provide useful points of departure to examine any IP teaching program:

  1. The purpose of IP practice must be to optimize patient care.  This is accomplished through common understanding and coordinated effort.  Our educational programs and those who lead them must share that single goal and reinforce it in their teaching programs.  IP must not be used to promote “political” causes.
  2. The various providers involved understand and accept that they cannot provide optimal care in isolation.  That is simply no longer a realistic goal, a reality that a visit to the home of my parents or any patients living with chronic issues will quickly make apparent.  Our educational programs must not simply state, but allow our learners to experience this reality.
  3. Health care providers must understand each other’s role in care delivery.  In practice, this is learned by practical experience.  Our educational processes must find ways to ensure providers learn these roles.  For this purpose, experiential learning in active practice is much more effective than theoretical exercises.
  4. There must be mutual respect.  This must be built on an understanding of the value of all contributions, and is best modeled through the behavior and attitudes of faculty.  The converse, of course, is that negative attitudes expressed through “hidden curriculum” behaviours can be highly damaging.
  5. Active practice opportunities are essential.  The awareness of roles, value, and mutual respect are best built through shared and successful practice opportunities where learners will find that their combined efforts bring added value. Their combined and cooperative effort, in essence, will be of greater value to their patients than the sum of individual and isolated efforts.

Our university based “ivory tower” can certainly provide a protected environment, isolated from the realities of clinical practice, and perhaps thus distracted by theoretical rather than practical concerns.  However, it can also provide a perspective from which we can appreciate the value of practices that are tested and successful in the “real life” arena, and motivated solely by the best interests of the patients we serve.  Many schools, including ours, have made great strides in IP education.  As we continue to strive to improve, we’d be well advised to pay close attention to the lived experience and successes occurring every day, so close to us all.