In September, 235 first-year Yale MD, Physician Associate (PA), and Graduate Entry Pre-specialty in Nursing (GEPN) students practiced patient-centered interviewing with over 200 volunteers aged 65 and older—virtually. Beyond gaining early telehealth experience, the students had the opportunity to incorporate questions about the “4Ms”—mobility, medication, mentation, and what matters most—into conversations with older adults.
The history taking session was part of the Interprofessional Longitudinal Clinical Experience (ILCE) course, which first-year students from all three programs participate in over the span of 16 weeks, from September through March. Students from the different programs are combined into small groups and paired with clinical coaches, to learn to work effectively as part of an interprofessional health care team and to practice clinical skills, including history taking, physical exam, oral presentation, and clinical reasoning. Starting last year, ILCE began incorporating training on the 4Ms, through the COACH 4M grant. One of the grant’s goals is to prepare more health care professionals to care for our aging population.
COVID-19 has required redesigning many parts of the MD, PA, and GEPN curricula, including the ILCE, since the pandemic limits student activity in clinical settings. And with telehealth now a critical component of health care, the ILCE team recognized the importance of students gaining experience with virtual patient interviews.
ILCE Associate Director Barry J. Wu, MD, professor of clinical medicine, who had the idea for this exercise, says planning for how to operationalize it was a collaborative effort. While he thought of having students ask older family members to volunteer, ILCE Associate Director Linda Honan, PhD, MSN, CNS-BC, RN, professor of nursing, suggested that students interview the family member of another student, to better simulate an interview with a real patient. Student outreach resulted in 100 volunteers, and ILCE Director Kirsten Wilkins, MD, associate professor of psychiatry and director of medical student education in psychiatry, and Danette Morrison, ILCE program coordinator, along with other ILCE colleagues, recruited over 100 additional participants. Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and section chief (Geriatrics), reviewed and suggested sample 4Ms questions and scripts for the students. And Assistant Professor Pamela Hoffman, MD, medical director of Telehealth Services at Yale New Haven Health Services and Yale Medicine, created a video for students, Introduction to Telehealth Interviewing. Honan emphasizes, “it takes a village to create curriculum for nearly 240 students!”
The telehealth video was important since, as first-year PA student Gloria Ho says, “we recently had a chance to practice history taking with each other, but this was the first virtual patient interview we've had.” Similarly, first-year MD student Ishan Ayyalasomayajula explains, “this was indeed the first time I'd ever interviewed anyone, let alone a patient, virtually. It was important for me to maintain the same level of professionalism during this virtual interview as there would be during an in-person encounter.”
Incorporating the 4Ms added challenges —and provided valuable lessons—for the students. Ho explains, “I really appreciate the openness of our interviewees,” since the questions, including about the volunteer’s mental and emotional state, can be very sensitive subjects.” Ho continued, “since we were asked to interview a particular age group (65 years or older), I must admit I had some preconceived notions about the livelihood and health status of people in this age group, but it was humbling to have the interviewee quickly dispel those negative stereotypes. I will definitely take this valuable learning point to my future patient encounters.”
Similarly, Ayyalasomayajula explains “though initially I felt uncomfortable delving deep into Mr. Wickwire's medical history, I became more comfortable as the interview went on.” Ayyalasomayajula adds “the most valuable lesson I took away from this experience was that I fully understood the level of trust patients place in medical professionals. Though I had never met Mr. and Mrs. Wickwire before, they were comfortable sharing private medical histories with me because I was a medical student. It was a humbling realization.”
Along with asking questions related to the 4Ms, students were to practice observation skills, since important information can be gained by observing a patient’s appearance, behavior, and surroundings. The virtual format created certain challenges. For example, some volunteers did not have their computer camera turned on. Ho describes how although there were limitations to what she was able to observe virtually, she was able to obtain a general impression— for example, if the patient was comfortable, well-appearing for her age, or in any physical/emotional distress during the conversation. Ho adds that she really appreciated “this valuable experience given the current challenges.”
After completing the interviews, each of the 62 ILCE groups met with their ILCE clinical coaches to discuss the experience and reflect on the lessons learned from taking the history of an older adult. While ILCE Associate Director David Brissette, PA-C, MMSc, PA program assistant director and assistant professor, and John Encandela, PhD, associate professor and associate director for curriculum and educator assessment, YSM Teaching and Learning Center, are coordinating a formal assessment of the students’ 4Ms history taking skills, several volunteers informally provided positive feedback.
Joan Lord, who was paired with Ho, says she “never would have known she was a student,” complimenting Ho on her professionalism. Lord added that Ho did an excellent job asking about mentation, noting that most medical professionals do not ask about this issue, which in her view is very important to physical health.
Bill Wickwire said Ayyalasomayajula “made me feel very relaxed and comfortable. He answered all my questions regarding conﬁdentiality of my information, how he will share the information from our interview with colleagues without identifying me, and who he would be sharing my information with. The student was very compassionate regarding my health history and showed an interest in my present health issues.”
Volunteer Laura Pizone explains she generally prefers in-person appointments because they provide the opportunity to build a rapport with a medical professional and feel less clinical than virtual appointments. However, Pizone continued, “I enjoyed my session with Elizabeth, and wouldn’t mind doing a virtual visit with someone like her,” adding that the nursing student was “kind, patient, and a good listener.”
Reflecting on the purpose of the exercise and his decision to participate, Wickwire stated, “I was pleased to assist in this process because I have excellent medical care from my physicians and medical staff in the Yale New Haven Health Care System. I wanted to share my information so that others of my age group might beneﬁt in the future with increased quality age-related health services.”
Wilkens echoes the importance of this training. “As the older adult population continues to grow, it is imperative that all future health care professionals are prepared to care for them. The 4Ms session offered students a chance to practice key interviewing skills, while also increasing their comfort with virtual care and challenging preconceived notions about older adults.” Additionally, she notes, “during a time when many older adults are experiencing social isolation, the opportunity to connect with a student was particularly meaningful. Our volunteers were overwhelmingly impressed with our students, with many offering to volunteer again in the future.”