It is a 19-item questionnaire that is designed to evaluate three
primary areas: teamwork and collaboration, professional identity, and roles and
responsibilities. The Interdisciplinary Education Perception Scale (IEPS) is another
tool that assesses attitudes toward IPE.
17 This scale is an 18-item questionnaire that
contains 4 subscale measures: competency and autonomy, perceived need for
cooperation, actual cooperation, and understanding the value of others. Assessment
instruments such as RIPLS and IEPS have been used to measure the impact that IPE
experiences may have on students’ pre-exposure acceptance and attitudes. Although
these and some other tools may be useful for measuring change in behavior or
attitudes concerning IPE, they do not assess the impact that IPE may have on patient
The creation of an effective model for IPE should start with the understanding that
this is just the initial step in providing patient directed care.
environment helps students from one profession learning from individuals
representing another discipline to better develop skills that will help improve their
own professional specific skills and to more effectively work in team-based setting.
It is important that all representatives of a particular profession, including students
and practitioners, be socialized to their own profession as well as to the
interdisciplinary setting. There also needs to be a commitment that IPE be
incorporated within the curricula of all programs within an institution to help sustain
In addition to other health profession students, pharmacy students should be
considered essential to any IPE model. Pharmacists have not always been considered
necessary on a healthcare team, and this needs to be addressed when developing IPE
IPE teams should ideally include a pharmacy student, in addition to medicine,
nursing, social work, and nutrition students.
The stage of socialization within the specific profession must be considered when
2 Socialization of healthcare students has been defined as “the
acquisition of knowledge, skills, values, roles and attitudes of associated with the
practice of that particular profession,” and can be exhibited by the language,
behavior, and demeanor that are representative of that specific discipline.
important that a student maintains his/her professional identity when participating in
an IPE models. Also when creating student teams, one should try balance them with
regard to what point they are in their professional socialization and education.
medical student who is in the 4th year of his/her program who is paired with less
experienced nursing or pharmacy student may negatively impact learning of the other
students if the medical student assumes a more dominant role.
QUESTION 1: M.M. is a 65-year-old retired man who presented to his provider three days ago with
the pharmacist to M.M.’s care differ from that of the other team members?
One element of an IPE model is understanding that different professions may vary
in how they approach patient care. Medicine and pharmacy tend to focus on
eliminating or “ruling-out” causes of a patient’s complaint, whether it is medical- or
2 While the physician will focus primarily on the medical evaluation of
M.M., the pharmacist would determine whether any of his medications were causing
any effects which may have contributed to his belief that they were not helping him.
The pharmacist would also work with M.M. to develop a plan that would enhance
adherence to his discharge medications. Some other members of the team, such as the
nurse and social worker, may take a more holistic approach and address the patient
2 This would include considering any family or
environment issues that may affect M.M.’s progress such as ability for self-care when
living alone and not having a relative living close by. They could make arrangements
to make sure M.M. has the proper support at home. The nurse can also educate the
patient about the importance of adherence to proper diet and to recognize early signs
and symptoms of exacerbation. Some professions such as social work or psychology
tend to be more involved with the patient or family for a more prolonged period of
time, particularly if change in behavior is warranted.
how different professions approach patient care is that medical students are typically
trained to be decision-makers regarding clinical problem-solving, which has been a
long-standing part of the culture of medicine.
18 As noted previously, team-based care
means a shared responsibility for patient care on the part of all team members and
should not be dominated by any one profession.
appropriate strategy for delivering IPE?
It is important to understand that IPE models can take place in a variety of settings,
such a classroom, laboratory, and a patient care setting. Regardless of the
environment, IPE-related activities should represent a “real-world” experience.
Simulation activities (simulating a patient care setting) and case discussions in a
seminar format, where participants can exchange information, are appropriate for the
early professional education years. Students may also observe activities of health
providers upon patient visits and reflect on the contributions of each to patient care.
The patient care setting is more appropriate for students with more experience.
addition to certainly being real world, it is more effective in developing the
confidence and skills needed for students to function as part of the team. In this
experiential setting, clinicians from multiple professions who are active and engaged
as role models and mentors are critical to the success of the model.
