Helen R Winefield & Anna Chur-hansen. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.
There are unique problems for clinical health psychologists in multidisciplinary settings compared with those faced by psychologists working in more traditional settings such as mental health clinics and private practice. These include professional isolation and the difficulties of communication with other professionals trained with different vocabularies and conceptual frameworks, status conflicts, and the risks of role ambiguity among the treatment team members as well as public confusion over roles affecting the expectations of patients/clients. Jones and Salmon (2001) consider “multidisciplinary” as two or more professional groups with parallel but independent goals, whereas “interprofessional” is the preferred term for situations where professionals from different backgrounds work together to achieve collaboration. In this chapter, however, these two terms are not strictly separated.
A number of authors have identified education at undergraduate and postgraduate levels as the linchpin for successful interprofessional practice. The United States, the United Kingdom, and Scandinavia all have in place a formalized system of policies that promote interprofessional agendas (Jones & Salmon, 2001), but this is not the case in Australia, even though public sector mental health services are most often provided by multidisciplinary teams, including psychologists (Australian Department of Health and Aged Care, 2000; Herrman, Trauer, Warnock, & Professional Liaison Committee [Australia] Project Team, 2002).
It is somewhat ironic that many of the interpretations and analyses of teamwork, decision making, and interprofessional relations are based on models from social and cognitive psychology, yet psychology as a profession is often not represented. In terms of a scientist-practitioner model, it appears that the science of psychology is used in an interdisciplinary way more often than are the practitioner aspects of the discipline. Because of this dearth of specific information, this chapter generalizes principles from studies involving a range of health care professions.
The traditional sociological wisdom that professions are self-interested groups divided by different identities, statuses, and autonomies was rejected by Hudson (2002) as pessimistic and problematic. He argued that members of one profession may have more in common with members of a different profession than with members of their own profession and that the promotion of professional values of trust and service to users can form the basis of interprofessional partnership. He further proposed that socialization to an immediate work group can override professional or hierarchical differences among staff, that professionals and bureaucracies can join forces in a collective effort to achieve their goals, and that effective interprofessional working can lead to more effective service delivery and user outcomes. Hudson’s vision is an enticing one, but to consider strategies to move toward his ideal, we first need to consider the benefits and obstacles of multidisciplinary health care. Advantages that have been identified include continuity of care for the patient, a wider range of skills and talents, greater choice for the patients in choosing a practitioner from the preferred gender, cultural/language background or sexual orientation (Balon, 1999), a more holistic approach to management, and (for the coworkers) more emotional and professional support as well as a more satisfying work environment and ethic (Cook, Gerrish, & Clarke, 2001).
We need to specify relevant outcomes to assess the success of multidisciplinary staff teams as opposed to other sorts of staff teams. The following seem the most important: (a) job satisfaction and consequent physical and psychological well-being for the clinical health psychologists and the other health professionals who work together as well as better staff morale, retention, and productivity (Barnes, Carpenter, & Bailey, 2000); (b) improved cost-effectiveness of service delivery such as better use of the skills and knowledge of professionals with diverse backgrounds, higher quality work performance, and fewer mistakes and errors in diagnosis and treatment; and (c) greater satisfaction with services for the clients as well as improved mental and physical health, including quality of life and functional capabilities.
The various health disciplines likely to be working together with psychologists in health care settings include physicians, psychiatrists, and other medical specialists; nurses; social workers; occupational therapists; physiotherapists; and other allied health professionals such as podiatrists, audiologists, speech patho-logists, and nutritionists. The collaboration between psychologists and medical practitioners is reported more fully in the psychological literature than is the collaboration between psychologists and other health care professionals. Whatever the reason for that, the sparse literature about nurse-psychologist collaboration or social worker-psychologist collaboration deserves augmentation through careful research investigations. The collaboration among the other disciplinary groups, excluding psychology, must be left for books about integrated care of those sorts (e.g., medicine with nursing, social work with physiotherapy). Other allied health professions may have a less ambiguous relationship with medicine than does psychology because they are more clearly identified as providers of auxiliary services. In contrast, psychology defines itself as a science as well as a health care profession.
