Abstract
The Council for Social Work Education has made a commitment to participate in interprofessional education and interprofessional curriculum building. Across medical professions, there is a common concern about the consequences of poor teamwork and implicit bias. Both medical error and interpersonal misunderstanding are an important contribution to health care disparities. Introducing interprofessional education opportunities early in professional education, offering common assignments to all professions, having a committed interprofessional faculty, and involving interprofessional students in curriculum design are all considered important to quality interprofessional education. At the core of this study is a student authoethnographic investigation of three different interprofessional interventions as part of her MSW internship. This research collaboration involved regular mentoring discussions with her field instructor to flesh out cultural context and theoretical relevance of her observations. The writing and discussion experiences of this partnership brought up concerns about unaddressed complexity in interprofessional team interactions. Professional-centrism was observed regularly, and this lack of respect for difference among team members often foreshadows the respect patients received from the medical team. Social separation, empathy, and avoiding team conflict were also a focus.
The social work profession has just started to prioritize the importance of interprofessional education (IPE) to include other professions in curriculum design. Social Work is late to the most recent health care collaboration table. The Council for Social Work Education (CSWE) became a member of the Interprofessional Education Collaborative (IPEC) in 2016 and emphasized IPE at the organization’s 2016 annual meeting with the theme, Advancing Collaborative Practice Through Social Work Education. In 2018, CSWE’s annual meeting again had an interprofessional theme, Expanding Interprofessional Education to Achieve Social Justice, and yet very few social work programs in the country are a vital part of rigorous IPE. Even as new members of interprofessional pedagogy, social work students and faculty have proven themselves leaders in better understanding cultural difference, bringing knowledge of social determinants of health, and encouraging the consideration of ways the health care team can tackle disparities on interpersonal, organizational, and community levels.
One of the main interprofessional faculty concerns in the United States is that medical error is the third leading cause of death, often caused by team misunderstanding and poor communication (Makary and Daniel, 2016). There is also concern about health disparities and the impact of implicit bias and social separation on the professions (Sloane, 2015). Lack of awareness on the part of professionals about unconscious bias is discussed in the work being done by Harvard’s “Project Implicit” (https://implicit.harvard.edu/implicit/) (Banaji and Greenwald, 2013). Stereotypes and media messages about marginalized groups act as default particularly when professionals make quick decisions in a crisis. The regular misrepresentation of marginalized individuals influences professional attitudes and behaviors unconsciously. The influence of these dangerous cultures is so embedded and unconscious that disrupting these common misunderstandings of difference is very difficult when using traditional education interventions.
Scholars dedicated to the inclusions of interprofessional training into higher education recommend the formal adoption of interprofessional curriculum early on in professional training. These recommendations include early exposure to a variety of professions, common classes that involve interprofessional student teams, committed interprofessional faculty, and interprofessional student representation in the design of the curriculum and standards (Pecukonis et al., 2008). Even though opportunities for IPE that meet these criteria are still rare, some health care educators fear these early criteria for IPE are over simplifications of what is needed to prepare students for the complexity of current-day medicine. These criteria do not provide ways in which students must learn to adapt to the complex, ever shifting medical environment.
Implicit bias is also evident among the professions as a result of professional centrism. Professional centrism is the belief that your training and knowledge is more valuable and superior to other professions. Professionals hold unconscious preferences for particular groups of people usually people with very similar worldviews. Professionals also have unconscious negative thoughts towards groups framed as negative by the larger society through the practice of stereotypes. This is not only an issue between the professional and their client but is also an issue within the team. Teams that respect and honor the unique contributions of multiple professions are less likely to make errors. Teams that involve the patient and family in discussions about the medical plan help to create environments where patients feel cared for by the medical team. Time spent directly with the patient leads to better understanding and empathy that disrupts implicit bias. Medical team members that partner with patients as part of the team are more likely to gain from the patient’s expert knowledge. Therefore, interprofessional educators describe the need to acknowledge the interdependence of medical teams and understand the importance of the patient, family, community and advocates as vital contributors to health care solutions (Pecukonis et al., 2008).
