A bomb had torn through the crowd, and now the emergency department was swamped with victims. Panic and injuries alike were causing respirations to become jagged. Glass shards pierced skin; broken limbs abounded. A traumatized young woman had gone into early—and earsplitting—labor.  Among the wounded was a thin young man who had been fingered as the bomber. A police officer stood guard while a doctor and nurse tended to the gashes on his arms and legs. Suddenly his mother burst into the room, sobbing and demanding her son’s release. A physician assistant spoke to her soothingly, while the officer tried to remove her from the chaos.

The mother’s hysterics did more than heighten the drama. They also inspired barely concealed grins among the onlookers, reflecting the reality that no lives were actually at risk. The woman was an administrative assistant from a nearby office; the bomber, a student with elaborate wounds fashioned from makeup; the guard, a Carilion Clinic police officer, but one who wouldn’t later be called to testify.

The scenario was a fabricated one, intended to help students across health professions learn to work in teams. What the designers of the mock exercise couldn’t have foreseen during their months of planning, though, was an eerie coincidence: the event took place on the very day that Boston was on lockdown as police hunted the surviving Boston Marathon bomber.

Making the Team

The bombing simulation was a sobering reminder that seemingly unfathomable emergencies can happen anywhere and at any time, and teams of health care providers must be prepared.

The three institutions running that particular drill—Jefferson College of Health Sciences, Carilion Clinic, and the Virginia Tech Carilion School of Medicine—have been at the ready for years, employing a critical tool in medicine: interprofessional teamwork.

Nearly two decades ago, Jefferson College of Health Sciences launched a pioneering program in interprofessional education, in which students in a range of health care programs learn together with the goal of fostering a collaborative team approach.

In 2006, Carilion became an early adopter of Team Strategies and Tools for Enhancing Performance and Patient Safety, or TeamSTEPPS, an evidence-based teamwork system aimed at optimizing patient care by improving communication and teamwork skills among health care professionals.

And, in 2010, when the Virginia Tech Carilion School of Medicine opened, its founders chose to adopt interprofessional education as one of the school’s core tenets, as the approach has been shown to promote more effective, patient-centered care.

The institutions’ shared interprofessional education program has been so successful, in fact, that Roanoke was chosen as the site of Collaborating Across Borders, the premier North American conference series on interprofessional education and collaborative practice in health and social care. All three institutions served as local hosts of the 2015 conference, along with Virginia Tech and the Virginia Tech Carilion Research Institute. Nearly 800 professionals from a half dozen countries attended to learn the latest best practices.

Reinvention of Medicine

The importance of interprofessional teamwork has become increasingly clear over the past few decades. An estimated 70 percent of medical errors are the result of miscommunication—or a lack of communication—among health care professionals.

In 2001, the Institute of Medicine issued a landmark report, Crossing the Quality Chasm, that called for a reinvention of the delivery of medical care. Teamwork became a hallmark of that transformation.

“Today no one clinician can retain all the information necessary for sound, evidence-based practice,” the report stated. “Effective working teams must be created and maintained.  Physicians groups, hospitals, and other health care organizations operate as silos.” 

“Health care is no longer run by doctors in Lone Ranger style,” says David Trinkle, M.D., associate dean for community and culture at the Virginia Tech Carilion School of Medicine. “Self-sufficiency has given way to interdependence and a reliance on others. We’ve traditionally trained and worked in silos, but in today’s world we have to work in teams. The earlier we train in teams, the better.”

In 1970, Dr. Trinkle points out, a typical hospitalized patient would see, on average, two health care workers. Today, that number is 15.

“The health care environment has changed drastically over the past 30 years, from solo practitioners who could rely on their own knowledge, to teams of health care professionals managing complex patients in complex situations,” Dr. Trinkle says. “Teamwork among care providers has been cited by many experts as one of the greatest factors in improving patient outcomes and reducing the number of medical errors.”