Much of what follows focuses primarily on effective collaboration between psychologists and medical professionals, whether specialists (principally psychiatrists) or those providing primary care. But several authors have drawn attention to the need for psychologists to learn to collaborate with other nonmedical health professions, pointing out, for example, the key role of nurses, especially in hospital care. It is clear that psychologists may need to develop effective models for working with mental health-trained nurses also in primary care. There are many more nurses than psychologists and will be for the foreseeable future, and nurses seem likely to have important functions to provide basic supportive community care.
Consultation-liaison psychiatry is based on the psychosomatic idea of health and disease arising from an interaction of biological, psychological, and social factors. Lipowski (1967) defined consultation-liaison psychiatry as the subspecialty of psychiatry concerned with clinical service, teaching, and research in nonpsychiatric health care settings. The parallel development in psychology has been that of the subspecialty of clinical health psychology (Belar & Deardorff, 1995). As explained by Horne,
The clinical psychologist is an expert in the application of clinical assessment and treatment skills to change an individual’s maladaptive behavior, thoughts, and emotions. Health psychology provides an expanding knowledge base regarding psychological factors in health and illness within a biological and sociological context. The clinical health psychologist draws on expertise from both clinical and health psychology to work as a practitioner in a medical/health care setting.
(Strain & Horne, 2001, p. 111)
Horne then outlined the key issues particularly well managed by psychologists, including (a) clinician-patient communication, (b) factors in adherence to treatment, (c) dealing with medical anxieties and phobias in patients and clinicians, and (d) preparing patients for invasive and surgical procedures (Strain & Horne, 2001).
Disadvantages of interprofessional practice between psychologists and psychiatrists have been identified, including factors such as the following:
- Perceptions by some members of the medical profession that shared care is unethical
- An unwillingness by some psychiatrists and psychologists to let go of ideological prejudices
- A concern that psychologists might not have sufficient expertise to deal with serious mental health problems
- Differences in training between psychiatrists and psychologists, in particular the biological bent of the former against the behavioral bent of the latter (Goldsmith, Paris, & Riba, 1999)
- A lack of knowledge about each other’s roles and capabilities (Neal & Calarco, 1999)
- Dilution of psychologists’ responsibility for patients
- The potential for personality clashes, compounded by professional differences
- The complexity of coordinating and arranging teamwork (Cook et al., 2001)
In a report on the roles and relationships of psychiatrists and other service providers, Herrman and colleagues (2002) identified five main obstacles to effective teamwork: (a) ambiguity or conflict over roles, with a common assumption in practice and in the literature that the psychiatrist or medical professional is the team leader who allocates roles and duties, with the other professionals viewed as “physician extenders” (Schuster, Kern, Kane, & Nettleman, 1994); (b) conflict and confusion over leadership, whereby the psychiatrist usually assumes leadership on the basis of superior knowledge and training; (c) differing understandings of responsibility and accountability, with psychiatrists sometimes hesitating to work in teams because they are concerned that they may be held responsible for other professionals’ errors (which in fact is not the case); (d) interprofessional misperceptions related to differences in skills and training, values, culture, socialization, and cognitive style; and (e) differing rewards among professions, with power, status, and income all playing a role. Gilbert and colleagues (2000) noted that these differences in rewards across professions may also become confounded with gender disparities across professions.
Nicholas and Wright (2001), in discussing collaborative work by psychologists and psychiatrists in pain clinics, commented that mostly the question of who provides which service should be decided on the grounds of who can do it best, not a priori on the grounds of discipline. However, as they noted, the biomedical background of psychiatrists makes them better able to use psychotropic medications and to assess how these may interact with other medical aspects of the patient’s condition, whereas psychologists are usually better able to use cognitive and behavioral interventions for individuals and groups and have more expertise in the development and use of psychometric measures. This situation is not static. Recently, some U.S. psychologists have gained the right to prescribe psychotropic drugs despite intense resistance to this innovation by psychiatrists—and some psychologists (Goode, 2002).