Bridges and colleagues describe three different practice models of IPE,
representing a didactic program, a community-based experience, and an
interprofessional simulation experience.
19 The didactic program focuses on
developing interprofessional team building skills, understanding other professions,
influences healthcare delivery. Students work in small groups and also engage in a
community service project. There is also a clinical component where students from
different professions form teams and attend a prescribed number of sessions at a
practice site. The community model illustrates how collaboration by different
professions can provide patient care services to many underserved individuals in
their homes. Teams of students are assigned home visits in a manner so that they are
exposed to a variety of family types (e.g., Medicaid family with multiple children,
older adult living alone, hospice patient). Each team has a project that they present to
their group at the end of the course. With the simulation model, students from
different professions use simulation and not real patients to promote interprofessional
teamwork. Even though there are a number of different strategies that may be used to
deliver IPE, the common elements that lead to more successful experience include
responsibility, assertiveness, accountability, coordination, communication, trust,
respect autonomy, and cooperation.
QUESTION 1: Although IPE is considered important, are there any barriers to implementing it?
Despite the progress made in advancing IPE over the past few years, some
barriers to implementing it exist on different levels, from the institution/organization
level down to the individual level. Overcoming these barriers is important in order
to continue to work toward preparing students to collaborate with other healthcare
On the institutional/organizational level, academic calendars and requirements
may differ between various healthcare disciplines. Also the requirements for
assessing students may differ between professions due to accrediting body standards,
and the timing of when topics are covered within the degree program may not be
consistent. Finding a common time for students to meet is often a challenge, and there
may not be available classroom space available to accommodate the increased
number of students. In addition, the curricula of the different professions may also
provide little flexibility in terms of incorporating IPE into the curriculum, although
mandates by accrediting bodies such as ACPE dictate that this needs to happen for
some professions. There may not be an adequate number of faculties trained in the
area of IPE, and there may be insufficient faculty development efforts to address this
issue. Collaboration with IPE efforts also may be negatively affected by geographic
separation between disciplines that may exist within the institution.
that the institution’s administration commits the necessary financial and other
resources necessary to address some of these potential obstacles to IPE.
There may also be barriers to IPE at the individual level. Differences in attitudes
that exist between heath care professions can impact the implementation of IPE. It has
been shown that healthcare providers may have negative opinions of each other’s
clinical knowledge and ability.
perceptions and stereotypes of their own as well as other healthcare professions.
The students rated the six professions based on nine distinct positive attributes
(academic ability, professional competence, interpersonal skills, leadership ability,
ability to work independently, ability to be a team player, ability to make decisions,
practical skills, and confidence). Although medicine rated highest for most of these
attributes, they rated lowest for ability to be a team player, which is contrary to the
mission of team-based health care. Compared to the other professions (nursing,
occupational therapy, physical therapy, couple and family therapy), pharmacy and
medicine also scored low on interpersonal skills, which is a negative when it comes
to working with others. Granted these are only perceptions of students about other
health professions before any interaction, but they may represent potential barriers to
providing team-based patient care.
Faculty also need to understand the value of IPE so they can be actively involved
in implementing any program at their institution. Faculty may resist IPE if it results in
an increase in workload and causes time constraints.
The first challenge is to sustain the IPE momentum that has been developed over the
past several years and to provide the necessary resources to support it.
of IPE is also been identified as a future goal.
collaboration between professions need to be identified, and the education of
healthcare students needs to advance to the point where team-based learning is the
norm, and that improved patient care is achieved.
It is believed that in the future,
students and faculty will have multiple opportunities to interact with others, and that
these experiences will further commit them to work together to improve patient
There are still a number of issues concerning IPE that need to be addressed. There
needs to be more objective evidence on the impact of IPE on improving patient
In addition, there are still questions concerning how much IPE is needed
to achieve learner competence, where in the curriculum does IPE have the greatest
impact and what are the most effective formats for delivering IPE.
The traditional model of practitioners working alone to provide patient care can
result in communication failures and is detrimental to patient safety. A care plan that
utilizes teams of healthcare providers, including pharmacists, to coordinate patient
care can optimize patient outcomes. IPE can lead to better understanding of the roles
and responsibilities of team members, improved communication and more effective
8 Table 7-1 summarizes some suggested criteria for an organization to be
Suggested Criteria for Engagement for Interprofessional Education
A well-known, observable, measurable IPE philosophy that permeates the organization.