When patients are seen as experts by the medical team about how cultures influence their understanding of illness, this is a demonstration of cultural humility. Cultural humility is awareness that no one culture is superior to another. Professional humility between professionals on a team is just as important as cultural humility to eliminating bias, which silently impacts health disparities. For example, patients cannot participate as a member of the team, if the language used to communicate to them makes no sense (Lehmann et al., 1997). Special care is required to properly acknowledge and respect patients and families with health literacy challenges. Written communication and the use of medical terminology would not fit the patient context in this situation. The adoption of cultural humility by medical teams counters cultures that promote profession-centrism (Pecukonis et al., 2008).
Interprofessional interactive education sites
The following aspects of IPE are listed as essential (Bridges et al., 2011). While learning, the students must consider the development of their professional identity. Students must have a good understanding of other medical team member’s roles. Students also benefit from dedicated faculty that believes in the importance of IPE and that models professional and cultural humility. The fostering of a team identity and a sense of community in the team is also important. The three interprofessional interactive education sites for this study (collaborative class combining health professions from main and medical campus, the student-run free clinic, and an elementary school mentoring program with mentors from the health professions) were chosen because the authors felt that the three different internship experiences met the criteria considered essential for IPE. All three sites are new to social work student involvement (less than three years). The newness of the social work role paralleled the newness of the social work profession to IPEC. Below are detailed descriptions of the three sites:
IPE experiential class modules (IPE Class)
The School for the Advancement of IPE facilitates the Interprofessional Approach to Patient Care (IPE) class, which is a semester long set of interactive modules designed to provide a variety of interprofessional learning activities and educational experiences. Nearly 600 students from both main and medical campuses (representing 10 different professions) are assigned to interprofessional teams, and students have the opportunity to collaborate on health care challenges utilizing the diverse thought and strengths from a variety of professions. This class teaches students the value of dedicated minds working together on difficult problems through interactive interprofessional sessions including clinical skills training, small group (team) work, interprofessional simulations, and standardized patient interviews. At the time of this study, the main topics covered in the modules were team formation, vital signs, roles and responsibilities, interviewing and interprofessional communication, interprofessional care planning, social determinants of health, and patient safety.
The student-run free clinic (community care clinic)
The student-run clinic borrows space from a local church located in a predominantly working class zip code. The church has multiple large branches in the city and has very little description of the denomination but advertizes widely on Billboards and yard signs with cryptic messages, like: “You Matter.” The Church is very modern on the inside, with inspirational slogans or campaigns that change yearly. At the time of this study, the volunteers that help with the clinic are friendly and serve consumers and student volunteers a free dinner prior to the clinic hours. The setting is clean and has huge windows that make the rooms cold in the winter and hot in the summer. The consumers pile up outside before the clinic opens. It is a first-come, first-serve process. There are triage stations and a place for the student teams to get practice at taking histories from patients. Volunteer doctors meet with the patients with the students and they discuss possible diagnoses and treatments as a team. Students from physical therapy, pharmacy, nursing, occupational therapy, speech, respiratory therapy, and social work are involved in these teams. The consumers wait for long periods of time on the very few volunteer physicians. The majority of consumers are older adults, there are many regulars, and some come solely for medication.
Interprofessional mentoring at an inner-city elementary school (Mentoring Program)
This program involves collaboration between a local church and the public school system. The city uses a hub school model where the elementary schools serve as a central location for needed community services. The mentoring program is one of several programs by the church that supplement academics for the students in the neighborhood. The mentoring program pairs elementary students, who participate in the afterschool programs, with university students in the various health professions. The student mentors are paired with one student throughout the academic year. The mentors commit to at least an hour a week doing activities and assisting with schoolwork. The program also involves the mentor pairings in regular field trips to art museums, the zoo, and a variety of college campuses in the area.
All three settings have an educational goal of interprofessional collaboration. The IPE class is the largest intervention, although the larger class is broken into smaller groups of 12. The community care clinic (CCC) allows students to get hands-on experience at leadership and interprofessional team creation, and the mentoring program exposes students from multiple professions to inner-city communities and working closely with children at an economic disadvantage. The interprofessional students in the mentoring program had opportunities to talk with each other about their experience through regular shared education and through organized activities, like college visits with the kids.