There are historical influences on the expectations of each profession regarding its roles in patient care, and in different amounts of emphasis on the scientific evidence base and how to evaluate the scientific literature and whether one is expected to contribute to it. Each profession probably has a different view of where it stands on various “skills pyramid” conceptualizations. The Australian Psychological Society (2000), for example, developed a model of the levels of expertise in mental health care that has specialized clinical psychologists at the top level, dealing with complex cases, innovations to treatment, and evaluations of effectiveness. At the bottom level are generic counselors who, after being trained by psychologists, offer first-line help to those in need and can recognize the need to refer upward as appropriate. The middle level of skill is characterized by the delivery of interventions (after some training) such as assertive therapy, couples therapy, and manualized cognitive-behavioral therapy. The middle level might be where medical practitioners with appropriate extra training would best fit, although in normal circumstances many of them will not have the time or interest to undergo the necessary extra training, thereby bolstering the argument for more public access to psychologists.
Other historical (and some continuing) influences include the reimbursement schedules via government and other third-party payers, insurers, and managed care organizations. In Australia, the universal public health insurance does not include payment for psychologist services; it includes payment only for medically qualified practitioners (including, of course, psychiatrists). Accordingly, private practitioner psychologists are very limited in what proportion of the population can afford their services. A recent governmental policy innovation, the Better Outcomes for Mental Health initiative, implies more extensive possible roles for psychologists in two ways, although their involvement is not stated explicitly. One is that primary care physicians, or general practitioners, will need training in mental health care to qualify for higher rebates for the longer consultations that this form of treatment requires. The other is that general practitioners may gain discretionary government funding to pay for specialist mental health care for their patients, and if they hire psychologists to provide this care, they will overcome the financial burden for patients that seeing a psychologist currently imposes.
In Britain, all clinical psychologists are employed by the publicly funded National Health Service and work alongside doctors and other health professionals, again at the discretion of the general practitioners who direct the spending of government funds for health care. The fact that psychologists are salaried rather than private practitioners, of course, increases their accessibility to the public enormously.
In the United States, the managed care movement has created much consternation for mental health workers who were not accustomed to concepts of accountability and cost-effectiveness (Todd, 1994). However, its focus on brief, evidence-based, problem-focused treatments sits well with the usual mode of psychological intervention in medical settings. Conversely, psychologists’ familiarity with empirically supported treatments is entirely compatible with medicine’s current emphasis on evidence-based practice.
Specialized Skills Needed for Multidisciplinary Work in Health Settings
Although medical patients are likely to show high rates of anxiety, depression, and other affective and cognitive pathologies, psychologists and other clinicians working in medical settings need a thorough understanding of normal psychosocial development, stress and coping, and behavioral health issues. In our society that retains dualistic mind-body concepts, the effort to bridge health and mental health may always be challenging. As Belar, Paoletti, and Jordan (2001) pointed out, psychologists and psychiatrists in medical settings act as bridges between their core disciplines and the rest of health care, being mainstream in neither. They have to accept a consultative role, and they also need to become comfortable in working with patients who are sick, disabled, disfigured, injured, or even dying. This is despite the possibility that a desire to avoid contact with illness and death might have been a motivating factor for some health professionals to be drawn to psychology or psychiatry.
Beyond patient care, there are large areas of interprofessional collaboration where the specific training of the psychology graduate may enhance the professional effectiveness and job satisfaction of health coworkers. The scientist-practitioner model equips psychologists to understand empirical evidence and interpret the literature critically; this skill is not emphasized in the training of many other health professionals. The model may assist members of a health care team to monitor their own practice and its outcomes in a scientific way, to keep useful records of the process and results of care, to design controlled studies of innovative treatments, and to communicate with others through the professional literature. One recent step in this direction has been the acknowledgment that the effort to be scientific about practice need not be abandoned if the “gold standard” multisite randomized control trial is impractical to undertake. Psychology has a history of deriving valid and reliable conclusions from the small-sample research study (Morgan & Morgan, 2001; Radley & Chamberlain, 2001). This methodological expertise is newly valued, particularly when managed care demands maximum accountability and the identification and use of the most cost-effective treatment plan.
