Amanda Moloney-Johns MPAS, PA-C Karly Pippitt, MD Michele Haight PhD, MS Ed, MAMC University of Utah School of Medicine
Goals and Objectives
At the conclusion of this presentation, participants will be
able to:
1)
Understand the objectives and goals of the
Interprofessional Clinical Integration Project (ICIP)
2)
Comprehend pilot project details, including individual
session goals, specific student roles and preceptor roles
3)
Discuss the results of the project and their relevance to
physician assistant student (PA) and medical student
(MS) education
4)
Describe ways to implement and expand the ICIP model
into other PA programs
Background
What is interprofessional education?
“Interprofessional education involves educators and learners
from two or more health professions and their
foundational disciplines who jointly create and foster a
collaborative learning environment. The goal of these
efforts is to develop knowledge, skills and attitudes that
result in interprofessional team behaviors and competence.
“ (1)
Background
Interprofessional Education is NOT:
•
Students from different health professions in a classroom
receiving the same learning experience without reflective
interaction among students from the various professions
•
A faculty member from a different profession leading a
classroom learning experience without relating how the
professions would interact in an interprofessional manner of
care
•
Participating in a patient care setting led by an individual from
another profession without sharing of decision-making or
responsibility for patient care(1)
Interprofessional Need
The Institute of Medicine:
“Once in practice, health
professionals are asked to
work in interdisciplinary
teams, often to support
those with chronic
conditions, yet they are not
educated together or
trained in team-based
skills” (2)
School of Medicine - LCE
Longitudinal Clinical Experience (LCE)
Involves students in their first two years of medical school
Traditionally focused on sciences
Phase I—Foundations of Medicine
Clinical Medicine
Students placed with primary care preceptor in
the University of Utah Community Clinics
Internal Medicine, Pediatrics, Family Medicine, Med/Peds
Students attend ½ day of clinic every other week
4 months 1
styear
School of Medicine - LCE
Students initially work in a medical assistant role
Initially “room patients”
Take vitals
Scribe as a medical assistant
Administer symptom questionnaire (x-file)
Goal is to gain a better understanding of the way MAs
function in the clinical setting
After approximately 3 sessions the student will move
towards more provider-specific care, including history
beyond questionnaire and physical exam
Clinical Schedule for Medical Students and PA Students
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec MS1MS2
PA2
The Problem . . .
•
Increased numbers of learners in UU Community
Clinics
•
Increased competition for UU Community Clinic sites
and preceptors
•
Preceptors must ‘choose’ which students to precept,
Needs Assessment
There is a need by the PA Program and the School of
Medicine to:
Provide our students with clinical experience
Train students in UU Community Clinics
Reduce burden on preceptors
Have students gain a mutual understanding of each
others’ roles in clinical practice
Increase interprofessional education
The Golden Opportunity…
Capitalize on a unique platform
for a longitudinal,
interprofessional education
experience in the clinical
setting
The Proposal . . .
Create MD/PA student ‘teams’ and allow 2
ndyear PA
students to teach 1
styear medical students in an
outpatient clinical setting, evaluating real patients
under the supervision of single preceptor
Share roles of history taking and physical exam
Practice oral presentations before delivering to the preceptor
Review and give feedback on documentation
Collaboratively discuss assessment and plan
ICIP Goals and Objectives
1)
To enhance clinical skills and knowledge through
peer-to-peer teaching and feedback
2)
To better understand the specific roles of both
professions on the medical team while
understanding the importance of collaboration and
teamwork amongst health care professionals
3)
To decrease competition between PA students and
medical students for clinical sites while avoiding
additional burden on the preceptors
Proposal Benefits
“Experiential learning is particularly important in IPE,
and workplace learning offers an ideal setting in which
professionals can reflect on their professional practices
and the ways in which they intersect/overlap/
complement the professional practices of others
within a multidisciplinary setting” (4)
-Academic Medicine
Proposal Benefits
Benefits for:
PA student
‘See one, do one, teach one’
Early interaction with future employer
PA students have already had near-peer teaching experience with 1styear PA students
Medical student
Becomes more familiar with PA profession early
Allows for more responsibility and learning than current objectives
Preceptor
Does not have to teach at two different levels—preceptor teaches PA student and can use PA student to teach ‘basics’ to medical student
No additional impact on practice
Potential Proposal Barriers
“Studies have shown that effective interprofessional collaboration can beundermined by boundary infringements, a lack of understanding of one another’s roles, limited communication and poorly coordinated teamwork” (3)
Preceptors
Finding preceptors willing to pilot project
Students
Opposition from both students about another student ‘imposing’ on
their learning
Both students getting the education that they need without
diminishing the experience for either student
Hierarchal attitudes
Personality clash (must hand-pick students for project)
Patients
Multiple learners involved in care, extra time
The Pilot . . .
