Learning with each other

“What the hell is going on?”

In a lecture hall at the School of Medicine, a group of students is having a boisterous discussion. David N. Berg, Ph.D., a clinical professor of psychiatry who specializes in group relationships, has presented a hypothetical clinical situation: A team leader is outlining new procedures on the wards. When a team member reacts with snide comments, the leader asks, in frustration, the question above.

From all over the lecture hall, students shout out ideas as to how to respond.

“This could be you,” Berg said. “You could be a team leader someday.” In health care, he points out, this is a quick transition: “You rise up the ladder in the shortest period of time of any profession. You go from intern to team leader in two years and a day.”

Berg was a guest lecturer in the Longitudinal Clinical Experience (LCE), a class that prepares students for the challenges they will face as clinicians. Part of that preparation is working with caregivers from different health professions. A major component of Yale’s new effort to incorporate interprofessional education, or IPE, into each health care program’s curriculum, LCE mimics the structure of team-based care and trains medical, nursing, and physician associate (PA) students together. IPE courses such as this one aim to acclimate clinicians to working together early in their education, so they will leave training prepared to collaborate effectively.

LCE, a joint effort among the School of Medicine, the School of Nursing, and the Physician Associate Program, places first-year students from each of the three professional schools in the classroom for 15 weeks of didactic lectures and “boot camps” that teach common skills (including history taking, vital signs, and physical examination). They then spend 15 weeks shadowing an interprofessional team at a clinical site, either at the hospital or in a community practice.

LCE began three years ago as a pilot program with nine students. Beginning this academic year, it will include all first-year students from the School of Medicine, the School of Nursing’s Graduate Entry Prespecialty in Nursing, and the PA Program. The impetus for the course was a desire, as the School of Medicine revised its curriculum, to introduce medical students to clinical care earlier in their education in an authentic setting with health care professionals. This year, more than 250 students will participate, along with more than 100 clinical coaches at more than 60 sites.

LCE was also a chance to incorporate IPE into the curriculum. The accrediting body for medical schools, the Liaison Committee on Medical Education, now requires students to have an IPE experience. LCE and IPE seemed to be a natural fit, as long-term clinical experiences are about building relationships with both patients and co-workers, said Eve R. Colson, M.D. ’89, M.Ed., professor of pediatrics and co-director of LCE.

“What we are doing in combining LCE with IPE has never been done anywhere else,” said Colson. “Nationally, IPE has been hard to implement. We are used to training our students in silos, and it’s been hard to change that paradigm. But I think we’ve come a long way at Yale, and we are now in a position to model how this can be done.”

According to the American Association of Medical Colleges (AAMC), IPE is on the rise nationally. In the 2013-14 academic year, 119 American medical schools required some form of IPE for medical students, up from 85 schools three years earlier. The challenges, Colson noted, include expanding IPE to include more students. Another challenge is logistics: often, schools in the health professions at the same university are not always located in the same place, said Maryellen E. Gusic, M.D., chief medical education officer of the AAMC.

Before IPE, medical, nursing, and PA students trained separately, and never crossed paths in clinical education. According to a 2010 report from the Institute of Medicine (now the National Academy of Medicine), said Linda Honan, Ph.D., M.S.N., associate professor of nursing and co-director of LCE. “If we really want to improve patient care delivery, and we want to avoid medical errors, then we cannot continue to believe that training in silos graduates people who know how to work together, and know the value of ‘other,’ whoever that other is.”

“All students come in with their biases or unknowns, but I think this experience will help them realize that we are all learning at the same level and we can rise together,” said David Brissette, PA-C, M.M.Sc., assistant professor in the PA Program.

Working together helps LCE students address biases and preconceptions about each other’s role. “People would say to me that everyone looks down on nurses,” said first-year nursing student Brittany Hughes. “But in this course, I’ve noticed the opposite. People seem to appreciate how knowledgeable we are.” Unlike medical students, who first encounter patients in their third year, nursing students begin learning clinical skills from nearly the first day of school. PAs begin clinical training in their second year. (The new curriculum at the School of Medicine has first-year students beginning a longitudinal clinical experience in their first year.)

What has become clear as the course develops is that despite differences in their roles and approaches to care, the three professions have a lot in common. This commonality not only serves to foster collaboration and understanding, but has an economic benefit also. “We have been teaching the same skills to three different types of clinicians,” said Honan. For example, medical students, nursing students, and PA students learn physical examination skills the same way. “If we can find more threads that are similar—and we can—then why are the three of us spending the time, money, and energy replicating it three times?”

With all first-year students in all three schools taking the class, the challenge has been to find clinical sites to house all of the students as the program grows, manage disparate class and clinic schedules, and convince busy clinicians to incorporate another team of students into their already hectic practices. “It’s a herculean effort to find the sites,” Honan said. But in the end, she said, LCE will help Yale send clinicians to hospitals prepared to thrive in the new team-based paradigms of care.