EDUCATION
620
Grover F. Powers, M.D., Contributing Editor
AN
EXPERIMENT
IN INTERPROFESSIONAL
GROUP
CONFERENCES
FOR
CARDIAC
PROGRAM
PERSONNEL
By Ruth Whittemore, M,D.*
D
URINC the past several years, with the establishment of local heart associa-tions, there has been an upward surge in the development of various cardiac pro-grams to serve tile community under thesponsorship of the voluntary and official agency. Official agency groups, in particu-iar the state crippled childiren services, had previously established a few cardiac
pro-grams as a result of partial grants-in-aid from tile United States Childiren’s Bureau
rnatclledl with state fundis.
As more of the vOltilltary and official
services developed, together with the
in-creased recognition of the magnitude and complexity of heart and rheumatic fever programs, the desire was expressed that working groups from various clinics or areas might meet together. An opportunity
to discuss and share experiences,
inter-change idleas and observe other programs was requested not only by the team mem-bers from well established clinics but also
by many who were in the early
develop-mental stages of such a program.
The request to the Connecticut State
Department of Health to undertake the establishment of these interprofessional conferences on the problems of rheumatic fever and cardiac programs came from the
Presented in part at the Second World Cardiac Congress, \Vashington, D.C., September 13, 1954.
0 Director, New haven Rheumatic Fever and Cardiac Program and Crippled Children’s Physi-cian, Connecticut State Department of Health;
Associate Clinical Professor of Pediatrics, Yale
University School of Medicine.
ADDRESS: Department of Pediatrics, 333 Cedar Street, New Haven 11, Conn,
United States Children’s Bureau which
de-sired to see such a teaching plan started
within an already active program under
public health auspices and preferably
as-sociated intimately with schools of
mcdi-cine, nursing, and medical social work. The
overall purpose was not only to discuss
and demonstrate the function of such
car-diac programs but to emphasize the public
health aspects and the need for professional
teamwork among the medical, nursing,
so-cial work, and nutritional personnel in order
that the patient might receive the best care.
Advance Planning
In the advance planning, a working or
planning committee of approximately 10
people was selected with representative
physicians, public health nurses, medical
social workers, and a nutritionist from the
Division of Crippled Children of the
Con-necticut State Department of Health, from
the pediatric cardiac diagnostic clinic team,
and from the Yale University School of
Medicine Departments of Pediatrics and
Public Health. Much valuable assistance
was obtained from many other willing
ad-visors. This committee immediately realized
that certain objectives should be compiled,
which incidentally was found to be an
cx-cellent method of self evaluation.
These objectives included such general
headings as:
(
1) the public healthimplica-tions of a rheumatic fever and children’s
cardiac program; (2) the organization and
administration of such a program; (3) the
patient’s attitude and viewpoint; (4) the
EDUCATION 621
public health nurse, medical social worker,
and others; (5) the use of community
re-sources to assist in such a program; (6) the
responsibility of such a program to the
com-munity and vice versa, and (7) medical
ethics and policies involved in the
estab-lishment and continuation of such a
pro-gram. These objectives proved to be well
illustrated by the problems presented by
the applicants.
The 6 conferences have been held an-nually in the spring since 1950 with tne
addition of a second conference held in the
fall of 1952 due to the large number of
applicants that year. Because of limited
space, some applications unfortunately had
to be rejected.
The announcements each year have stated
that conferences on the Public Health
As-pects of Rheumatic Fever and Pediatric
Cardiology would be held at the
Grace-New Haven Community Hospital during the spring over a period of 10 to 12 days,
and would be sponsored by the Connecticut
State Department of Health, the Yale
Uni-versity School of Medicine Departments
of Pediatrics and Public Health, and the
New Haven City Department of Health. Those invited to attend included preferably
the team members of physicians, nurses
(
usually public health nurses), medicalso-cial workers, and nutritionists, but
non-medical administrative personnel and others
interested in or associated with rheumatic
fever programs for children were also
in-vited. No tuition was charged. It was
stipu-lated that everyone would be asked to
par-ticipate, and that attendance was limited.
That the primary emphasis would be on
the public health aspects of the problem
was clearly stated, but a few clinical
ses-sions would be included. The general
sub-ject headings probably to be discussed were
listed although it was understood these were
subject to change depending on the
prob-lems and questions to be submitted by the
applicants.
Application for the first meetings was
by letter, but later an application form was found to be more satisfactory in which not
only the applicant’s position and experience
was stated but also a list of the problems
he or she wished discussed.