A one-month pilot project was implemented in April,
2011 to see if ICIP would be not only feasible in clinic,
but valuable to all involved
3 second-year PA students
7 first-year medical students
3 UU Community Clinic sites-2 Family Medicine, 1
Pediatrics
4 preceptors
And a partridge in a pear tree
Student Roles
Session 1
•
PA to demonstrate and teach history and physical exam skills to
MS; MS scribes for PA
•
MS to practice an oral presentation to PA, receiving helpful
feedback
•
Together formulate a differential diagnosis and plan for the
patient, looking up necessary information in the medical
literature
•
PA gives formal oral presentation to preceptor as MS observes
•
Review and finish patient case with the preceptor
•
PA to review and critique medical documentation performed by
MS
Student Roles
Session 2
•
MS to take a focused patient history while PA scribes; PA fills in
any gaps in history
•
MS to perform physical exam on patient while PA observes and
explains any abnormal findings
•
MS to practice an oral presentation to PA, receiving helpful
feedback
•
Together formulate a differential diagnosis and plan for the
patient, looking up necessary information in the medical
literature
•
MS gives formal oral presentation to preceptor as PA observes
•
Review and finish patient case with the preceptor
•
PA to review and critique medical documentation performed by
MS
Did it Work?
Attitudinal Surveys (for students)
•
Pre-experience survey
•
Post-experience survey
Debriefing Sessions
•
Conducted by Michele Haight, PhD, MS Ed, MAMC
•
Performed independently with medical students, PA
students and preceptors shortly after the pilot
Survey results
1 2 3 4 5 PA Student 1
PA Student 2 PA Student 3
I Have a Clear Understanding of the Medical Student Role on a Medical Team (on a scale
of 1-5) Pre-survey Post-survey 1 2 3 4 5 Med Student 1 Med Student 2 Med Student 3 Med Student 4 Med Student 5 Med Student 6 Med Student 7
I Have a Clear Understanding of the PA Role on a Medical Team (on a
scale of 1-5)
Pre-Survey Post-Survey
Survey Results
1 2 3 4 5 PA Student 1
PA Student 2 PA Student 3
I Feel that Training as a Team with a Medical Student will
Enhance my Educational Experience Pre-Survey Post-Survey 1 2 3 4 5 Med Student 1 Med Student 2 Med Student 3 Med Student 4 Med Student 5 Med Student 6 Med Student 7
I Feel that Training as a Team with a PA Student will Enhance
my Educational Experience
Pre-Survey Post-Survey
Debriefing Results—PA/MS
What was your understanding of the purpose of this
dyad community experience prior to participating in it?
Medical Students:
PA Students:
• “Learn what the PA did and the
role on the medical team”
• “Work with the PA to further our
knowledge and learn from each other”
• “Work in a non-threatening
environment”
• “MS sharing science knowledge,
PA sharing clinical”
• “Exposure to folks we will work with in the future and foster cooperation between”
• “Better dialogue with other students”
• “Did not fully understand; sharing clinical sites”
• “Opportunity (for medical students) to understand and recognize what PAs do and understand them (MS) and how the school of medicine works”
Debriefing Results—PA/MS
What do you feel was the most valuable part of this
experience?