Another contribution that psychologists may be able to offer their professional colleagues is their understanding of systemic factors in the workplace that may facilitate or impede effective delivery of care. Specifically, jobs in health care are often high in the demands they make on workers (e.g., workload, responsibility, complexity). Therefore, organizational theories such as the demand-control-support model (Johnson & Hall, 1988) predict that the levels of control and autonomy that workers have, and the supportiveness of coworkers and supervisors, will have a major impact on worker satisfaction, retention, and even quality of work performance (Dollard, Winefield, Winefield, & De Yonge, 2000; Judge, Thoresen, Bono, & Patton, 2001; Winefield, 2003). Although risk management in health care is a huge and specialized field that must take account of the multiple pathways through which mistakes and adverse events may occur, psychologists’ educational background may uniquely fit them to see the management and job design issues behind these and other work stressors and to suggest sustainable remedies (Barach & Small, 2000; Griffiths, Randall, Santos, & Cox, 2003; Jones et al., 1988).
Skills Needed for Hospital Settings
Milgrom, Burrows, and Schwartz (2001) provided a checklist for new psychologists adapting to work in medical settings. Items include being brief and clear in communication, respecting the organizational culture and unwritten rules of conduct, becoming familiar with medical procedures and drugs as well as their side effects, being prepared to admit ignorance and ask for advice, and adopting a long-term approach to educate colleagues over time. For example, it will be necessary to attend and participate in team meetings, however time-consuming this seems, in the interest of increasing familiarity and confidence among team members.
Nicholas and Wright (2001) described the gradual replacement of “multidisciplinary” health care teams (headed by physicians) with “interdisciplinary” teams (led by individuals who can coordinate the collaboratively agreed-on treatment plan and manage the team dynamics). These are bound to be tense occasionally as people with different conceptual frameworks try to deal effectively with highly distressed and complex patients. It is essential, according to Nicholas and Wright, that team members agree on the treatment model they are using and that mechanisms exist for them to cope with disagreements and continue supporting each other.
Milgrom and colleagues (2001) noted that nurses often have a unique role to observe patients, their responses to treatment, and their family interactions on a daily basis, making nurses key members of multidisciplinary teams. Doctors may seem pressed for time but should not be excluded from consideration of the psychosocial aspects of patient care. Such teams have a complex and largely unspoken hierarchy of status roles and expectations that are bound to cause some conflict. Psychologists and psychiatrists, with their training in interpersonal relations, should be in a good position to keep the systemic perspective in mind and to facilitate the resolution of these conflicts. Mutual respect and understanding among team members is vital for the team to function effectively. Dual relationships increase the risk of exploiting the power differences between therapists and patients, confidentiality can raise difficulties, and all practitioners have a responsibility to continually update their own professional learning. Team approaches increase the possibility that responsibility for patient care may become diffused (Belar et al., 2001), so it becomes very important to maintain alertness to follow-up and to appropriate documentation of cases.
At the more preventive health promotional level, Michie (1998) wrote about consultancy or targeted research undertaken at the request of another health professional. The examples she cited came from requests from surgeons, physiotherapists, nurses, occupational health officers, medical educators, and primary health care visitors and nurses. She commented on the empathy and tact, in addition to the communication skills and research design expertise, needed by consultant psychologists. She also advocated that psychologists in this role act collectively and strive to avoid “the trap of the individualism that has sometimes been associated with psychologists” (p. 167). Members of the College of Health Psychologists of the Australian Psychological Society are also trained in public health psychology and health promotion. Very few physicians, with the possible exception of epidemiologists and public health specialists (who rarely work directly with patients in delivery of care settings), have this perspective, and neither do nurses or other allied health professionals.
Skills Needed for Primary Health Care
All of this is relevant to psychologists working in multidisciplinary primary care settings, although these settings have their own special characteristics as well and in fact represent one of the most exciting new directions for applied health psychology at the current time. With the unresolved difficulties of providing mental health care through a separate system that is often parallel but inferior in resources to the “physical” health system, countries such as Britain and Australia are actively exploring the value to consumers of making treatment for psychological difficulties and dysfunctions available where the public is—in primary health care.
In Australia, 82% of the population is likely to visit a primary health care physician (general practitioner) each year. Although about one of five adults will experience a psychological problem sufficient to interfere significantly with daily life and function (Andrews, Hall, Teesson, & Henderson, 1999), only a minority of those receive any mental health treatment, and when they do it is unlikely to be from a mental health specialist. However, general practitioners are poor at both detecting and treating high-prevalence psychological disorders such as anxiety, depression, and substance abuse.