These problems fell under several major
headings for all the meetings and included:
(
1) the epidemiological and public healthaspects of rheumatic fever; (2) the
conva-lescent care of a rheumatic child; (3) case
finding; (4) how to carry on adequate
follow-up care (usually with insufficient
personnel); (5) how to interest communities
in rheumatic fever programs; (6) the
ad-ministration of a cardiac program, (7) the
use of community resources;
(
8) the role ofeach member of the team; (9) the
coordina-tion and integration of patient care; (10)
professional and lay education; (11) an
understanding of the emotional needs of
the patient, and (12) how to stimulate
ap-propriate legislation. Over these few years
there has been somewhat less concern
about surveys as a method of case finding,
and much more concern about
administra-tive problems, professional and lay
educa-tion, and coordination of patient care. Many
of the participants expressed the opinion
that it would be beneficial just to talk with
the members from other clinics and
pro-grams, and to exchange problems and
ideas.
Various changes in the conduct of these
conferences have evolved. At first, the
con-ference was called an Institute on the
Pub-lic Health Aspects of Rheumatic Fever and
Pediatric Cardiology. In view of the need
for increased participation by all present,
the following 2 conferences were conducted
as workshops. The last 3 conferences,
how-ever, have combined both methods in order
to give better direction to the discussion
as well as provide free opportunity to
par-ticipate. These sessions have been called
simply “conferences.”
The planning committee, during weekly
meetings for 2 to 3 months prior to each
of the conferences, studied carefully the
problems submitted by the applicants and
tried to incorporate as many as possible
into the panels or other methods of
I
Priva te or aea(I(’tfl\I.l). Fellows Puhlic health Nurse
Ie(1i(al social worker Nutritionist
44.1
16.8
8.3
TABLE I
1)IsTli I lOTION OF PARTICIPANTS A((O1Il)ING TO PuoEssux
193O 1951 .4 195? 0 195! 1953 1954 Total %
I 6 4 6 4 ‘2i
,5 6 4 1 4 4
4 3 3 2 6 18
6 6 5 S 6 8 39
6 3 4 4 4 3
3 1 1 3 4
1Adtiiiistritor 1 1
Others IleIlith educator I I .5 3.5
Puh. health advisor I
‘I’otal Participants IS 8 ‘2 4 ?4 7 143
committee responsible for a panel worked
closely with the other members on the basic
content of the panel andi selection of re-sources personnel, in this way establishing
sOme relationship and continuity of thought throughout the conference. The committee member met or corresponded with his panel iiiembers well in adivance. He informed
tilem of the l)ackgroundl of the persons who WOtildi attend tile conference, of the
prob-lems these per5)fl5 had raisedi and of how tllis particular panel wouldi diovetail with other elements iii tile conference program.
Participants
Throughout the 6 conferences to date, 143 applicants have participated. Twenty-three states, the District of Columbia, andl 2 foreign countries (Canada and Indlia) have
been representedi. Over one-third of these
states were west of the Mississippi River
extendling to the coast. Many of the states
have been representedi several times.
Of the 143 participants 44.1 per cent have
been physicians, 27.3 per cent nurses, 16.8
per cent medical social workers, 8.3 per
cent nutritionists, and 3.5 per cent others
such as administrators and health educa-tors. Of the 63 physicians who attended, 21 were in private practice or in academic
teaching positions, or both, 18 were in
pub-lie health positions, and 24 were physicians
011 fellowship training under Children’s
Bureau grants. Most of the nurses, medhcal social workers and nutritionists were in
public health positions first (Table I).
The majority of those attending
repre-sented cardiac programs under official state
crippled children’s services, although
sev-era! groups were from local heart
associa-tion projects and a few represented joint
sponsorship of a cardiac program. Fourteen
complete teams consisting of principally a
doctor, nurse, medical social worker, and
in some instances a nutritionist have been
present from 11 different states, 2 of the
states dividing the representation of their
team over 2 conferences. Seventeen states ilave sent partial teams.
PROGRAM OF MEETINGS
Introduction
The conferences opened with registration,
welcoming remarks and informal
round-the-room introductions after coffee and
dough-nuts had been served. Each participant
in-troduced himself, gave a brief word about
his or her cardiac program, and answered a few questions to clarify the difference be-tween the programs represented. This rather
prolonged “get-acquainted” period seemed
advisable in a group representing such
varied interests and backgrounds.
Observation Trips
The introductory session was followed
by the observation trips during most of the
conferences. These trips originally were
EDUCATION
623
but subsequently were grouped early in the session in order to be less interrupting
to the trend of thought of the conferences.