Medical Students
PA Students
• “In the patient room it was really helpful; the PA would explain things more and how they would treat the patient and why”
• “The PA asked me questions beyond just the ‘x-file.’ We asked good questions during the interview, not the standard book questions”
• “It gave me more of a purpose at clinic—I felt like I was actually doing something
• “Being able to get immediate feedback from a non-threatening person who was encouraging”
• “There was a shared common benefit; the experience amazing and so useful”
• “We are gaining a better understanding of the MS educational process”
• “It was enlightening for the MS to see where we are at and how we manage patients. We surprised them, they think they are smarter”
• “It is good to see the MS do the history and realize they can”
• “Doing the patient workup as a team benefits the patient”
• “Sometimes we feel pounded down; this increased our confidence to be a teacher; it helped us grow as clinicians and to ‘be’ the authority”
Medical Students
PA Students
• “I do not know of any least valuable part; it ran smoothly and was very helpful”
• “Give us more time doing this”
• “One situation in which the PA did not reverse the role as indicated during the second visit; the PA took over. Did not give me the opportunity to interview; I did the PE while she was interviewing”
• “On the first day, we did not have a clear picture of what to do”
• “There was a lack of interest on the part of the MS; there was no interest in the profession, they were more worried about what to do with the doctor; there was no reciprocation as far as educating one another”
• “The MS were not ready—did not know about a history, meds or scope of practice; did not know what to ask”
Debriefing Results—PA/MS
What suggestions do you have for improvement?
Medical Students
PA Students
• “It takes a while to get used to the
flow; be more clear regarding expectations of each student”
• “Do this more, it was incredibly
helpful”
• “Everyone would benefit from this”
• “Earlier EMR training, more
exposure to EPIC first”
• “We need to learn about checking
in patients and doing “MA stuff” for the first couple of weeks”
• “Make sure the PA has enough clinical experience-this would not work if the PA is in the early part of their training”
• “Lacked time and needed planning to prepare presentation”
• “The current structure makes it work; we would not have the same teaching opportunities if the structure were MS2, PA1”
• “More training for preceptors and students as to understanding how this fits together”
• “MS never worked with a computer system. They need a week in clinic prior to this experience to prepare”
• “2 sessions are not long enough”
Debriefing Results—PA/MS
What did you learn about your own role on the allied health care
team? The role of the medical student (PA student)?
Medical Students
PA Students
• “How the PA did more in-depth tests and patient interviews and brings out the pertinent points for the physician”
• “The PAs lay the groundwork for the physician; they come up with a different or another viewpoint”
• “We functioned as a team rather than as individuals”
• “The teaching aspects of our role”
• “Learned about precepting and giving proper feedback and constructive criticism”
• “We learn from the MS and need to have this dynamic continue”
• “The team approach; remember we are learning together”
• “I need to be at a place that I can learn something from this person. I was intimidated by the medical student”
• “It was nice to see the intersection of perspectives”
• “There are potential ego conflicts; there is a hierarchy”
How did this arrangement impact the quality of your interactions
with your preceptor and with patients?
Medical Students
PA Students
• “I had more of a role. I could discuss the patient with the PA first and he helped me and gave me good advice”
• “We functioned as a team rather than as individuals; this helped with the skill and comfort of practicing clinical skills”
• “This really helped; we practiced presenting with the PA and they gave us a couple of tips; when I presented to my preceptor she remarked how well I did. This was directly related to the feedback I got from the PA student”
• “Good for the patients…they liked it because we spent more time with them”
• “PAs acted as preceptors; this was beneficial for (the medical students). We were able to prompt MS and this was less threatening for them. It took the stress off and made more teaching and learning opportunities”
• “The preceptors explained more and invited the PA student to add information”
• “Patients were hand selected and they were receptive; the elderly patients loved having two people come in”
Debriefing Results—PA/MS
How do you feel this experience will help you be a better
PA/Physician?
Medical Students
PA Students
• “I got to see the role of multiple people; it is helpful to see what the PA does”
• “Most physicians ask questions of the PA, i.e.: what would you do? I had no idea”
• “We had practice in a way that we got constructive feedback; we were not rushed”
• “I learned presenting skills, clinical skills and applicable questions”
• “I got more out of those two days than the rest of the time here”
• “It was a mentorship and a friendship; we will be colleagues for the rest of our lives”
• “Proper exposure to employers, supervisors; opened the door to get us a job because these are the folks we will be working with”
• “Greater understanding of the background and dynamics of medical school. There is a level of intimidation with physicians. A better understanding decreases the intimidation”
• “It was a great opportunity to teach. We will carry this with us throughout the rest of our lives”
• “Teamwork. This cements my job choice and I appreciate the medical students”
Debriefing Results—PA/MS
Other Comments . . .
Medical Students
PA Students
•
“It was fun. I loved it. It was
better than me by myself”
•
“I LOVED this program. It
needs to be implemented as it
was structured and
described”
•
“The PA helped to guide (us).