Method
As Krumer-Nevo (2009) points out in his autoethnography on working as a social work educator with poverty, social workers are valuable autoethnographic researchers because they spend time with individuals in the community that have no voice and work beside these individuals to amplify their voice. Because of macro, mezzo, and micro systems education, social workers understand the need to put their experiences in political and historical context. In many ways, autoethnography challenges the social work researcher to be unafraid of going against the grain, to be committed to the search for difficult answers while also being vulnerable by writing about personal experiences and sharing emotions, behaviors, and attitudes. There have been recent calls within medicine to increase qualitative research approaches when looking at medical care (Maragh-Bass et al., 2016). The appreciation for the contribution of qualitative, direct observation research has also been noted within interprofessional team education environments (Sloane, 2017). Qualitative methods used to investigate interprofessional care have typically been in the form of interviews, and the analysis has been theme based.
There is limited research, however, that uses direct observation of team interaction, and there is even less analysis from the learner’s perspective (Lingard et al., 2012). Pecukonis et al. (2008) point out that an environment where students learn that their perspective as students is as important as seasoned professionals is important to successful IPE and also demonstrates cultural humility (Pecukonis et al., 2008). There is rare research, however, looking at the student’s perspective of interprofessional curriculum interventions. Mentoring in health disparities research encourages students to engage in research once they begin practicing as professionals (Green et al., 2006). Autoethnography and ethnographic methods are practical qualitative approaches that make continued research even more likely while balancing the demands of direct social work practice in the community.
This study is based on collaboration between an MSW student investigator and her field instructor. The student engaged in regular ethnographic observations and analysis of personal experience as a student participant in three different IPE settings already mentioned. The settings chosen utilize different education strategies to reduce medical team error and to disrupt health care disparities. The method included weekly reflections and field notes by the student investigator and weekly supervision discussing observations and possible themes discovered over roughly 24 weeks of research. The student field notes were explored with the field instructor and connections were made between the student experience and larger cultural, social political conversations, and theories surrounding health care disparities.
Instead of focusing her observations on other students, as is the case in more traditional ethnography, the student-investigator reflected on her own feelings, attitudes, and behaviors in these environments. The student was encouraged to write more about certain situations and to write more provocatively from all the senses to paint a picture about her experiences. As Carolyn Ellis describes in her book, The Ethnographic I: A Methodological Novel about Autoethnography (2004), autoethnography is a blending of literature and social science method. This work was led by the experience of the student and discovery from regular synthesis with her field instructor. This work was not led by a pre-conceived hypothesis.
Research mentoring was used as a model for learning about and intervening in health care disparities for this study. In a true mentorship, the learning is mutual. The mentor also offers emotional and practical guidance. The mentee is providing thoughtful observations and analysis when first learning about interprofessional teams and research. This research, therefore, was a blending of the student’s direct observations and the mentor’s knowledge from experience as a seasoned social worker on health care teams and from theoretical and pedagogy knowledge gained from previous research on health disparities. The mentor’s main job was to provide opportunity to explore and grow, to be there in moments of confusion, and to push the student to think about other possible perspectives. The results section of this article includes excerpts from the student field notes and an example of a typical exchange during supervision.
The first author/field instructor is a part of the interprofessional faculty team working to develop social work opportunities in community-based IPE sites. This study incorporates interprofessional service learning opportunities with early exposure to ethnographic and autoethnographic research experience (Warren, 1998; Sloane, 2017). Autoethnography was chosen as the method for this study because it encouraged the student to reflect on her observations and build confidence in her voice to speak out about disconnections that might lead to medical error or contribute to health care disparities. On a weekly basis, the student was encouraged to use her voice to question authority both the field instructor’s and the faculty and student leaders. Writing about these experiences served as practice and an opportunity to consider how to approach these situations in interactive interprofessional teaching settings. The following results section is a sampling of written work, thoughts, and discussions that occurred between the student and instructor. The student’s work in italics and the instructor’s thoughts are below.
