Interprofessional Education (IPE): A Cautionary Tale
Commentary by Director Paul S. Casamassimo, DDS, MS
The potential benefits of a collaborative approach to care must be weighed against such possible disadvantages as training time, turf wars and quality concerns before the implementation of interprofessional education (IPE) programs. The Institute of Medicine’s (IOM) recent report1 on interprofessional education comes at an opportune time as more and more institutions look to collaborative practice models within the health professional education system. The lack of evidentiary studies, the call for research to validate improved outcomes with IPE, and the IOM’s admonition that these studies won’t be easy, should help in setting both the path and velocity of IPE. This is particularly important as the health care system adjusts to the Affordable Care Act and other shifting and tightening, much of which also lacks sound scientific underpinning.
The engagement of primary care providers (PCPs) in oral health may be a good example of interprofessional care that makes perfect sense, yet has not gained the traction that we would have hoped. Initially, lack of education about oral health in the pediatric and family practice provider community was assumed to be a major factor, but as the effort evolved, such systemic obstacles as low, inconsistent or non-existent reimbursement grew in importance. A dental care system not structured to accept referrals of very young children added to frustration. Further, the value premise of primary care oral health was questioned as physicians had to choose between oral health assessment and guidance on what most would agree were farther-reaching health issues in children. Even those most supportive of physician-driven oral health have to admit that with morbidities of obesity, aberrant behavior, substance abuse, learning problems and dozens more health issues, oral health with its own standing workforce doesn’t make a lot of sense without compelling - and the word is compelling - evidence that outcomes of benefit and minimal harm from diverting time from systemic issues justify PCP efforts. In addition, practice pattern workflow has emerged as a major issue in busy pediatric primary care practices and is very difficult to change. There is far more work to be done here.
Dental education seems on its way to an IPE shift, but also without a set of hard data to determine what makes sense. The Health Resources and Services Administration, in a report titled, Integration of Oral Health and Primary Care Practice2, suggested moving forward with modification of the education and care infrastructure, as well as reimbursement, and only then evaluating its effect. Shouldn’t we tread carefully with well-constructed pilot programs and tight studies as suggested by the IOM?
The dental education system has enough confusion already. Some call for a fifth year of dental school to master traditional skills, while others believe a two-year post-high-school program can prepare a provider to offer surgical care in an aging society and a more and more medically challenged child population. The ability of oral health professionals to adopt cross-professional skills at a level matching quality and comprehensiveness of traditional pathway providers remains to be demonstrated. Patient outcomes come later. Few if any have commented that, with the broader exposure of oral health providers to other disciplines comes an expectation that the oral health provider adhere to an even higher standard of quality, knowing now the ramifications of oral health in that other discipline. Can we fit that ramped-up expectation into already jammed curricula? So many questions need to be answered before we can consider IPE and subsequent application in clinical practice successful.
The AAPD Pediatric Oral Health Research and Policy Center will report soon on its own study of the extent, limitations, and obstacles of interprofessional practice in pediatric dentistry in this country. Can pediatric dental providers, already challenged with a significant care burden of early childhood caries, provide interprofessional care and assume the time and training commitment, the unavoidable reimbursement issues, the ultimate turf boundary squabbles? Can they bear the challenge of referring false positives and the medicolegal anxiety of false negatives? We should thank the IOM for its impartial and wise caution to gather data before moving much further. IPE and cross-discipline care may be in our future, but let’s get the data first. These issues pose complex questions related to quality care, and patients deserve the best possible answers.
- Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Report Brief, April 2015. The report brief is available at http://www.iom.edu/~/media/Files/Report%20Files/2015/IPE_RAAG.pdf and the full report is available at http://books.nap.edu/openbook.php?record_id=21726
- Health Resources and Services Administration. Integration of Oral Health and Primary Care Practice. February, 2014.
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