Faculty from different healthcare professions working together to develop the learning experiences.
collaborate, and how working together can improve patient care.
IPE learning experiences being incorporated into to the curricula as a requirement.
Competence demonstrated by students with a defined set of competencies such as those outlined by the
Interprofessional Education Collaboration.
collaborative activities across the various professions.
Adapted from Barnsteiner JH. Promoting interprofessional education. Nurs Outlook. 2007;55:144–150.
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT11e. Below are the key references and websites for this
chapter, with the corresponding reference number in this chapter found in parentheses
Am J Pharm Educ. 2009;73(4):59. (1)
pharmacy. Pharmacotherapy. 2009;29(3):145e–164e. (2)
INTERPROFESSIONAL EDUCATION AND PRACTICE
Am J Pharm Educ. 2009;73(4):59.
pharmacy. Pharmacotherapy. 2009;29(3):145e–164e.
National Academies Press, 2003.
Core competencies for interprofessional collaborative practice. 2016 Update. Available at:
promoting patient-centered care. J Nurs Educ. 2010;49:696–699.
Brock T et al. Health care education must be more of a team sport. Am J Pharm Educ. 2016;80(1):1.
Centre for the Advancement of Interprofessional Education. Defining IPE 2002.
http://caipe.org.uk/resources/defining-ipe/. Accessed August 25, 2016
program in pharmacy leading to the doctor of pharmacy degree. “Standards 2016”. 2016. Available at:
https://www.acpe-accredit.org/standards. Accessed August 28, 2016.
interprofessional learning (RIPLS). Med Educ. 1999;33:95–100.
Perception Scale. J Allied Health. 1990;19:181–191.
Educ Online. 2011;16:60350. doi:10:3402/meo.v16i0.6035.
Interprofessional Care. 2014;28:305–310.
interprofessional education. J Allied Health. 2013;42:202–213.
The risk of atherosclerosis is directly related to increasing levels of
serum cholesterol. Cholesterol, specifically lipoproteins, plays a central
role in the pathogenesis of atherosclerosis. Thus, low-density lipoprotein
cholesterol (LDL-C) is the primary target for intervention. The
American College of Cardiology/American Heart Association
(ACC/AHA) guideline and the National Lipid Association (NLA)
recommend management for patients at high risk. This includes patients
with atherosclerotic cardiovascular disease (ASCVD) as well as those
with familial hypercholesterolemia (FH).
Every patient with dyslipidemia should be evaluated for secondary
causes of elevated LDL-C, non–HDL-C, or triglycerides (TGs). These
causes may be related to concomitant medications or due to a clinical
LDL-C goals and the thresholds for instituting therapeutic lifestyle
changes (TLC) and pharmacotherapy are guided by the presence of
clinical atherosclerosis or based on cardiovascular risk.
An adequate trial of TLC should be used in all patients, but
pharmacotherapy should be instituted concurrently in high-risk patients
and patients should be monitored for adverse effects.
In most cases, statins are the medications of choice to treat high LDL-C
because of their ability to substantially reduce LDL-C, ability to reduce
effects is necessary in order to optimize benefit.
Statins are the agents of choice to reduce LDL-C with low risk of
adverse effects. However, drug interaction knowledge is needed in
order to optimize efficacy without compromising safety.
Patients with high TGs are at increased risk of acute pancreatitis. The
primary goal in these individuals is to lower their TG levels with diet,
exercise, weight reduction, and TG-lowering drugs such as nicotinic
acid, fibrates, and omega-3 fatty acids.
Combination drug therapy is often needed in patients with severe lipid
abnormalities, higher risk individuals with lower LDL-C goals, or
patients with multiple lipid abnormalities such as those with the
metabolic syndrome who have a secondary target of non–HDL-C.
