Campbell

Reviewers ’ conclusions: Despite finding a large body of literature on the evaluation of IPE, these studies lacked the methodological rigour needed to begin to convincingly understand the impact of IPE on professional practice and/or health care outcomes.

Citation: Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, 4, 2002. Oxford: Update Software.

The Opportunity for Improvement Craig Campbell, MD

Based on the lack of methodologic rigor in selected studies, the systematic review of interprofessional education (IPE) to improve collaborative prac- tice and/or health/well-being concluded there was no convincing impact of IPE. Of the 1,042 stud- ies initially identified, none of the 89 studies retained for further consideration met the review’s inclusion criteria: a randomized trial design (using either a before and after or interrupted time series) and objectively measured or self-reported patiendclient outcomes or improvements to health care process measures.

Is the lack of methodologic rigor a commen- tary on the scientific validity of these continuing medical education (CME) research trials or a reflection of the inappropriateness of the review’s inclusion criteria for studying the effects of IPE?

A clear definition of IPE or description of a conceptual model for how health professionals can collaborate to enhance patient care outcomes or health care process measures would be a start. For example, does IPE mean different health pro- fessionals participating together, rather than sep- arately, in traditional continuing education events? Or does it refer to health care professionals work- ing and learning together as members of a team or community to enhance professional practice?

Reprint requests: Craig Campbell, MD, Director, Professional Development, The Royal College of Physicians and Surgeons of Canada, and Associate Professor of Medicine, Faculty of Medicine, University of Ottawa, 744 Echo Drive, Ottawa, ON K1S 5N8.

If IPE simply means that more members of the health care team participate together in CME, then one could argue that this strategy may or may not result in a meaningful enhancement to patient care outcomes or health care process measures. In randomized controlled trials that study the impact of traditional continuing education, with its emphasis on updating medical knowledge, skills, and awareness of new evidence-based prac- tice guidelines, it is clear there is limited impact on changing physician performance and health care outcomes.’ However, if IPE means promot- ing strategies for health care professionals to work together as members of a team or community with the potential not only to review and validate new evidence for practice, but also to contribute prac- tical knowledge and expertise gleaned from han- dling the uncertainties of practice to enhance the knowledge, management practices, and health care outcomes of the team, then the research strate- gies would look entirely different.

The “communities of practice” model of Wenger et al. conceptualizes the integration of learning and practice as a continuous process in which members of the community work in an environment that encourages the exchange of knowledge and practical wisdom. Outcomes of the team’s collective performance are used to identify educational needs and opportunities for further improvements to practice. If less “communities of practice” less is an appropriate model to guide research to evaluate the impact that IPE may have on patient outcomes and health care process mea- sures, there are several research questions that

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Cochrane Review

Table 1 IPE Review Findings and Implications for Providers and Learners ~

Findings from the Review Implications for Providers Implications for Learners

Multiple studies on the topic of There is a need to develop a clear Traditional CME is limited in its IPE exist in the literature. definition of IPE. ability to enhance physician perfor-

mance and health care outcomes.

physicians and other health care professionals to use their practices as a stimulus for learning.

Studies published to date include Research into IPE needs to be IPE offers the potential for a wide range of health care professionals.

No studies met the inclusion criteria based on either trial design or outcome measures.

The effectiveness of IPE on health care outcomes could not be determined.

guided by theoretical models for how IPE can contribute to improved health care process variables and patient care outcomes.

Research should focus on how Learning with other health profes- teams validate and share information, sionals creates an environment in make decisions, and refine their which learning has the potential not practices based on shared wisdom only to address gaps in the applica- and knowledge and reflection on tion of best evidence but also to their practice experiences. acquire practical wisdom to address

the ambiguities of practice.

CME = continuing medical education; IPE = interprofessional education.

should be clarified before deciding whether a ran- domized controlled trial is the appropriate research design:

1.

2.

3.

4.

5.

Are there strategies to help team members share their personal knowledge and practical wisdom to enhance team learning? Are there specific learning behaviors that ensure members will function effectively within a community of practice? What health care process variables contribute to health care decisions and patient care out- comes? Are communities of practice models applica- ble only to functional care units? How are performance variables identified and practice improvements implemented?

Methods and Procedures

The objectives and search strategy for the Cochrane Review are thorough; the outcome vari-

ables are important and appropriate. The challenge is coming to conclusions about the appropriate- ness of the research methods because none of the studies reviewed met the inclusion criteria. Given multiple variables that may or may not contribute to enhanced health care process or health care outcomes, the decision to limit the assessment of the impact of IPE to a randomized trial design (either prelpost or interrupted time series) seems inappropriate, allowing our current state of knowledge.

References

1. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physicians’ perfor- mance: a systematic review of the effect of continuing education strategies. JAMA 1995; 274:700-704.

Wenger E, McDermott R, Snyder W. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business School Press, 2002.

2.

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