Ethics and Policy for Interprofessional Scopes of Practice: Preparing Bariatric Care Teams

Legislative Policy Impacts on Collaborative Care

At the national level, the National Institutes of Health advocates the organization of a multidisciplinary team of health professionals for the care of bariatric populations. ⁴ At the international level, the World Health Organization touts its own integrated health and education policies meant to promote effective interprofessional education and collaborative practice. ⁷ Retchin notes that state health reform efforts (often through professional practice legislation) have increased the rate of positive movement toward co-managed care models, which expand the autonomy of nonphysican providers by broadening their scope of practice. ⁶ An overwhelming barrier beyond scope of practice is payer issues relative to nonphysician reimbursement for medical services. Pennsylvania legislators have sought to overcome these practice barriers—for instance, by removing payer obstacles that thwarted nonphysician providers, mandating the inclusion of qualified providers in the state health plan—and in doing so have created a model for other states. ⁶ This action opened the door to expanded services for populations in need.

How might expansion of nonphysician practice reduce costs and improve bariatric care? Maciejewski et al. conducted a retrospective longitudinal study of male veterans undergoing bariatric surgery and found that inpatient and overall expenditures were significantly higher when compared to outpatient services, which were lower. ⁸ While the researchers called for greater evaluation of bariatric outcomes within this population, use of nonphysician health co-managers of bariatric patients holds the potential to reduce the cost of encounters. Arrow et al. note that replacing the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care is an effective strategy for reducing healthcare costs. ⁹ Interprofessional practice innovation thus suggests itself as a possible solution, one that warrants greater study. Further, another strategy is to simplify and rationalize federal and state laws and regulations to facilitate organizational innovation. ⁹ This too supports restructuring of the ways in which health professions engage in collaborative practice, similar to the Pennsylvania experience. However, it should be noted that Arrow et al. (2009) emphasized that the key to sustainable reform is changing the organization and delivery of systems of care—not just “access to” or “finance of” healthcare, but “HOW” health professions efficiently and effectively collaborate. ⁹

The United States Institute of Medicine has in the last decade offered several publications supporting interprofessional education. These include (1) To Err is Human, (2) Crossing the Quality Chasm, and (3) Health Professions Education: A Bridge To Quality.^10–12 Only recently, however, have these documents given rise to actual change from professional accrediting bodies. In that bariatric practice involves the care of complex patient populations, and since it relies upon such a complex system of care, it is difficult to predict how sweeping healthcare reforms will affect interprofessional bariatric practice. ¹³ However, focusing on simple changes in professional educational competencies will help enhance measurement of interprofessional outcomes within bariatric care. Szabo et al. (2008) reports that although bariatric surgery has a mortality rate of less than 1%, payers and accrediting bodies such as Joint Commission are requiring competency verification measures, bearing out the importance of interprofessional competency in bariatric care. ¹⁴

Professional Accreditation Advancing Interprofessional Competencies

The World Health Organization (WHO) has developed guidelines for interprofessional education and practice, noting the improved health outcomes expected to result from effective collaborative practice across professions. ⁷ The WHO notes also that achieving this goal will require interprofessional education where professions learn from, with, and about one another. ⁷ A Lancet Commission in health-professions education for the 21st century reported systematic mismatches in health-professional competencies and found that revision of health-professions education is crucial to ameliorating such mismatches. ² Specific noted weaknesses in health-professions education included poor teamwork, imbalance in gender stratification across professions, lack of technical skills with inability to use existing skills for health systems management, lack of coordination skills for continuous care, and failure to recognize the extension of care into community settings, among others. ² Essential to the future education of health professions is “critical reasoning and ethical conduct so that they are competent to participate in patient and population-centered health systems as members of locally responsive and globally connected teams” (p. 1924). ² Specifically, Frenk et al. stated that to transform health-professions practice required a fundamental shift “from seeking professional credentials to achieving core competencies for effective teamwork in health systems” (p. 1924). ² Hence, to achieve harmonized interdependence in bariatric practice calls for reform in health-sciences education that has interprofessional competency-driven approaches.

Convening first in 2009 and again in 2010, the following professions set out to establish a framework for interprofessional competencies: medicine, dentistry, nursing, osteopathic medicine, pharmacy, and public health. ⁵ Although not exhaustive in health-professional representation, their work has laid a foundation for further dialogue. Four basic interprofessional competencies were outlined: (1) shared values and ethics, (2) roles and responsibilities (scopes of practice), (3) communication, and (4) teams and teamwork. ⁵ The panel acknowledges that these stated competencies are only a starting point for engaging other professions, and sets the stage to “inform professional licensing and credentialing bodies in defining potential testing content for interprofessional collaborative practice” (p. 1351). ⁵

What interprofessional competencies promoted by these policy efforts could affect bariatric care? Let's start simply by highlighting those outlined by the recent accrediting bodies.