Results
IPE class
Vital experience
The Vitals module was the first session of the IPE course. The teacher entered the room and introduced herself – she was a different professor than who we had at orientation. Everyone appeared nervous. No one talked to each other, the room was very quiet. The instructor began talking to us about medicine and the importance of learning how to take vitals. We split up into pairs and went to work. We practiced on each other, learning how to take blood pressure, oxygen levels, BMI, etc. As a social work student, I didn’t know my role in this case. I was feeling nervous, overwhelmed, and unknowledgeable. I was observing my peers and watched a SLP student who was feeling the same way that I was. We were thrown into the experience as if everyone knew how to do it.
I couldn’t figure out the blood pressure, so the professor came over to give me assistance. She had a two-way stethoscope so that we could both hear. I did not understand and was not hearing what she was. She made me feel very uncomfortable – so I lied and said I heard the beats, when in reality I did not.
At the end of class we had to do vitals on a dummy and record our results.
As I reflect on this situation, I feel as though the professor was modeling the opposite of what the course stands for. There are several medical students in the room watching her embarrassed that this doctor belittled someone who didn’t know the same things that she did. There was no discussion of teamwork or communication. There was no discussion of roles or responsibilities. Lastly, the team activity was not done as a team. It was completed individually and in a competitive manner.
The vitals activity that begins the IPE modules bothers me as an educator, so much so that I wrote an essay framing the first class as one way in which medical teams begin to engage with the patient and respect the patient’s knowledge about their health and illness. I also wrote asking the students to consider how doctors that respect the old, hands-on ways of medicine may do a better job at connecting with patients. New technology and tests can keep medical teams from spending time with the patient, which could lead to disconnect between the patient and medical team. Patients are an important part of the team and need to be treated as such. The essay that I wrote (edited by one of my pharmacy faculty teammates) is now included in the material that students read prior to this module.
Belittling students for their lack of knowledge is a demonstration of a lack of respect for the learning process and the varied roles and responsibilities across professions. This lack of respect prevents students from contributing their unique insights about problem solving as a team. Identifying as a team and valuing team members leads to good team communication. Environments that stress authority and see professional roles as rigid are the exact opposite of what encourages interprofessional communication. Social workers are particularly sensitive to these behaviors because of their training about injustice and advocacy. To preserve value, students will not speak up about the injustice and lack of professional humility. This silence gets the student no experience of standing up for themselves, for others on the team, or more importantly the patient. An early experience where the students learn that their feedback is crucial to team growth would support much better outcomes for the patient. The focus on getting a task completed correctly is counter to cultural and professional humility. The focus could be shifted to team interaction and how to create comfortable, open communication, so that difficult problems can be solved by valuing multiple perspectives.
***
Crying standardized patient
One of the IPE sessions was a standardized patient interview. During the interview, we found out that the patient had recently lost her husband, and her parents in recent years prior. After being ill and having surgery our suggestion was to have her return to a rehab center until she was able to be more mobile and independent. Note, rapport had been made with the patient.
After two interviews, I was asked to provide our suggestions to the patient. When speaking with the patient, she quickly became upset. She began crying and seemed very unsettled with our suggestions. I leaned in closer, to show that I was listening and being sincere. When her crying persisted, I gently rubbed her shoulder.
After the interview was over and the patient left – she was sat before us and gave us feedback on the successes and challenges we faced while interviewing. One of the medical students raised his hand and said, “You touched her arm.” By his tone of voice and facial expressions – you could tell that he wasn’t sure if it was a good thing or a bad thing that I made physical contact with the patient.
The professor asked me why I chose to touch the client in that moment and I said, “because she was upset and it wouldn’t be genuine of me to sit back and watch a person cry – while having no reaction. I followed the patient’s cues and chose to lean in and touch to show empathy for her and her given situation.” The professor pointed out the word “empathy” on our interviewing checklist.
