Breaking down silos: engaging students to help fix the US health care system

Problem

In the era of US health care reform, providers, payers, and patients across the country are being held more accountable to improve the quality, access, and cost of health care. Given the multifactorial nature of health care, it is no surprise that initiatives including accountable-care organizations and patient-centered medical homes are emerging as viable new care models across the country. These new approaches have one resounding goal in common: to bring multiple professions together in teams to provide better patient-centered health care. In fact, more than a decade ago in 2001, the Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Healthcare System for the 21st Century called for such a multidisciplinary approach to health care.¹ More recent reports from the IOM have established guiding principles and values for team-based health care while reiterating the need for health care practitioners to embrace the transition from being soloists to members of an orchestra.² Adding to the urgency is the ongoing transition from a predominantly volume-based health care system to one governed by value.³

Multidisciplinary teams have the potential to create value by increasing quality and patient satisfaction while simultaneously decreasing costs.² Additionally, such teams allow individuals with different expertise to complement one another for the holistic care of the patient. One study has estimated that the average primary care physician connects to 266 other physicians when assessing the medical care network of his or her Medicare patients over a span of 1 year.⁴ However, this estimate does not include the interaction with other professionals, including nurses, physician assistants, pharmacists, social workers, dieticians, technicians, administrators, and many other integral team members. Given the diversity and quantity of health care disciplines, it is imperative for all health care professionals to understand the issues afflicting one another for increased transparency and communication.

The problem of ill-equipped health care professional graduates is not local to the US. The international community has also underscored the need for interprofessional collaboration; in fact, the World Health Organization has indicated that interprofessional education is necessary in creating a “collaborative practice-ready health workforce” capable of improving health outcomes.⁵ Similarly, the groundbreaking report Health Professionals for a New Century featured professional and academic leaders from around the globe who beckoned for an end to the “tribalism of professions”, while sharing a global vision and framework calling for change and system redesign of professional health care education.⁶

As noted in the IOM report, change begins in the classroom. To help students and future health care workers prepare for this transition, educators and institutions should provide a means for students to learn and actively problem-solve with one another. Eventually, integration of interprofessional collaboration and endorsement of a team mentality into educational programs will increase multidisciplinary competence, thus leading to better patient outcomes as students join the workforce.

The Emory–Georgia Tech Healthcare Innovation Program (HIP) is a multi-institutional network focused on facilitating health services research, education, and service (http://www.hip.emory.edu). As part of its activities, HIP hosts quarterly symposia with prominent guest speakers from around the country on the topic of “US Healthcare: What’s Broken and How to Fix It?” In October 2013, HIP organized its first-ever student-driven symposium to feature the multidisciplinary student perspective on the challenges facing the US health care system.

Approach

“It’s about the journey, not the destination”: this popular sentiment aptly embodies the planning process behind the student symposium. From the initial formation of the student planning committee to the final symposium presentations, a multidisciplinary mindset was adopted and integrated throughout the entire process.

Student planning committee

The initial student planning committee was comprised of ten student leaders from the HIP Student Advisory Group, representing different departments, schools, and universities, with each bringing a different discipline, perspective, and context. Many of these students were selected by the program director based on their leadership positions within various student organizations related to their respective disciplines. The different disciplines represented by the planning committee included public health, medicine, nursing, allied health, business, and engineering. Members of the planning committee included students from Emory University, Georgia Institute of Technology, Georgia State University, and Morehouse School of Medicine. The planning committee members were responsible for 1) selecting a student speaker on behalf of their respective discipline, 2) identifying faculty members from their respective disciplines as mentors for the student speakers, 3) organizing meetings with each of their own respective student organizations, and 4) providing multidisciplinary feedback for the student presentations.

