Untapped opportunities: Leveraging the entire health care team in workplace learning

Abstract

In this issue of Medical Education, Miller et al. review interprofessional interactions in medical training and highlight potential gaps in learning between different professions that arise due to professional hierarchy, siloed training structure and role boundaries.¹ These barriers, however, also occur in learning between individuals from different specialties within the same profession, as is perfectly illustrated by this quote from a medical trainee reflecting on learning and collaborating with physicians from different specialties: ‘I think they don't always realize where our expertise lies, and vice versa … and that's, I believe, also simply a matter of ignorance on both sides. So, you only later realize: “wait, but this is why they think what they think, and why we think what we think”.’² In other words, ‘the physician’ is not a singular, uniform entity.

Intraprofessional collaboration between physicians of different specialties, in fact, presents an untapped opportunity for learning and has its own unique challenges and opportunities that physicians must learn to navigate to collaborate effectively.³ By juxtaposing inter- and intraprofessional interactions, we can gain valuable insights into how to prepare trainees for collaborative patient care. Like interprofessional interactions, intraprofessional interactions tend to be frequent, brief, informal and implicit, with no predefined educational goals.^{2, 3} Furthermore, they also hold great potential to develop trainees' medical skills, collaboration and professional identity formation.^{2, 3} In this commentary, we attempt to shine additional light on workplace learning by further juxtaposing inter- and intraprofessional experiences through the lens of the individual, social and situated dimensions discussed by Miller et al. and others.^{1, 4}

Along the individual dimension, Miller et al. discuss how ‘credibility judgements’ influence how trainees recognize and receive feedback from other professions.¹ Although one might expect that trainees would always recognize intraprofessional feedback as valuable, given that they share the same profession with the feedback provider, medical trainees often perceive physicians from other specialties as too distinct, leading to less interest in learning from them.^{2, 5} In fact, medical specialists tend to view their specialty's approach to patient care as superior to that of other specialties, which hinders perspective taking and learning.⁵ These perceptions are heavily influenced by intraprofessional stereotypes deeply ingrained in the practice of physicians.^{2, 5} Here, it is noteworthy that Miller et al. report medical trainees may view other professions as ‘safe’ learning resources because they are not involved in formal assessment.¹ The same should apply to intraprofessional interactions, where physicians from other specialties are rarely involved in formal assessment. In practice, however, speaking up to other specialties carries an extra layer of complexity because trainees are concerned not only about appearing incompetent or ignorant themselves but also about the potential negative impact of a poor performance on the reputation of their entire specialty.^{2, 6}

On the social dimension, Miller et al. highlight how other health professionals can facilitate learning by serving as stable fixtures in the workplace, often through direct interactions at the patient bedside.¹ Valuable bedside learning can similarly take place between medical trainees from different specialties. These ‘in-the-moment’ learning opportunities allow trainees from different specialties to learn from each other within their zone of proximal development. Unfortunately, learning opportunities are not always recognized in practice and bedside interactions do not occur automatically because work routines differ.² Additionally, unlike interprofessional interactions that nearly always involve trainees, intraprofessional collaboration in complex patient care often occurs through supervisors, effectively bypassing trainees and limiting their chances to learn.³

Along the situated dimension, Miller et al. discuss the potential for misalignment when medical trainees hold the hierarchical role of making decisions in situations where other health professionals have more experience.¹ Such conflicts in interprofessional interactions are generally less identity-threatening for the medical trainee.² However, in intraprofessional collaboration, responsibilities often overlap, thereby exacerbating the potential for tensions and conflict.^{2, 5} Studies have shown that trainees can become disengaged in such situations, highlighting the importance of learning how to navigate these processes.^{2, 5} Interactions between specialties are inherently shaped by power dynamics, which can become unproductive and limit engagement from different perspectives when power distribution is unequal and contributions from different specialties are not valued.⁶ Each specialty carries its own beliefs, language and culture, and supervisors play a crucial role in influencing whether trainees remain open to alternative perspectives.^{2, 6} In medicine, there is a culture that prioritizes medical content and apparent efficiency over collaboration and mutual learning, often resulting in specialties working separately.^{2, 5} In the absence of proper guidance and reflective support towards desired collaborative attitudes and behaviours, there is a risk that trainees adopt and internalize unconstructive collaborative behaviours they observe in clinical practice.²

These three dimensions and the pitfalls they reflect sum together to emphasize how self-regulated learning skills play an important role in deliberate learning in the workplace. In this regard, Miller et al. focus on selection and interpretation of cues from interprofessional interactions for self-regulated learning.¹ Additionally, intrinsic motivation, attention and explicit learning goals are crucial for purposeful learning from intra- and interprofessional interactions.⁷ Self-regulated learning is shaped in interaction between the learner and the context, emphasizing the need for supervisors and the organization of the workplace to support trainees to learn across the boundaries of their profession.^{2, 3, 7} Miller et al. describe that working with other professions triggers learning mechanisms of identification, coordination, reflection and transformation.¹ However, in practice, research on intraprofessional learning shows that these learning mechanisms rarely occur spontaneously beyond recognizing and understanding differences between specialties (identification).⁸ Nevertheless, research also indicates that with intentional attention and support—such as through educational meetings and reflection with supervisors—it is possible to facilitate processes of coordination and reflection to ultimately achieve a positive transformation in practice.⁸ Such observations further our fundamental point that both interprofessional and intraprofessional learning, while related, each offer unique challenges and opportunities that require deliberate attention to fully leverage the learning potential of workplace interactions with all members of the health care team.

Notably, the role of patients and their caregivers remains as underexplored in Miller et al.'s critical review of interprofessional interactions as it is in the literature on intraprofessional learning. In his conceptualization of workplace learning, Teunissen explicitly positions the patient as a learner.⁴ There is a lack of literature, however, regarding how and what can be learned from patients and which preconditions are necessary to facilitate inclusive and participatory learning from, with and about patients in the workplace that reflects on the role of the patient in ‘cross-boundary teaming’.

In conclusion, inter- and intraprofessional learning face similar challenges despite undoubtedly maintaining distinct nuances. Ultimately, fostering more deliberate learning with all those involved in health care is essential. To this end, we need to reconceptualize our learning teams to include members of other professions and other specialties.⁵ Investing in both inter- and intraprofessional learning may create a synergistic effect, better leveraging untapped opportunities and paving the way for a truly collaborative health care landscape.

Lara Teheux: Conceptualization; writing – original draft; writing – review and editing. Janiëlle A. E. M. van der Velden: Conceptualization; writing – review and editing.