Interprofessional Ethics in Bariatric Care

Collaborative practice is a moral imperative, especially given the complexity of human illness. ¹⁵ A single discipline is unable to address all domains of human need holistically. Consequently, health professions have an imperative duty to prepare for interprofessional practice. Moral dilemmas are bound to a given person's situation and not to a specific discipline. Thus moral deliberation is a shared interprofessional duty not bound by disciplinary thought, but rather is patient-centered. The virtue of mutual respect is vital to relationship building in support of collaborative care, and this involves both interprofessional teamwork and inclusion of the bariatric patient. That said, while the principles for health-professional ethics are essentially the same, the disciplinary philosophy that underpins those principles might be operationalized differently, causing conflicts in perspectives and affecting health outcomes of bariatric patients. For this reason, interprofessional education in ethics should also be a core competency, that ambiguity in care should be reduced. ¹⁵

Autonomy within an interprofessional practice framework is viewed as a relational and interdependent relative to the decision-making process of a patient-centered team care rather than solely independent. ¹⁵ This viewpoint may challenge the ways in which some disciplines engage in resolving ethical conflicts. Professionalism demands the acquisition of competencies that will foster equitable negotiation in patient care, furthering healthcare effectiveness. ¹⁶ Another duty is delegation of tasks to the appropriate healthcare personnel, and this requires knowledge of self and of others. ¹⁶ Delegation when working within interprofessional teams requires knowledge of various professional scopes of practice. As mentioned previously, the complexity of bariatric populations and their accompanying comorbidities already require a team approach, so knowing the scopes of those on the team is vital to safe and effective delegation.

Bariatrics: Understanding Scopes of Practices

Santry et al. concluded from their national study that there was a need to establish minimum standards for multidisciplinary evaluation of bariatric surgery patients. ¹⁷ Health-professionals standards across disciplines are needed to assist bariatric surgeons in perioperative evaluation of prospective bariatric surgical patients. ¹⁷ Health professions are typically trained to cultivate a certain disciplinary identity; specialists are seldom educated about the identities of other professions. ¹⁸ However, understanding “otherness” within the paradigm of clinical practice requires sacrificing some measure of professional self-identity; it could even be perceived to involve forfeiting some share of professional power. ¹⁸ After all, when a health professional is educated to know only self and to think only about unique, specialized knowledge, that person operates on the basis of centrality—in other words, the specific discipline is focused only on that professional practice. When forced to recognize both the differences and the similarities of other health professions to one's own, centrality is disrupted, creating an altered power dynamic. ¹⁸ In fact, Retchin notes:

For some physicians, the political concern over the potential for conceding this professional sovereignty often trumps the benefits of substitute care. It also creates an unusual paradox—some physicians actually embrace co-management models that involve shared authority in patient care, and yet, they may resist legislative efforts to formally surrender their authority to transdisciplinary care models. (p. 932) ⁶

Interprofessional education that incorporates understanding of self and of other scopes of practice results in reciprocity: learning about, with, and from each other.^18,19 Thus reciprocal learning becomes interprofessional practice where there is collectivism in communication, shared meaning, and distributed knowing. Therefore, health professionals trained using an interprofessional model of education are equipped to practice collaboratively, in an ecological practice framework.^18,19

Interprofessional Communications

Kenward cites many examples of perioperative miscommunications, indicating conflict among various levels of health professionals, including teams and departments. ¹⁹ Given the complexity of bariatric patient populations, these communication conflicts are prone to affecting patient outcomes owing to the critical environmental forces of time and the high-risk judgments made by professionals involved in bariatric care. One strategy to facilitate clarity and alleviate ambiguity relative to interprofessional teamwork for the bariatric patient population is use of integrated documentation systems. ²⁰ Integrated care pathways that are formed with interprofessional team input allow for timely communications, reducing the high-risk judgments that can lead to medical errors. ²⁰ Here again, better understanding of scopes of practice across the professions can assist in controlling the safety, quality, and cost of bariatric systems of care on a collective basis.

Bariatric Teamwork

In addition to the primary care physician who refers the obese patient to a surgeon, other members of the team may include nutritionists, registered dietitians, exercise physiologists, nurses, and psychologists. ⁴ When including the perioperative team, the members of that team are further expanded, including anesthesiologist, pharmacist, radiology technologist, and potentially physical and occupational therapist. Such an expansive team requires clarity in roles and responsibilities to prevent redundancy. According to Bleakley, interprofessional communication in the operating room is reflective of a relational virtue known as “hospitality,” where power differentials are neutralized for the sake of teamwork. ¹⁸ The bariatric team must assume with intentionality a new identity, one of collective distinctiveness rather than individual characteristics. The uniqueness of a bariatric team is found in its distributed cognition, affect, and situational awareness, all unified for patient-centeredness. Bleakley posits that ethical interprofessional practice is characterized by suspension of personal desire for the safety and care of the patient and is achieved through the virtue of hospitality as a basis for relational friendship across professions on a team. ¹⁸

Future Bariatric Team Training

Given the health reforms being undertaken at state and national levels, the actions taken by accrediting bodies in health-professions education, the criteria set by accrediting bodies of health systems practice, and the climbing rates of obesity, one can accurately say that “the times they are a-changin’.” ¹ Change per se is not a bad thing. But change should always be evaluated, whether in education or practice. Bariatric science is a growing field of research and practice. Those developing bariatric science must be “systems aware” of the forces driving change in health-professions education and practice. Forward planning and professional engagement, in setting legislative and ethical policy that frames education and practice, are important to verifying that future bariatric professionals have the competencies needed for interprofessional practice.