They asked questions and let
(us) do things”
•
“It was a great experience
because we both learned
about one another”
•
“We need insight”
•
“The learning experience was
great; it was positive and
beneficial”
•
“We learned about the
teaching aspects of our role”
“Very positive and productive experience which is worth expanding and building upon”
Less Burden on Preceptor
• Because the PA student took the time to teach the medical student, the burden was taken off of the preceptor and the time the students spent with the preceptor became more focused and efficient
Did Not Affect Productivity
• Did NOT slow preceptors down or interfere with flow of clinic; preceptors reported enhanced time in clinic because the PA student acted as a mid-level ‘teacher.’ The PA student was able to give initial feedback which allowed the preceptor to give ‘better’ feedback
Increased Efficiency
• Team set-up was effective and made things more efficient; preceptors were comfortable delegating teaching responsibilities to the PA student and were not concerned about the quality of teaching
Debriefing Results—Preceptors
Any concerns and/or suggestions for improvement?
Concern about patient
experience and the
increased amount of time
patients spent in clinic
•“Were patients off-put by
this?”
Debriefing Results—Preceptors
Would you do this again? Final thoughts:
•
All pilot preceptors would repeat this experience
•
It did not affect productivity or patient flow
•
Win-win experience; students felt comfortable and med
students especially loved this
•
No burnout reported
•
Would be better if it took place for a longer period of time
•
It is feasible to continue and expand—word of mouth best
way to expand
Where Do We Go From Here?
Expand ICIP to run January through April, 2012
“The continuing lack of longitudinal studies remains problematic” (5)
Journal of Interprofessional Care
• HRSA Primary Care Training Grant Funding
• Start a longitudinal experience with 3 primary care sites, involving
2-3 preceptors, 2-2-3 PA students and 4-7 medical students (hand-select); students develop relationships over a total of 6-7 sessions (MS with MA for first 1-2 sessions)
• Build more detailed objectives for each session; establish clear goals;
(i.e, by the end of ICIP, MS will have improved history, PE and oral presentation skills, PA student will develop teaching skills and thus improve their own skills in history taking, PE, assessment and plan)
Where Do We Go From Here?
•
Formal orientation/training together with medical students and
PA students; outline clear expectations
•
Educate students on each others’ roles, where education is up
until this point, etc. Also teach MS the role of a PA in practice
•
Obtain more objective data through student and patient
surveys—qualitative data becomes quantitative data
•
In the next few years, evolve into specialty care, increase number
of students, sites and preceptors involved—possibly work into a
patient-centered medical home model
Unanswered Questions
Does this decrease competition for clinical sites?
What is the long-term effect on clinic productivity?
How does this impact the patient experience?
Does this affect interest in physicians working with a
PA in the future?
How will this impact numbers or types of patient
Acknowledgements
John Houchins, MD
Michael Magill, MD
Susan Terry, MD
Kelly Thomas, MD
Elizabeth Smith, MD
Susan Cochella, MD
Dan Crouse, PA-C
Dave Keahey, PA-C
Nadia Miniclier, PA-C
Olivia Walton, PA-C
Jennie Coombs, PhD, PA-C
Melody Berg
Questions?
References
1. Buring, SM, Bhushan A, Broeseker A, Conway S et al..Interprofessional Education: Definitions, Student Competencies, and Guidelines for Implementation. American Journal of Pharmaceutical Education . 2009 Jul 10;73(4):59.
2. Institute of Medicine. Health Professions Education: A Bridge to Quality. 2003.
3. Reeves S, Zwarenstein M, Goldman J, Barr H et al. Interprofessional Education: Effects on Professional Practice and Health Care Outcomes. The Cochrane Library. 2009; 4.
4. Ho K, Jarvis-Selinger S, Borduas F, Frank B et al. Making Interprofessional Education Work:The Strategic Roles of the Academy. Academic Medicine. October 2008; 83 (10): 934-940.
5. Thistlethwaite J, Moran M. Learning Outcomes for Interprofessional Education (IPE): Literature Review and Synthesis. Journal of Interprofessional Care. September 2010; 24 (5): 503-513.
6. http://www.aippen.net/what-is-ipe-ipl-ipp Accessed 10/5/11
7. http://tutorialblog.org/writing-a-project-proposal/Accessed 10/5/11