Untreated anxiety disorders are associated with substantial health care costs, including unnecessary ambulance trips, hospital emergency department presentations, diagnostic procedures such as ECGs (electrocardiograms), and frequent use of primary health services. Greenberg and colleagues (1999) estimated the annual cost of anxiety disorders, adjusted for demographic factors and comorbid psychiatric conditions, to be U.S. $1,542 per sufferer in 1990, with 54% of the total costs being for nonpsychiatric medical care. The human and social costs of anxiety disorders are also substantial (Mendlowicz & Stein, 2000). Psychological interventions have been demonstrated to be successful treatments for a range of conditions, including anxiety and depression (Chambless & Hollon, 1998; Chambless & Ollendick, 2001). In addition, psychological interventions have been shown to increase the well-being and decrease the health care use of a group of patients generally regarded as problematic and frustrating in primary care, namely those individuals with undiagnosable physical symptoms and high rates of consultation, sometimes referred to as somatizers. Many of these patients are likely to be suffering from anxiety or depression (cf. McLeod, Budd, & McClelland, 1997).
Bray and Rogers (1997) provided some valuable examples of the differences in professional culture and practices between clinical psychology (focused on understanding and questioning) and primary health care (focused on fixing problems). The number of patients seen per day, speed of access to referral sources, and expectations about the confidentiality of patient records all vary greatly, as do reimbursement opportunities. Practical tips about how a doctor can manage referrals to a therapist center on demonstrating the collaborative nature of the care, making it clear that the therapist will provide specialist help while the doctor continues to provide other medical care, with a shared first consultation in the doctor’s office for resistant patients. Physical proximity of the providers and regular settings for contact seem crucial to the maintenance of the collaboration between practitioners, just as physical sharing of training experiences is crucial to their initial entry into the collaboration. Openness to the emotional impact of the work (especially in difficult cases) and the chance to discuss such issues within the team may help the professionals to prevent burnout and secondary trauma. Being able to give each other feedback and support creates a cohesive team that is greater than the sum of its parts (McDaniel & Campbell, 1997).
Stulp deGroot, Price, and Leslie (1998) reported their experiences in developing a collaborative primary health care service for more than 10,000 patients using primary care physicians (PCPs) and mental health clinicians (MHCs). They carefully documented this process and were able to derive the following conclusions about how to make the project successful. First, the MHCs had to learn to listen and ask questions in a way that helped the PCPs to sort things out for themselves rather than to give them answers to their questions. Second, collaboration involves the whole system—including office staff, family members, case managers, and so on—and not just the PCPs and MHCs. Third, frequent and timely communication is essential in the various forms of face-to-face hallway conversations, written chart notes, voice messages, e-mails, and responses to pages. Fourth, roles should stay flexible and include attention to the mental health needs of the staff. Fifth, collaboration can work best when the process is informal. Sixth, not everyone engages in the collaborative process at the same rate.
Training to Work in Multidisciplinary Health Care Settings
In what follows, it is assumed that the specifically health psychology content of the health psychologist’s training and education has been thoroughly mastered. It must contain, as we have seen, a comprehensive review of the knowledge base in psychology as applied to health and illness, measurement, research design, and an understanding of health service delivery systems. Hopefully but less predictably, the other health professionals with whom the psychologist will end up working conjointly will also have received at least basic training in the principles of human behavior and how to study it scientifically (cf. Winefield, 1998). This section focuses specifically on methods to facilitate effective collaborative work shared by health professionals with multidisciplinary backgrounds.
McDaniel and Campbell (1997) described in detail the training experiences that facilitate collaborative care by psychologists and physicians. First and foremost, members of each discipline must experience shared training. Here they learn about each other’s knowledge bases, conceptual frameworks, and expectations of both patients and how the health system operates. The frequently negative stereotypes that physical and psychological health professionals have of each other need to be discussed and set in the context of the different professional cultures and working styles.
