This week I had the privilege of attending a grantee convening of the Josiah Macy Jr. Foundation - one of the agenda setting institutions in medical education. Macy's insider role in medical education makes it even more significant that the topic of the meeting was Interprofessional Education in health care. Today, some ten years after the Hartford Foundation's Geriatric Interdisciplinary Team Training initiative faded, the notion of teams in health care is again ascendant and I am struggling with hope: Is it going to be different this time? Can we make interprofessional education effective, widespread, and permanent so that people—especially older Americans— can get the care they need? Or, is this just another fleeting interest that will die away at any moment?

When George Thibault, MD, became the president of the Macy Foundation and began investigating options for his new agenda in 2008, we at Hartford were cautiously supportive of an interest in interprofessional education. But still smarting over the collapse of our own Geriatric Interdisciplinary Team Training program in the early 2000s, I know I was just as glad to let someone else be first back into the battle (read about the evaluation of Hartford's grants here).

In Hartford's view, good care of complex older adults requires exquisite teamwork across disciplines/professions, time, and settings. The problems faced by older adults sprawl across silos of expertise - e.g., you never know if you're going to need a pharmacist to help with an esoteric medication question, a nurse to educate family members on proper administration of the medicine, a social worker to help make the medication affordable, or a physical therapist to get the older adult physically active enough to get off the medicine. The high performing team that can flexibly respond to geriatric complexity needs lots of training and practice. As our GITT tag line had it, "Good teams don't just happen." And, unfortunately, in our experience, mostly they still don't.

Over the last few years, Macy has made 20 grants, jointly to medical and nursing schools, to begin to create its own movement in what is now called Interprofessional Education (IPE - as opposed to IDT - InterDisciplinary Training, as it was back in the day). This week, calling in its grantees and other leaders in the field, Macy tried to take a pulse of where IPE stands, what its next steps might be, and how we might get where we ultimately need to go.

The Macy grantees include many of the sites in our Geriatric Interdisciplinary Team Training initiative (e.g., University of Minnesota, Baylor, Case Western Reserve, Hunter, and University of Colorado) as well as NYU, whose division of nursing acted as the GITT program’s national resource and coordination center. And yet, few of this decade’s grantees had any knowledge of what had gone before.

The Macy initiative is simpler than ours, requiring only Medicine and Nursing as professions and offering great flexibility as to level of trainee, clinical content, and pedagogical approaches. GITT specified a minimum of Medicine, Nursing, and Social Work on the team and that the trainees be resident physicians, and nurse practitioner and master’s in social work students. It also required a mix of classroom didactic and real world practicum experiences and, of course, a focus on the care of older adults. Nonetheless, Macy grantees are still struggling with issues I remember all too well: the need for substantial faculty development; the crowded curriculum; access to well-functioning practicum sites; questions about adequate “dose” of training; difficulty measuring student competence; and the perception that interprofessional education is an “extra” unwarranted cost. They are also struggling with the existential question that ultimately led us to follow GITT with our Geriatric Interdisciplinary Teams in Practice initiative -- Can we “prove” that IPE/team training produces better outcomes for patients?

But I *do* think that IPE is important and the "right" thing to do. It seems self-evident to me that little important is accomplished in any domain by people working alone, much less one as complex as health care. Health care is always done by a team--at the very least because the patient is a key team member. And, if we want to offer the best care at the lowest cost, we need to have the right person with the right skills working at the right time--be it physician, nurse, social worker, or “self-care specialist” (AKA people).

This focus on the needs of the patient at the center of the team and our belief in the potential benefits for that person is, of course, the “sole reason” (as Dr. Thibault put it) for the IPE effort.Don Berwick, former CMS administrator and founder of the Institute for Healthcare Improvement, observed that it is not possible to have universal access to health care without health reform, which, in turn, has to include more effective teams. Coincidentally he cited the example of Alaska’s Southcentral Foundation, discussed in a recent post - Returning Joy to Primary Care, as a high performing team. Dr. Malcolm Cox, VA’s Chief Officer for Academic Affiliations speaking of the VA's interprofessional education initiative, drove home the point, arguing that educational reform and practice redesign are inextricably linked and must be approached together.

I've adapted one of Dr. Cox's figures here - trying to capture the vision of patient needs at the center and a virtuous cycle of practice, reform, learning, and redesign spinning around that axis. I just hope we can keep the momentum.