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Innovative Interprofessional Education for all Yale Medical, Physician Associate, and Nursing Students

April 29, 2019
by Abigail Roth

Our complex health care system requires coordinated, interdisciplinary care, yet most health professional schools offer limited interprofessional clinical opportunities during students’ formative preclinical time. Not so at Yale, home to the Interprofessional Longitudinal Clinical Experience (ILCE) course. This innovative, impactful program is a logistical feat for its organizers that requires a significant time commitment from its many clinical coaches. For the past three years, every first-year MD, Physician Associate (PA), and Graduate Entry Pre-specialty in Nursing (GEPN) student has participated in ILCE, which occurs each year over 16 weeks from September through April.

Yale’s Schools of Medicine (YSM) and Nursing (YSN) view this as a highly worthwhile investment due to ILCE’s effectiveness in advancing its two important learning objectives: interprofessional education, with medical, PA, and nursing students working with clinical coaches to learn about, from, and with each other; and clinical skills (history taking, physical exam, oral presentation, and clinical reasoning). The positive impact on student outcomes is apparent. For example, over the past few years, ILCE students from all three programs have demonstrated a significant increase in empathy, according to the Jefferson Scale of Empathy, based on testing before and after the course.

Kirsten Wilkins, MD, associate professor of psychiatry and co-director for the psychiatry clerkship, served her inaugural year as executive director of ILCE this academic year, overseeing a course involving 123 nursing students, 104 medical students, and 40 PA students, organized into 72 teams. Each team was comprised of three to four students from at least two of the participating degree programs. These teams were placed at 72 different clinical sites, under the guidance of 151 clinical coaches, who included both active and retired YSM and YSN faculty. Among the wide range of inpatient and ambulatory clinical sites used for the program were Yale New Haven Hospital (YNHH) Emergency Medicine, YNHH Hospitalist, VA Psychiatry, VA Rehab Unit, Middlesex Hospice, Fair Haven Clinic, and the APT Foundation.

The ILCE’s associate directors mirror the interprofessionalism of the program: David Brissette, PA-C, MMSc, PA program assistant director and assistant professor, directs the ILCE simulation curriculum; Linda Honan, PhD, MSN, CNS-BC, RN, professor of nursing, directs the clinical skills curriculum; and Barry J. Wu, MD, FACP, professor of clinical medicine, directs the clinical coach program.

The ILCE’s many moving parts and people came together at the New Haven Lawn Club (NHLC) on Friday, April 12, 2019, to celebrate the end of the academic year. Students, coaches, and leaders from across the three degree programs filled the reception spaces. YSN Dean Ann Kurth, PhD, CNM, MPH, FAAN; PA Program Director Alexandria Garino, PhD, PA-C; and YSM Associate Dean for Curriculum Michael Schwartz, PhD, all were present to congratulate the students and thank the clinical coaches.

The dedication and intensive coordination of Danette Morrison, ILCE course coordinator (YSM), Tracy Yale, manager of clinical education programs (YSM), and Tracy Chidsey, ILCE clinical coach coordinator (YSN), who are critical to the success of ILCE year-round, also contributed to the success of the April 12 gathering.

The energy and comradery at the celebration were evident as the evening’s formal remarks began. Each speaker emphasized how ILCE enhances interprofessional education and develops clinical skills. Another key message was appreciation for the clinical coaches’ dedication to the program, with Schwartz remarking, “they love teaching, they love fostering the development of our students. We can’t thank them enough.”

Wu shared that this year’s clinical coaches included 13 PAs, 39 nurse practitioners, and 99 physicians. He also noted that 46 clinical coaches have participated in ILCE for three years, 14 for four years, and 3 for five years. Morrison created a special pin that was presented to all clinical coaches who had participated for three or more years. Wu described the pin a sign of appreciation for the clinical coaches “volunteering their time to pass on the profession to the next generation.”

Clinical coaches weave their ILCE teaching into their already full schedules. For example, some hospitalists on overnight shifts arrive a couple of hours early to teach their ILCE teams. Each week the clinical coaches strategize about the patient interactions that will be most beneficial for the students to develop their clinical skills. And the clinical coaches spend time at the beginning of each clinical session reviewing lessons learned the previous week, and about 30 minutes at the end of each session providing what Wu describes as “just-in-time” direct observations from the session, concrete feedback about one thing each student did well and one area each student could develop for their next session.