In the United States, interprofessional collaboration is facilitated by the Interdisciplinary Professional Education Collaborative, a body that stresses the need to incorporate interprofessional expectations and skills into education (Gelmon, White, Carlson, & Norman, 2000). The collaborative has identified some of the obstacles to achieving integration of professions at the training level. Historically, there has been reluctance by staff from the different health science disciplines to interact with one another in teaching as well as in the professional sense (Gilbert et al., 2000). Although psychologists are often employed within medical schools, their role within the teaching of medicine and medical students tends to be in the role of scientists rather than practitioners. Psychology students do not, as a rule, train next to medical students in the clinical components of their courses as fellow apprentices.
A further difficulty is the method of teaching that is commonly employed at universities. Didactic teaching through lectures, where students sit passively in the classroom, will not result in better collaboration between professionals (Gelmon et al., 2000). Hilton and Morris (2001) argued that the ideal learning environment for developing skills for collaborative practice is the clinical setting, where learning is experiential and in context. They stressed that in addition to students being on placements, successful implementation requires collaboration between clinicians and academics, with the former sharing their practice philosophies and the latter promoting appropriate teaching and learning principles. Because most clinicians are trained not as educators but rather as supervisors, academics have an essential support role. The responsibility of students is also stressed; during clinical placements, more senior students should be responsible for the coordination of an aspect of patient care within the team. Some educators have attempted to use simulated placements (Fallsberg & Hammar, 2000) or 2-day workshops (Gilbert et al., 2000) instead of real clinical placements using an existing authentic team due to the number of difficulties involved in arranging such placements. To date, we have no empirical studies to provide us with information about the relative merits and weaknesses of particular teaching approaches. However, Hilton and Morris (2001) are convinced that encouraging students to collaborate with other professionals in a real setting with experiential learning is educationally beneficial in terms of outcome. Such student experiences are likely to result in graduates who are able to function as team members, with more positive attitudes, abilities in collaborative problem solving, and better professional development.
In situations where didactic lectures are the most appropriate, students from across different disciplines could be taught together, where the same base knowledge is required. Problem-based learning curricula in medicine work on the premise that there are no departmental or discipline boundaries (Harden, Davis, & Crosby, 1997). Therefore, the problem-based philosophy lends itself easily to the incorporation of interprofessional collaboration in training. Rather than groups of eight medical students, groups composed of students across a range of health professions would be possible. This ambitious suggestion would require a major shift in university structures. Indeed, the Interdisciplinary Professional Education Collaborative (Gilbert et al., 2000) suggested that higher education institutions offer many barriers to implementation of change that would foster interprofession-alism. It listed as major challenges a lack of institutional reward structures for faculty engaged in curriculum improvement, traditions of inflexibility and fear of the innovative, and a resistance to community-based and project learning. Few interprofessional courses have been incorporated into curricula, with time, expense, funding, cooperation, and coordination difficulties hampering implementation (Gilbert et al., 2000).
Multidisciplinary work is highly politicized and complex, so students of professions where teamwork will be required need “policy acumen” (Jones & Salmon, 2001, p. 67), which should be included as part of their education. Psychologists, like all health care professionals, need an understanding of the social, political, and economic frameworks around which policies that affect their work are structured, and curricula need to address this. Such knowledge will encourage proactive responses to social policy so as to benefit both the individual practitioner and the wider professional body. Without such knowledge, there may be a tendency to focus on profession-centered arguments and perceptions that are antithetical to interprofessionalism.
McDaniel, Hargrove, Belar, Schroeder, and Freeman (in press) prepared a detailed curriculum for the education of psychologists to practice and research in primary health care settings. For example, in the “professional issues” module, they suggested the following student exercises that neatly demonstrate some of the necessary skills:
- Construct a strategy for seeking reimbursement in your community for psychoeducational groups and collaborative sessions (i.e., sessions for which there is more than one clinician present).
- Write a justification to an insurance company for a child to be treated by a psychologist for attention deficit hyperactivity disorder.
- Write a one-page advocacy statement for inclusion of psychological services in primary care for submission to your state legislature.
This training needs to be carried out jointly by members of the disciplines concerned who model a respectful partnership, shared care, and shared inquiry.
Students need to learn which sorts of problems need which kind of professional expertise. In their article on teaching health care professionals to collaborate, McDaniel and Campbell (1997) urged primary care doctors to use counseling skills for simple and mild problems and to use collaboration with a therapist for more complex problems such as nonadherence, somatization, significant anxiety or depression, and coping with terminal illness. In addition, these authors distinguished “red flag” problems that demand collaboration and referral, including psychosis, physical or sexual abuse, previous treatment failure, and nonresponse to three or four counseling sessions with the primary care physician.