***
Most of the medical professions are taught to approach patients with detached empathy. This is a concept that began in the early days of modern medicine (Sloane, 2015). Detached empathy requires the professional to stay emotionally distant so that they can remain objective like a scientist, but also requires the professional to show compassion. Medical professionals must rationally understand emotions surrounding pain, suffering, illness, and disease. The lessons that are taught students are in part to never touch a patient because this snaps twigs in an invisible boundary that must always remain firm between the practitioner and the patient. This student demonstrates by leaning in and touching the patient that touch may have new possibility for connection. The only way to properly assess if a team is able to empathize with the patient is to get feedback from the patient. This level of understanding requires open communication and a willingness to change an approach if it is not working for the patient. The team in this example felt that empathy was demonstrated; however, the team is not the true judge of this; it is the patient. Typically, standardized patients do not give feedback on empathetic connection. Giving feedback about professional understanding of the patient’s perspective could disrupt implicit bias that contributes to health disparities.
In both of the examples so far, practice of honest feedback seems crucial to improving team problem solving and to create understanding and connection between the professional and the patient. In the case of the vitals class, to change the learning outcome of the exercise, the student could benefit from the opportunity to give feedback to the facilitator. In the case of the crying standardized patient, the student team needs feedback from the patient about empathy. The IPE class has built in debriefings after every module. There is opportunity to have open discussion and to provide feedback but even with this space for open discussion, students do not always feel comfortable speaking up.
***
Community Care Clinic
The chart mix-up
The patient that they brought to the table was a young male – clean cut and well dressed. He kept to himself and it was clear that he was bothered or uncomfortable with the news he received from meeting with the doctor. He was well spoken and pleasant.
During the interview, I was going over lab work paperwork with the patient and his follow up instructions and he mentioned that the last name on his lab sheet was incorrect. After looking through the day’s paperwork – I found that his information as all documented on another man’s chart.
I found the patient’s medical team and discussed the problem. They took the chart and started to figure out the information. Although this was their job, they didn’t address the patient. The medical team took the patient’s paperwork and left the patient sitting at discharge with no explanation or apology.
I sat with the patient and his partner.
The medical students returned with an answer to the problem after 20 minutes. The students addressed the issue with me and never addressed the patient for the mistake. I went over all of the corrections and made sure the client was satisfied with the services he received.
After processing the situation, I was left with questions about the sincerity that the students had for the patient. I was also upset for the lack of consideration for his feelings and loss of time. It’s unfortunate and I was left wondering how that patient felt leaving the clinic – even though he appeared thankful.
***
This is a proud moment for the student. She did a great job, felt competent, and understood that if there had not been a social work student at the clinic the outcome for the patient might be different. The patient left feeling cared for, which is important to his future pursuit of medical care. This is also a moment of missed opportunity to learn as a team to do a better job. The student identifies with her professional values and begins to generalize about medical students and empathy. She is reflecting on a moment of team conflict and the negotiation of power. If the clinic were a setting that allowed team members to talk honestly and respectfully with each other, this could be a moment to suggest ways to connect with the patient and have him leaving feeling cared for even after a mistake. If patient care and connection as well as team connection was valued over authority and hierarchy….what would that look like? This experience is similar to the classroom conflict from before where a medical student bravely asked about the appropriateness of touching a patient. Leaning into the conflict opened an opportunity for a discussion of power and dynamics between the team. The student admitted to not speaking up out of fear of making an error. In the case of the chart mix-up, instead of empathizing with team members and admitting to her own fear of mistakes, this was instead an opportunity for professional centrism on the part of the social work student. Empathy stopped with the patient and was not extended to the team.
***
Students with commitment to the poor
A situation that stands out to me is a medical student that goes above and beyond to help those in need. I was lucky enough to witness this person in a medical student role at the clinic and in a mentor role for the mentoring program. The medical student has been mentoring the same child for two years. During the summer, he continued his relationship. He spent 8-hour days with this child in order to continue their relationship and have a presence in the child’s life. He attends mentoring every Tuesday to meet with his mentee. In addition, this med student was trained and leads the Too Good for Drugs program for the 5 and 6 grade students. He does this every other Tuesday with a fellow medical student.
As if that is not enough, the medical student volunteers regularly at the community care clinic (CCC) and sits as a representative on the board of directors. My first night at the clinic, this individual knew that I was new to the CCC and introduced hisself to me. He told me a little about the clinic and about his role and involvement at the clinic. He is always smiling and full of life. Each time he brings the patients to discharge, he introduces us to his patient and thanks us for taking over the patient. He’s genuine when working with the patients and it shows through each time he brings a patient to discharge.