Dr. Trinkle uses the pit crew analogy first offered by Atul Gawande, M.D., an advocate for patient safety internationally. When a racecar comes off the track, crew members are responsible for specific tasks—refueling, changing tires, adjusting the suspension. To work with speed and tight synchronicity, crew members must understand not only their own roles, but also the roles of their crewmates. Without that understanding, they cannot send car and driver off safely.

 “Learning to work like a pit crew member in health care isn’t easy,” Dr. Trinkle says. “It involves humility, creativity, and a recognition that other team members have something important to offer no matter where they fall in the traditional hierarchy. Mastering those skills, though, is critically important.”

Early and Often

From the start, Virginia Tech Carilion School of Medicine students are educated alongside Jefferson College of Health Sciences students, particularly those in training to become nurses and physician assistants. In a reflection of that close coordination, Nathaniel L. Bishop, D.Min., president of the college, also serves as the medical school’s chair of interprofessionalism. 

“Good communication among care providers is key when focusing on positive patient outcomes,” Dr. Bishop says. “Interprofessional education gets students used to communicating and collaborating with each other while respecting the expertise and opinions of others. The result is better patient outcomes.”

The Virginia Tech Carilion School of Medicine was the first in the country to integrate interprofessionalism across its entire curriculum. The groundwork is laid during year one, in the Interprofessional Leadership Course. There, students develop interprofessional knowledge and skills through personal reflection, conflict resolution, and teamwork building exercises. Students also explore the roles, responsibilities, and biases of different health care professions.

The teamwork building extends beyond the classroom and into the community, where medical, nursing, and physician assistant students collaborate on an intensive service-learning project. These projects offer the opportunity to work both as a team and with populations with whom the students may have had little experience. In the past several years, student teams have assisted dozens of local organizations with a range of missions, from warning new parents about the dangers of shaking infants to helping women shake addictions.

“We’re looking to educate well-rounded physicians, both inside the hospital and out,” Dr. Trinkle says. “The service-learning projects are just one more way to connect our students to the full reach of medicine. The students need to know their patients’ daily challenges and they need to understand that their own hard work and passions can make a difference. By the end of their projects, the students have added value to the communities they live in—and to themselves.”

In their second year, the students focus on ethics, legal issues, and medical humanities as they relate to interprofessionalism. When students undertake clinical rotations in their third and fourth years, they continue to participate in team exercises, and their clerkship evaluations incorporate an assessment of their interprofessional skills. A real test of what they’ve learned, of course, is the annual disaster drill.

Recipes for Disaster

During the drill, held at Carilion Roanoke Community Hospital each year, teams of medical students and students in a range of academic programs at Jefferson College of Health Sciences—including nursing, physician assistant, respiratory therapy, emergency services, and public health—are assigned mock patients. The students aren’t informed of the nature of the disaster until the exercise begins. They must assess the situation and treat their patients as a team on the spot.

They’re also thrown a series of curveballs intended to simulate real challenges—unrecognized internal bleeding, preexisting conditions, hysterical family members.

“Although each year the scenario is one of a mass-casualty disaster, the goals of the simulation are not related to disaster preparedness,” says Bruce Johnson, M.D., the medical school’s associate dean for faculty affairs and a key architect of the annual event. “Instead, they’re intended to improve leadership skills and encourage interprofessional collaboration.”

Dr. Johnson likens the drill to language immersion. “You may have spent years studying a language, but when you find yourself in a country where everyone speaks only that language, you suddenly realize that you don’t know all the idioms, and everyone is speaking much faster than you expected,” he says. “That can be a shock.”

The drill has revealed that some medical students initially struggle to find their place in the team. The other students look to them for leadership, but they often find themselves deferring to emergency medical technicians with far more hands-on experience.

Dr. Johnson points out that it’s much better for medical students to experience any deer-in-the-headlight moments early in their training, when patient care is not compromised.

“Our graduates report to us that they’re ahead of their peers when they start their residencies,” he says. “They find they’re confident in their roles. They understand and respect what other members of the clinical team have to offer, and their communications skills are well honed. Ultimately, we hope, their patients will benefit, with better, safer care.”