Student speakers

Seven different student disciplines were selected for the symposium: public health, prehealth, medicine, nursing, allied health, business, and engineering. These disciplines were chosen based on their extensive presence across the multiple institutions. The prehealth discipline was designated for an undergraduate student, while all other disciplines were represented by graduate students. The designated planning committee members were asked to select student speakers based on who they thought would best represent their respective discipline, as well as who provided the best response to the question of “Why is a multidisciplinary approach needed in healthcare?” Student speakers representing each discipline were selected through various methods, including submission of YouTube videos, written essays, and personal interviews. Upon selection, student speakers were asked to 1) present one health care-related problem associated with their discipline, 2) identify the contributing factors associated with the problem, and 3) propose a potential multidisciplinary solution. To assist with their presentations, student speakers were paired with a faculty mentor and provided access to consult the deans of their respective schools. Additionally, student speakers were encouraged to attend the meetings of other student clubs and organizations across the network.

Open-call student roundtable

To further assist student speakers with their final presentations, weeks prior to the symposium, an open-call student roundtable was held by the planning committee. The roundtable was organized loosely on the concept of speed dating. Seven roundtables were organized, with each table comprised of approximately five students from the same discipline who were handpicked and selected by the respective planning committee member. The student speakers began at their respective “home” tables, and were asked to rotate to another table every half hour until they received input from students across all seven of the disciplines represented.

Prior to the roundtable, planning committee members researched and printed a “startling” fact pertaining to their discipline. These facts were meant to be provocative, and were used to help stimulate conversation during the roundtable discussions. Overall, the roundtable process was both organic and refreshing: it offered students the opportunity to uncover the real issues troubling each of the other disciplines. It also provided a means to better understand the nature and scope of one another’s discipline. Most importantly, the roundtable helped cultivate an environment where students were able to candidly voice some of their concerns, opinions, and questions.

Frequent questions brought up at many of the different roundtables included: “What is the role of your discipline in healthcare?” and “What can we do to help make your job easier?” Fittingly, the student roundtable revealed two salient themes: 1) there was a lack of understanding of one another’s profession and role in health care delivery, and 2) students were interested in learning how to work together to complement one another’s role. Overall, the open-call student roundtable provided the student speakers with valuable feedback and an exposure to diverse viewpoints outside their respective disciplines. As such, the process was able to inform and help the student speakers formulate multidisciplinary solutions for their final presentations.

Outcomes

The symposium attracted hundreds of students and faculty from the Atlanta metropolitan area, with additional participants joining via webcast. The student presentations addressed multiple topics within the US health care system, including public health awareness, health care-delivery models, nursing scope of practice, the evolving role of allied health, the medical education curriculum, insurance-led quality improvement, and the risk-averse culture of biomedical engineering. All student speakers successfully presented a health care problem associated with their respective discipline and subsequently provided a multidisciplinary framework to address the problem (see Table 1; access to all the student presentations and a video stream of the symposium is available in Figure S1). Throughout the symposium, social media sites, including Twitter and Facebook, were used to help engage students. Following all the presentations, student speakers formed a panel to entertain an interactive question-and-answer session with the audience.

Table 1 Student-identified US health care problem and solution for each discipline

The symposium was unanimously well received, garnering positive reviews from both students and faculty members across multiple institutions. Since its inception, the student symposium has helped cultivate a greater interest by students across disciplines in health care delivery and multidisciplinary collaboration. It has led to the creation of multiple student “mixers” between various graduate school programs and student clubs, as well as new interdepartmental activities. Of note has been the development of a university-wide course at Emory entitled “SICK: Healthcare in the Modern Era”, which was launched in the spring of 2014. The course was developed to provide students with a multidisciplinary and holistic understanding of the challenges facing the US health care system. The course is available to all students of all disciplines, and covers the US health care system from a myriad of different viewpoints through discussion panels and lectures covering topics in medicine, public health, business, law, ethics, policy, and informatics. Lectures are given by a multidisciplinary assortment of prominent university and health care professors and faculty members. Though the course focuses on US health care delivery, modules on international and comparative health systems are also explored. The course culminates with students forming multidisciplinary groups and presenting a capstone project addressing health care-delivery issues (Table S1; for course syllabus, visit https://scholarblogs.emory.edu/sick for additional information regarding the course). The introduction of this course has led the way for additional university-wide coursework, including a course that opened to all students in the fall of 2014 titled “Health Services Research”, which aims to provide students with a better understanding of how multidisciplinary research can be used to improve health care cost, quality, and access.