The individual was raised in the T-town area
******
According to the research, students are more aware of really good examples of team leadership and of really bad ones (Burack et al., 1999; Burford, 2012). All the other behaviors go unnoticed, even if the leader is practicing in a way that creates barriers to good communication and that supports bias. Leadership is more than power, as in this example, leadership is also fostering an appreciation for team and community. The student mentions that her role model is from the city that the program and University serve. She admires that he values the community over his professional identity and she sees this quality as leadership. The social work student makes passive observation and merely considers the leadership style of an interprofessional colleague. She is not motivated to adopt his model of leadership. That this young man seems unusual is a problem. That his example is considered an anomaly puts his quality of care on the fringe and not as the norm. If compassionate leaders get noticed as well as insensitive leaders, there is a risk that the majority of students that fall in between are not contributing to conversations about leadership, many voices are left out. These extremes of leadership are held as examples of impossible or avoidable. There is never a conversation about what leadership model is most admired or that students have an opportunity to practice leadership while students. An open conversation about what motivates compassionate leaders could be helpful to those students passively observing.
***
The rude volunteer Spanish interpreter
One of the medical students brought a patient to the SW table to be discharged. She was in a wheel chair and didn’t speak English. The medical student mentioned that the patient didn’t speak English. J (a social work student who speaks Spanish) was on the computer looking up information for another patient. He was working on getting up from another table to do the discharge interview.
The medical student on the case also spoke Spanish and was translating for the patient. She rolled her eyes several times and insisted that J come right away demanding, “hurry up … come on.” There was a high level of disrespect in the situation. J sat down to take the interview and she stood. She didn’t sit next to the patient; she stood and had the presence that the interview was an inconvenience. As I sat back and observed I reflected back on similar situations where I felt disrespected by this individual.
There are times at the clinic when the role of social work is viewed as a minimal portion of the clinic – or is it that the medical aspect is just more important? There have been times at the clinic that comments have been made about ‘Oh, it’s just social work.” In this specific situation, I was left frustrated and wondering why we were talked to in such a manner.
***
Disrespect of team tends toward disrespect for patient. If an individual team member is not able to demonstrate professional humility, cultural humility is likely just as hard. Each member of the team has something valuable to contribute to problem solving. The patient has valuable knowledge as well. When a team member is convinced in their superiority, this superiority mimics ethnocentrism. Ethnocentrism is discrimination, a believing that you are better because of your group membership. This is an overt example of bad behavior on the part of a student. Unfortunately, it is also evidence of more hidden bias that is equally dangerous. Professionals of all sorts have a harder time empathizing with those they see as different. This bias could be a doctor not recognizing the value of a social worker in the case of professional centrism. This bias could also be a white middle-class male unable to recognize the discrimination faced by an African-American woman living in poverty (Sloane, 2015). It is not enough to simply recognize individual bias, it is also important to become conscious of the process that creates unconscious bias.
Mentoring Program
Saying goodbye
Being removed from the mentoring program was sad and unexpected. In the moment I thought about how I was going to miss the kids, but I truly didn’t think it would impact the students (only 5 or 6 came to my mind). My role at the mentoring program was very general and I didn’t have a lot of time to make one-on-one deep connections with multiple students. I was supervising the program as a whole – so I found it hard to build those lasting relationship, only one day per week. My perception on that changed the day I told the kids that I was leaving and that I had to say goodbye.
The students that I was worried about, displayed sadness (several hugs, saying goodbye on multiple occasions throughout programming, “I will miss you,” why do you have to stop coming).
But, what surprised me most was the students that gave me a difficult time. – Flash back, I lead the Too Good For Drugs program on several occasions. There were select students that didn’t want to participate, that would disrespect me, talk out of turn, play on their phone, roll eyes, etc. These students often intimidated me and made it difficult to discipline. But – after I said my goodbyes and students were leaving, two of these students approached me. One said, “Miss K., you will truly be missed” – (this students is normally talking in a loud confident voice, was now in a quiet mumbling tone) His friend, “I agree with him, everyone is going to miss you”
I spent my drive home thinking about this moment specifically and the impact these two young boys had on me.