In addition to the small-group clinical experience, all students participate in four large group sessions on topics including oral presentation and clinical reasoning, as well as three simulation sessions, starting with history taking, then layering in physical exam, and finally progressing to include clinical reasoning. 

In her formal remarks, YSN student Caitlin Simons reflected “what I learned during my ILCE sessions is invaluable. I was fortunate to get to spend my time with three incredible clinicians who showed me what it means to be a skilled and caring provider and were kind enough to pass those skills and lessons on to me. I leave a much more confident student thanks to your time and guidance and will carry your lessons into my future practice as an APRN.”

Simons specifically thanked Wendy Mackey, MSN, lecturer in nursing, “thank you for everything these past months. Watching your warm personality put patients and families at ease showed me how important patient provider interactions and trust are. You served as a role model of the type of APRN I hope to one day be.”

MD student Julian Weiss, whose ILCE was at the Yale Addiction Recovery Clinic  at YNHH’s Saint Raphael Campus, similarly viewed his clinical coaches, Stephen Holt, MD, MS, FACP, associate professor and associate program director of the Yale Primary Care Residency Program, and Caroline Falker, MD, addiction medicine fellow, as role models. “I want to thank all the ILCE clinical coaches, especially Dr. Holt and Dr. Falker, for the time and energy they put in to give us an amazing experience. The valuable clinical skills we learned - of interacting with patients, accepting and being proactive about progress or the lack thereof - will provide the foundation for all our clinical experiences moving forward. The effort and thought they put into each of their patients was so incredibly heartening, and something I aspire to do moving forward.”

First-year PA student Madeline Kratz’s remarks reflect her appreciation of the scale of commitment ILCE requires from clinical coaches and organizers, “I want to say thank you to not only my ILCE clinical coach but to all clinical coaches and everyone who had a hand introducing us to our first round of patients as students. Thank you for volunteering your time every week to help further our education. Your guidance and commitment to teaching was extremely valuable and the skills we learned will be reflected in our future practice.”

Schwartz shared a snapshot of the history of the program during his remarks, describing how Brissette, Honan, and former colleague Eve Colson, MD, launched ILCE in 2013 as a pilot, involving nine students and six ILCE faculty, who themselves served as clinical coaches, at three different clinical sites. Schwartz described the “remarkable effort” in gradually expanding the program over its three-year pilot phase, including shifting to the model of recruiting interprofessional clinical coaches, eventually resulting in the current structure. In 2016, ILCE was implemented as a required component of the first-year curriculum in all three programs, with now over 250 students and 150 faculty.

Tish Knobf, PhD, RN, AOCN, FAAN, professor of nursing, described ILCE as having “redefined interprofessional collaboration in practice." Garino described how “collaboration is part of the PA's DNA- it's a basic tenet of our professional identity - so it should come as no surprise that the ILCE has become a valued part of our curriculum. It is also something that is uniquely Yale. The ILCE provides students with the space to learn from and about each other.”

Simons reflected on her ILCE team’s growth over the year, saying “one of the main goals of the ILCE program is to teach students how to work effectively in an interprofessional team and our simulations were a great opportunity for us to do that. At the end of our last simulation we were able to look back at the prior ones and see just how far we had come in history taking, physical exams, and successful collaboration.”

Similarly, Weiss reflected upon his team’s and his own development. He shared that he had called his parents after his first day of clinical training “to tell them how upset I was about this patient’s story, and how I didn’t feel equipped to help her as a provider. While I could offer comforting words, I did not yet have the skills or knowledge to truly do anything concrete for her, or even tease apart the different threads of her story and address the overwhelming number of issues in an effective manner.” He continued “while working with Dr. Holt and my ILCE group, we all got better at sifting through all that was going on with her to zero in on the most contributory problems and determine how to tackle them.” After describing steps they took working with the patient, he explained “it finally feels like our holistic goals are in reach. It’s like we are now dealing with a completely different patient, and I similarly feel like a completely different provider than I was for her at the start of ILCE.”

Wilkins ended the evening’s program, thanking the “unsung heroes, the hundreds of patients who shared their stories to help make you a better healthcare provider,” adding “our patients inspire us to do this.”  

Submitted by Abigail Roth on April 26, 2019