The observations included: (1) following a patient through his work-up at a pediatric cardiac diagnostic clinic; (2) visiting a follow-up pediatric cardiac clinic;
(
3) at-tending a rural cardiac clinic of the state crij)1)led children services with its post clinic conference; (4) making a home visit to a cardiac child with a visiting nurse (which many doctors requested), and (5) making a trip through a convalescent home forrileumatic children. This latter was followed
by a lively discussion among all the
par-ticipants concerning the ever present
prob-lems of Coilvalescent care.
Clinical Discussions
Prior to the P1nei discussion or worksilop of the niorning, the physicians met together for an ilour or more of informal clinical discussions on various newer aspects of
pediatric cardiology. The other members
of the conference met together at this time for a clinical review session with one of tile conference physicians or discussed various aspects of patient care within their
OWn I)rofessionai groIl).
These introductory sessions, observation tri1)s, and preliminary clinical sessions served nlany purposes, one of which was to provide a more common ground of experi-ence aild basic understanding through which all participants could become better acquainted, witness certain public health aspects of the programs in action, and overconie a certain reluctance on the part of some of the physicians to accept such an essentially non-clinical conference.
Basic Content of Meetings
During the first conference, called an institute, the time was fully planned with 7 panels around the questions presented by the students, and many resource persons were used. The panels were similar in sub-ject to those presented at the final 3 con-ferences and will be discussed later. Foi-lowing the evaluation of this institute 2
major changes were decided: to call the
members “participants” rather than “stu-dents,” and to encourage more participation and a more democratic approach.
Therefore the contents of the second and
third conferences were planned in the
form of workshops, the participants to select
the subjects to be discussed, and then
choose their own group leader. This form
of meeting was increasingly used for such
purposes. Guidance was given before and
during these workshops sessions by several
people familiar with this technique. The
problems again fell into much the same
categories. During the first workshop the
participants divided into 3 groups, the
see-ond workshop into 2 groups. One group in
each workshop discussed the care of the
patient. Other groups discussed community
planning, organization and administration
of a children’s cardiac program, and
team-work.
At the close of these 2 workshops, it was
felt that such group discussion had
ac-complished considerable participation and exchange of ideas by all, yet more
direc-tion was advisable. A combination of panels
and workshop discussion groups, it was
thought, might better meet tile needs of such a group.
Consequently, the final 3 sets of meetings have been entitled simply “conferences”
and have consisted of 5 or 6 small panel
discussions in the mornings followed by
workshop groups in the afternoons. Again
as the result of preliminary problems sent
in, the morning panels were centered
around the following subjects:
I. Rheumatic fever as a public health
problem was a topic for early discussion.
II. How to work together to provide care
for the patient was a panel which illustratedi
teamwork and defined the function of each
member of the team.
III. How a cardiac program could use
and help develop community resources and
services always provoked much discussion.
IV. Professional education, its problems
and trends in the fields of medicine,
in-corporated during the last 2 conferences.
V. The panel on education of the patient,
the parent, and the lay public was added by popular request during the last con-ference.
VI. Administrative problems and
ap-praisal of a cardiac program included dis-cussion of the federal, state, and local responsibilities in the development of a
pediatric cardiac program as well as the
relationship between official and voluntary
public health agencies.
Another less formal session was held each
time with particular stress on the emotional needs of the patient and his family,
al-though the emotional problem was not
wholly confined to this session.
In contradistinction to the institute, only
3 to 6 members sat on the panels for these conferences. There was consequently some-what less formality in the presentation,
more discussion between the panel
mem-bers, and later much more participation from the floor.
Discussion Groups
During the first institute, very few
dis-cussions were held other than at meetings of individual professional groups. At this
time it was evident from questions asked
that some of the physicians, in particular
those who had had no more than hospital
experience, little understood the role and
qualifications of the other team members.
Subsequently the observational experiences
early in the conference helped this
situa-tion.
Wilen the workshop method was used cx-elusively, the participant selected his
dis-cussion group according to subject and then the group chose its own leader.
During the last 3 conferences, in com-parison to the institute and workshops, the
afternoon workshop groups were arbitrarily
selected to provide equal representation between the various states and professional illterests; the group leaders were chosen
before the conference, and the discussion
topics were enumeratedi according to the desires of the group. The topics at all
con-ferences covered the subjects previously
listed as problems by the participants.
Eight to ten participants in each group
were found to be more satisfactory than a
larger number. In all discussion groups, at
least 2 members of the planning committee
served as participants and guided the group
to resource material when indicated but
never served as instructors.
Resource Persons and Material
Throughout all sessions, 180 resource
people representing many varied disciplines
have been used other than the participants
present and exclusive of the members of
the planning committee. Many of them
have served more than once and several
for all 6 meetings.