Sometimes it’s the moments that you think you are least impactful- that in reality you are affecting others in a way you’ll never know.
***
Instead of passive observation, this is an example of active reflection. In Cleland and Johnston’s (2012), they suggest that giving students opportunities to be critical of their learning environment empowers them to change discriminatory cultures. The last statement in the reflection is powerful, “Sometimes it’s the moments that you think you are least impactful – that in reality you are affecting others in a way you’ll never know.” We can have mysterious impact on our clients in good ways and in bad – this is an important lesson to learn that our interactions hold meanings we don’t understand. In general, health care teams are unaware of hidden dynamics between team members and with their patients. In the case of this example, the student underestimated her value to her mentees.
The student shared worries that I believe she was taught by other social work academics that she could never possibly connect with inner-city black children and that no matter how hard she tried she would never understand their lived experience. This warning might be true on some level, but that we will never completely connect or understand should not stop us from trying. One of the most important lessons of the internship experience was realizing the impact of social separation in the United States. That the student was experiencing black children for the first time in her life is in part the result of long-term discriminatory policies in the United States. When that separation is erased, people who would not have an opportunity to learn from each other learn there is value in their fostered relationship, but it also strikes down the myths created by separation as false.
Discussion
In each of these experience examples, there are unrecognized connections and disconnections between team members and between patients and the medical team. Much like students do not speak up about mistakes, injustices, and disconnects out of fear of being wrong or going against the grain of the power structure, patients also remain silent about concerns they are having about their care. When researchers look at how students in medical settings consider equality, dignity, and empathy, they tend to remain neutral, and fit in where they can, not questioning the system (Phillips and Clarke, 2012). They feel powerless and identify with the powerlessness of the patient. Internships, service learning, community-engaged research are all spaces were students must negotiate a mix of personal values, professional values, institutional values, and the values of the greater society. In the example when the student leads with disclaimers about why she was certain, there would be no meaningful connection between her and her students at the elementary school, she learned a powerful lesson that her time and genuine concern are more powerful than she would guess. Medical teams underestimate the power of their interactions both positive and negative.
In past studies looking at power and conflict on medical teams from the student perspective, rarely did students speak up when witnessing injustices or mistakes about to be made. Students regularly see examples of poor communication and dismissal of the patient and family. Instead of disrupting these attitudes and behaviors, students avoid conflict and privately commit to practice differently when they begin to practice. Interns and residents are conditioned in medical school to not dare question the authority of their professors (Janss et al., 2012). This is likely true for other professions and not just a part of medical education. This lack of open reflection on power dynamics does not allow for recognition of knowledge from personal experience or emotional intelligence, which are crucial to professional humility and empathy for others.
Within professional curricula, there are unplanned lessons that influence our students quietly to not value genuine human connection. Phillips and Clarke (2012) have found that this implicit curriculum encourages loss of idealism, a professional centrism, emotional neutrality, and an acceptance of hierarchy – among other things. From this experience of a research mentorship, we were able to witness and analyze some of the obstacles to connection between the team and between the team and the patient. IPE that was task-centered became more about getting the task done correctly than it was about learning how to take in multiple perspectives and face a task as a team. In the student’s experience task-centered environments perpetuated a climate of one right answer and therefore a fear of error. The interactions of the team were not a topic of discussion except in the IPE class. All settings could benefit from open and honest feedback about how the team is working or not working well together. Moments of empathy and moments of professional centrism can be called forward by instructor and student but rarely happens.
The regular written reflections allowed the student to express outrage. Ethnographic and autoethnographic analysis is helpful for leaning in to outrage. From the students writing and supervision, she was able to be angry at the systemic discrimination that she witnessed coming in the way of the parents of the kids at the elementary school and how the same issues come in the way of children’s opportunities to meet their potential. Children do not chose poverty, or make decisions that cause poverty. That this part of the American experience has been hidden from the student inspired emotions that are a catalyst for advocacy. This experience has countered the damage done by stereotypes, media messages, and social separation. The connection with the kids now stands in for the student’s ideas about black youth, which are positive. This experience created an awareness of societal and environmental influences.