The semiannual Healthcare Innovation Seed Grant Program is also sponsored by HIP to fund multi-investigator, multidisciplinary teams examining health care services and clinical effectiveness. Following the symposium, and for the first time in the 3 years of the program, a proposal was submitted by a group of students to examine the effectiveness of their own multidisciplinary volunteer health care-related programs.

Next steps

The success of this symposium and the processes that have engaged multiple student disciplines and activities will be extended to become an annual series of events, and will be expanded to include additional perspectives. The patient perspective will be an especially integral and enlightening perspective to include, mirroring the recent emergence of patient and family advisory councils across a majority of health care systems. Indeed, such a perspective can help reinforce the patient’s central role in every health care team and the increasingly popular “nothing about me, without me” mentality.⁷

Initiatives similar to the student symposium, though small, can help lay the foundation and trigger a domino effect for multidisciplinary collaboration and education. Health care educators should view the open-call student roundtable as evidence for the need and interest among students for multidisciplinary education. In addition, the student presentations should be a testament to how multidisciplinary collaboration can engage students and help them think “outside the box” to formulate innovative, multidisciplinary solutions to real-world problems.

As a parallel, business schools across the US have long been recognized for their team-based course structure, where students from all branches of business work together on case studies for which they share the same grades. In fact, certain business schools have recently adopted nondisclosure policies in which students’ final grades are only disclosed to employers after being offered employment, as a means to reduce internal competition among students and increase collaboration within the classroom. Conversely, the majority of students pursuing fields in health care are often still taught in independent silos, despite being “graded” and assessed on the same common denominator of patient outcomes upon graduation. Consequently, a strong case can be made for health care educators to adopt a similar approach in which students from all branches of health care interact and work together prior to entering the workforce.

Although a multidisciplinary approach to health care starts at the bottom with students as the foundation, the adoption and implementation of such a philosophy starts from the top. Administrators and faculty members of all disciplines should seek to work together to transform the education system for future health care professionals. In addition, they must serve as role models when interacting and collaborating with one another. It is incumbent upon educational institutions to indoctrinate students into a culture of multidisciplinary collaboration. Though there is no quick fix to the US health care system, a cultural transition toward team-based care could certainly be one of the most crucial and enduring solutions for future generations.

Acknowledgments

The authors wish to thank HIP Program Manager Maryam Carn, the HIP Student Advisory Group, and the student and faculty participants that helped make the symposium a remarkable success. This study was supported in part by PHS grant UL1TR000454 from the Clinical and Translational Science Award Program, National Center for Advancing Translational Sciences, National Institutes of Health, and the Woodruff Fund, Emory University.

Disclosure

The authors report no conflicts of interest in this work.

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References

1.	Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academies; 2001.
2.	Mitchell PH, Wynia MK, Golden R, et al. Core Principles and Values of Effective Team-Based Health Care. Washington: Institute of Medicine; 2012.
3.	Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007;297(10):1103–1111.
4.	Pham HH, O’Malley AS, Bach PB, Salontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150(4):236–242.
5.	Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–1958.
6.	World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO; 2015.
7.	Wynia MK, Von Kohorn I, Mitchell PH. Challenges at the intersection of team-based and patient-centered health care: insights from an IOM working group. JAMA. 2012;308(13):1327–1328.

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Supplementary materials

Figure S1 HIP student symposium presentations and video stream. Abbreviation: HIP, Healthcare Innovation Program.

Table S1 SICK: Healthcare in the modern era, 2013: course prospectus and materials Abbreviations: ACA, Affordable Care Act; Dept, department; GA, Georgia; GSU, Georgia State University; LGBT, lesbian, gay, bisexual, and transgender; Min, minutes; NA, not applicable; TBD, to be determined.