In the literature about training health professionals to enhance their capacity for later multidisciplinary work, it is noteworthy that although authors are quite often able to report on long experiences with large numbers of students and practitioners, there are very few reports of controlled studies. Yet especially to psychologists with their awareness of methodological issues in discovering new knowledge, it is a concern that the powerful nonspecific effects of having enthusiastic, highly committed faculty offering innovative programs with determination to seek student feedback could engender a corresponding student enthusiasm for the training method that was independent of other outcomes. It is only by random allocation of students to treatment and control groups (including placebo control groups) that the highest standards of scientific evidence could be attained. Such standards are probably unreachable in most educational settings.
There is a body of interesting qualitative literature emerging into the efficacy of teamwork and interprofessionalism, but there is a lack of hard evidence to demonstrate the effectiveness of interprofessional training across the board and there is a need for quantitative, large-scale, longitudinal evaluation studies (Jones & Salmon, 2001). Hammick, Barr, Freeth, Koppel, and Reeves (2002) have conducted a substantial systematic review of evaluations of interprofessional education seeking evidence linking professional education to a change in either professional practice or patient care, but their work has not yet been published. In educating students about interprofessionalism, the users of services are also stakeholders, so their views must be solicited and taken into account in any evaluation.
A major methodological consideration of any evaluation of interprofessional training or practice is that studies conducted in one location might not necessarily be meaningfully compared cross-culturally because cultural factors can affect the strategies used. For example, Skj⊘rshammer (2001), in his study on interprofessional negotiations in a Norwegian hospital, suggested that the high incidence of avoidance to allay conflict may reflect a cultural norm of evasion rather than a generalizable finding. Jones and Salmon (2001) also pointed out that different issues are pertinent, depending on the setting, even within the same culture. The results of research into interprofessional training and practice will be difficult to generalize across different situations and teams due to the considerable variations encountered in educational institutions and team composition as well as to cross-cultural differences.
There are even greater difficulties of demonstrating better quality of health care work in multidisciplinary settings compared with the other models such as that of parallel work by different professions. The problems hinge mostly on the unsolved task of measuring quality of health care work. Beyond patient satisfaction, other measures might be the job satisfaction of the health care providers and the numbers of patients cured or returned to work or normal activities. But to demonstrate the cost-effectiveness in economic terms that are meaningful to accountants and shareholders is more challenging. Certainly, one requirement would be a way in which to capture the entire health system utilization costs for patients treated with the two models of professional care (multidisciplinary and parallel).
This chapter has reviewed some of the potential hazards and advantages for clinical health psychologists of working with colleagues who have multidisciplinary backgrounds. This challenge is not unique to medical settings, but in these highly responsible and complex workplaces and in caring for very vulnerable patients, the need to develop high-quality work practices is acute and unarguable. Further careful research is still required to establish the details of the most effective models for health care shared among providers from diverse professions, but this chapter focused on how psychologists may extract the maximum benefit from this arrangement for their clients, their coworkers, and themselves. The history of interprofessional relationships in health care has included suspicion, stereotyping, and jealousy. Nonetheless, there seems to be agreement among experienced practitioners that these negatives can be overcome by mutual respect and a focus on the common goal of improved patient well-being. This chapter suggested that psychologists’ particular contributions to multidisciplinary teams, beyond their specific expertise in understanding patient behaviors, can lie in reducing conflict within mixed groups, translating scientific evidence for colleagues, and monitoring the stressfulness of the work environment.
To gain acceptance in multidisciplinary hospital and primary care settings, psychologists need to learn about these settings’ prevailing cultures and acquire the skills needed to negotiate them effectively. There is now a growing literature about how to do this, although it is a descriptive literature rather than an experimental one. A fundamental recommendation about shared training opportunities to teach such skills has often proved to be too difficult to test in practice. There are likely to be many opportunities for psychologists to add to the current scientific literature and to use this chapter’s findings constructively to improve the contribution of psychologist practitioners within multidisciplinary health care teams as well as to enhance the functioning of such teams.