In these internship settings, there was a great deal of autonomy afforded. In this way, students learn to be leaders together as novice professionals without the overbearing influence of experienced teachers. As mentioned before, traditional medical internship sites tend toward a culture of not questioning experience and respecting authority. Social workers are notoriously undervalued, fraught with role confusion, and are rarely given authority and autonomy in medical settings (Sweifach, 2015). This is no different in student-run settings. In the social work classroom, less time is spent on assertiveness, facing superiority and abrasive personalities, and dealing with power dynamics and conflicts faced by social workers in medical settings.
Bias toward medicine as the only possible leader on medical teams makes social work leadership in medical settings a challenge. The social work research role is a leadership role. Presenting alongside medical students at conferences, which is a regular part of this internship, acts as a catalyst for students to embrace and be enthusiastic for the possibility of social work leadership on medical teams. The experience builds confidence in the social work student’s unique abilities much more than the clinic, IPE, and mentoring experience. Empowering patients and focusing on strengths are unique skills that social work has to bring to the team (Barnes and Hugman, 2002). Students often do not see themselves as leaders.
Conclusion
Listening to the student experience of interprofessional pedagogy for insights about the lack of complexity in the current models of IPE was fruitful. As the literature would suggest, the student experienced moments of professional centrism and cultural humility when working with several interprofessional student groups. But instead of professional centrism and cultural humility being topics that were specifically brought up in her internship and interprofessional classroom, she was left to struggle and negotiate these common experiences on her own.
The student demonstrated leadership on the student medical teams around empathy and understanding of difference, however, was not recognized or listened to for this expertise without the formal facilitation of a dedicated IPE faculty member (pharmacy). To be the leader on the team about emotion, interpersonal conflict, and power dynamics is daunting. After this experience, both researchers struggle with how to embrace the controversial role of raising consciousness about implicit bias and professional-centrism. In reality, lessons about empathy and discrimination should be the responsibility of all professions. Empathy and genuineness can be modeled by the social worker on the team but these qualities need to be a priority of the entire team. Again empathy, power, conflict, discrimination are topics that were not delved into in the classroom or in preparation for the internship site and community sites.
Because of the focus of this study, the patient perspective about empathy, genuineness, professional-centrism was not investigated. Unfortunately, without patient input, we are missing a huge part of the story and miss out on the wisdom from that vital team member. What we found missing from the critique of current interprofessional curriculum approaches is a discussion of social separation in the United States and how this separation impacts our students and in turn their clients. Social separation should be addressed specifically with students. In our experience, moments of student outrage were fruitful for investigation of injustices within the interprofessional team. Student opportunities to reflect during their learning is key to beginning conversations about emotions and concerns brewing under the surface for students when first encountering individuals and neighborhoods that are different and outside of the interprofessional student experience.
We also identified that the authority of faculty, particularly in task-centered activities can come in the way of questions that could be crucial to improving communication on the team and to disrupting bias. Creating a climate were students regularly question authority and that mistakes within team interaction are normal and important to learning demonstrates empathy and acknowledges the complexity of current-day medicine. Part of professional humility within the faculty group would be regular discussions about social workers (and other similar professionals on the team) having difficulty getting respect, having autonomy, and difficulties with role confusion. Involving the team in the tension within the profession about what can be done practically and what should be done is a smart idea.
Social workers know how to identify strengths, empower, and are not afraid of looking carefully at social disadvantage. Social workers are also not strangers to thinking about process and systems that are inspired from the bottom up and that value humanist theory over positivist theory. To disrupt professional-centrism as well as other hidden tendencies toward superiority, IPE faculty needs to discuss power dynamics openly. Not only do the hidden demands of health care need to be openly discussed as part of what is invisible in health teams, it is also important to discuss the hidden consequences of medical error and implicit bias. Students need opportunities to acknowledge dynamics of power and feelings by team members about conflict as normal realities of a team.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.