Interprofessional Dialogue: One of the most enjoyable aspects of being involved with the National Academy of Medicine (NAM) of the National Academies of Sciences, Engineering, and Medicine is the opportunity to interact with colleagues from a wide range of disciplines while addressing issues that are of importance to our nation. This year I was fortunate to have been appointed to the NAM Culture of Health Program Advisory Committee and received a copy of the Academies' intriguing 2017 report Communities in action: Pathways to health equity. Coming from a psychology-legal orientation, there are elements of their report that I would enthusiastically endorse; and not surprisingly, there are perspectives expressed which with which I am admittedly less comfortable. Highlights:
"Health equity is the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance. Health equity and opportunity are inextricably linked. Currently in the United States, the burdens of disease and poor health and the benefits of well-being and good health are inequitably distributed. This inequitable distribution is caused by social, environmental, economic, and structural factors that shape health and are themselves distributed unequally, with pronounced differences in opportunities for health."
The report notes that health equity is fundamental to a good life and a vibrant society due to its practical, economic, and civic implications. Further, health inequity is very costly. It is estimated that eliminating health disparities for minorities would have resulted in reduced direct medical care costs by nearly $230 billion for the years 2003-2006. From a national security perspective, nearly one third (32 percent) of all young people experience health problems – other than their weight – that would keep them from serving in the military. Infant mortality, age-adjusted death rates, and life expectancy are considered critical to judging the overall health of a population. In international rankings, the U.S. ranks lower than other wealthy nations on each of these indicators – while spending considerably more.
The Academies' report identified nine social determinants of health: education, employment, health systems and services, housing, income and wealth, physical environment, public safety, social environment, and transportation. "Based on its review of the evidence, the committee concludes that health inequities are the result of more than individual choice or random occurrence. They are the result of the historic and ongoing interplay of inequitable structures, policies, and norms that shape lives." And, "In the committee's judgment, civil rights approaches have helped mitigate the negative impacts of many forms of social and health discrimination. Continuing this work is needed to overcome discrimination and the structural barriers that affect health."
Where I do have a different perspective from that of the committee on achievable priorities relates to their conclusion: "For many years researchers, public health practitioners, and others have known that health status in this country and around the world is determined as much by socioeconomic as biologic or behavioral factors. Despite that recognition, approaches to improving health status and health outcomes have narrowly centered on improving medical interventions, technologies, systems, and access. Beyond clinical approaches, some health promotion strategies have focused on changing behavior, despite the robust evidence indicating that they are ineffective in addressing health inequities. Although these strategies play a role in improving population health, it has become amply clear that they are necessary but not sufficient. Health is the result of much more than health care; the social, economic, environmental and structural factors – for example, education, poverty, housing, and structural racism – that shape health outcomes also create health inequities. Addressing and putting an end to health inequities will only be possible if society and decision makers broaden their view of health to fully grasp how steep and unjust disparities in social and other conditions limit, thwart, and even destroy some people's ability to live healthy and full lives." From my perspective, the committee did not go far enough in recognizing and reaching out to psychology and a number of other disciplines which can, and shall, contribute significantly to this important dialogue.
Interprofessional Collaboration: Ken Pope recently shared with us a John Hopkins Bloomberg School of Public Health comparison of the quality of physician, Nurse Practitioner (NP), and Physician Assistant (PA) prescribing protocols, covering over 700,000 patient visits. They examined 13 quality indicators across a range of chronic diseases, including antibiotic use and concurrent prescription of contraindicated medications. The conclusion: the quality of prescribing was similar across the board and while there was room for improvement in all of their indicators, no one discipline was more likely than another to be nonadherent with guidelines. NPs and PAs continue to be one solution to physician shortages, with data such as this providing support for their growing autonomy and prescriptive authority.
"Over the past few years, the Psychiatric Mental Health Nurse Practitioner Doctor of Nursing Practice (DNP) program and the Psychology program at the Uniformed Services University (USU) have increasingly engaged in interprofessional education activities. Our first effort was our joint Health Policy class exposing graduate students from both disciplines to a wide range of accomplished speakers describing their personal journeys. These included APA's Heather Kelly and Steve Behnke; former APA Presidents Ron Fox, Barry Anton, and Don Bersoff; current and former Surgeon Generals and VA Secretaries; as well as a former Prisoner of War. Dialogue between our disciplines increased and psychology faculty began assisting with topics in the GSN Therapeutic Modalities course, including presentations on cognitive behavioral therapy and biofeedback. Psychology faculty and graduate students have helped supervise DNP students at the university's simulation center. Students from both programs train together and are placed in joint teams at Operation Bushmaster, a large scale simulated operational field training exercise, where they see simulated mental health patients, perform a mock unit needs assessment, and assist with operational stress control. Psychology students are invited to participate in our Wilderness Medicine field experiences. Most recently, GSN faculty were selected to teach in the psychopharmacology course for clinical psychology students. We are now working to start a joint psychotropic interest group, which will involve case-based presentations, and to collaborate on leadership development" [CDR Eric Pauli, USN, NC].
"I am thrilled to see that the APA Committee, formed to review the Clinical Psychopharmacology Curriculum for prescribing psychology trainees, has recommended that the didactic training can be done at the graduate, predoctoral level. Certainly, our Illinois graduate students are thrilled with the opportunity to do their training in Clinical Psychopharmacology, as a joint Master's degree, alongside their doctorate in Psychology. It is most satisfying that our profession continues to move forward, striving to meet the needs of our psychology students as well as the needs of our larger community" [Beth Rom-Rymer, APA Board of Directors, Council Leadership Team]. In enacting the 2014 Illinois Psychological Association RxP legislation, Beth and her colleagues worked tirelessly in developing a broad based, interprofessional coalition enthusiastically supporting their bill on behalf of the entire community. [Father Damien]. Aloha,
Pat DeLeon, former APA President – HPA – March, 2018