Dyslipidemias (one or more abnormalities of blood lipids) play an important
etiologic role in the pathogenesis of ASCVD, including coronary heart disease
(CHD), cerebrovascular disease, and peripheral arterial disease.
lifestyle changes and pharmacologic management of dyslipidemias have been shown
to reduce the risk of ASCVD events such as heart attack and stroke.
cardiovascular disease prevention, the clinician estimates the individual patient’s
treatments to meet and maintain treatment goals.
Knowledge of lipid and lipoprotein metabolism is essential to understanding
therapeutic targets for pharmacologic agents. Lipids are small molecules that function
in the body’s storage of energy, in cellular signaling, and as components of cell
membranes. Cholesterol, an essential lipid, is the precursor molecule for the
formation of bile acids (which are required for absorption of nutrients), the synthesis
of steroid hormones (which provide important modulating effects in the body), and
the formation and integrity of cellular membranes. However, excess cholesterol plays
a central role in atherogenesis and subsequent atherothrombotic complications.
Cells derive cholesterol in two ways: by intracellular synthesis or by uptake from
the systemic circulation. Within each cell, cholesterol is synthesized through a series
of biochemical steps, many of which are catalyzed by enzymes (Fig. 8-1). The
catalyzed by HMG-CoA reductase. One of the most effective lipid-lowering
therapies developed to date for managing dyslipidemias, HMG-CoA reductase
inhibitors or statins, competitively interferes with the binding of substrate to this
critical enzyme, thereby reducing the cellular synthesis of cholesterol. The
biosynthesis of cholesterol in humans follows a circadian rhythm with maximum
cholesterol synthesis occurring near midnight and minimum synthesis at midday.
Free cholesterol is esterified to cholesteryl esters for intracellular storage by the
action of the enzyme acetyl CoA acetyl transferase (ACAT). Two forms of ACAT
have been identified. ACAT1 is present in many tissues, including inflammatory
cells, whereas ACAT2 is present in intestinal mucosa cells and hepatocytes. ACAT2
is required for the esterification and absorption of dietary cholesterol from the gut. In
theory, inhibition of this enzyme could reduce the absorption of dietary cholesterol,
the secretion of cholesterol by the liver, and even the uptake and storage of
circulating cholesterol in inflammatory cells in the arterial wall. Several inhibitors of
ACAT have been developed; however, in clinical trials they did not appear to reduce
atherosclerosis and were possibly pro-atherogenic.
It is unlikely that there will be
any further development of this class of drugs for cardiovascular prevention.
TGs are lipids that serve as an important source of stored energy in adipose tissue.
TGs are synthesized from three molecules of fatty acids esterified to a glycerol
backbone. Phospholipids (PLs) are a class of lipids formed from fatty acids, a
negatively charged phosphate group, nitrogen-containing alcohol, and a glycerol
backbone. PLs are essential for cellular function and the absorption, storage, and
transport of lipids in the circulation. They form the monolayer on the surface of
lipoproteins which function to transport neutral lipids throughout the body. PLs are
amphipathic with a hydrophilic head and hydrophobic tail and form a membrane
bilayer of lipoproteins to deliver hydrophobic cargo (cholesterol and energy in the
form of fat) to other organs. PLs are also secreted into bile to aid in the digestion and
absorption of dietary fat and lipid-soluble nutrients from the diet. They stabilize
proteins within the membrane, function as cofactors in enzymatic reactions, and
participate in the oxidation of lipoproteins in the arterial wall (Fig. 8-2).
Cells also obtain cholesterol by extracting it from the systemic circulation. The
source of this cholesterol is the liver, where it is synthesized and secreted into the
systemic circulation. As discussed above, cholesterol and other fatty substances are
secreted into the aqueous medium of the blood. These lipoproteins contain an oily
inner lipid core made up of cholesteryl esters and TGs and an outer hydrophilic coat
made up of PLs and unesterified cholesterol (Fig. 8-3). The outer coat also contains
at least one of a number of proteins known as “apoproteins,” which provide the
ligand for interaction with receptors on cell surfaces, act as cofactors for various
enzymes, and add structural integrity.
The three major lipoproteins found in the blood of fasting (10–12 hours) patients
11 These particles vary in size, cholesterol and TG
composition, and accompanying proteins (Table 8-1 and Fig. 8-4).
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