Representatives assisted from state and
local departments of health, various
de-partments of Yale University School of
Medicine and other professional schools,
the Children’s Bureau, American Heart
Association, state and local heart
associa-tions, state and local medical societies, and
other public and voluntary health agencies.
Private physicians, hospital administrators,
and administrators of home care programs
contributed a great deal. Assistance was
also obtained from state and local
depart-ments of education as well as from
adminis-trators, rehabilitation councillors, health
educators, program consultants, educational
material specialists, occupational therapists,
volunteers, and many others. Most of these
people served not only on the morning
panels but also as resource participants to
the discussion groups in the afternoons.
Other resource material consisted of a
bibliography compiled by the planning
committee, a reference table in the
con-ference room, exhibits, and a library shelf
set aside in the medical school library.
A final report was prepared by each
work-shop group and presented the final day.
Evaluations also were obtained from each
participant at this time. Mimeographed
re-ports of all but one of the conferences were
EDUCATION 625
Follow-up
Letters or personal contacts from 84 of
the former participants still active in their
work have been received recently in an
endeavor to evaluate the worth of these
conferences. Forty-five of the 143
partici-pants are either no longer associated with
a cardiac program or contact with them
has been lost. These reports showed in part the following remarks of interest:
Four new cardiac programs have been
started, 2 of these in areas where opposition
was anticipated; 6 states have increased
their programs of service, and several
pro-grams have reorganized their clinics or enlarged their staffs. The majority of
par-ticipants expressed the belief they had
bene-fited from the opportunity to interchange ideas at the meetings, and that their
work-ing relationships with their fellow workers
had improved considerably as a result of
better understanding the role of each. Of
particular interest is the close cooperation
which has developed between the official
and voluntary heart agencies in 2 of the
states.
Edlucational projects conducted by some
of the participants have included
work-shops or conferences with similar personnel
within the state, extensive reports to other
staff workers, and assistance with numerous
professional and lay educational meetings
or projects which have included school
personnel in several instances. Certain
representatives from schools of public
health, medical and other professional
schools have also enlarged their teaching
program to include certain public health
aspects stressed at tilese meetings. These
reports, in general, have been gratifying.
DISCUSSION
There are many different ways such
con-ferences may be conducted, we are sure,
and these attempts merely illustrate the
struggles of one group. It has been
fortu-nate that essentially the same committee
has functioned as the planning committee
throughout these 6 conferences to date. The
conferences have been the work of the
corn-mittee and not of any one individual.
Par-ticipants who were genuinely interested in
this work were important in order to obtain
maximum participation and interchange of
ideas. Each conference has been different
as a result of the helpful evaluations and
criticism from all these participants,
to-gether with the close collaboration of the
committee members and advisors.
Major changes evolved in the basic plan
of the various conferences as the needs of
the participants of mixed professions
be-came more apparent. The first conference,
called an “institute,” had been probably
too didactic with insufficient time allowed
for discussion and participation. The next
2 workshops, on the other hand, probably
did not have enough direction although a
great deal depended on the experience and
interest of the group of participants as to
how well this method worked. As a result,
the final 3 conferences assumed an
inter-mediate course giving some guidance by
small informal panels in the morning and
encouraging participation by all in the
after-noon discussion groups. At no time were
answers defined as each situation
repre-sented was very different, but rather
con-structive thought and free interchange of
ideas was stimulated. Throughout, the
de-tails of the Connecticut programs were not
stressed but primarily used for initial
stimu-lation or expression. Of course the informal
discussions outside of scheduled sessions
were of great benefit to all.
Some constructive criticism toward
fu-ture conferences has raised the questions
as to whether the workshop meetings have
been held at the best time, whether they
should convene around a given problem in
each discussion group, and whether the
group leader should be chosen in advance
and be well versed in a particular subject.
Organization and operation of such
con-ferences has required supplementary
ad-ministrative and secretarial assistance
be-yond the clinical staff in order to give the
individual attention advisable for all
CONCLUSION
In conclusion, the plans which have
evolved during the conducting of 6 different meetings of mixed professions on the
pub-lie health aspects of rheumatic fever and
pediatric cardiology have been presented
with the hope that, because of the benefits
and better understanding derived, such
cx-periences may be of some assistance to
others and possibly stimulate other groups
to hold conferences of a similar nature.
ACKNOWLEDGMENT
Grateful ascknowledgment is hereby
made to the members of the planning
com-mittee, the resource personnel, the
partici-pants, the administrative assistants, the staff
of the New Haven Rheumatic Fever and
Cardiac Program, and the many professional
advisors whose constant stimulation and
assistance have made these conferences
