Precepting a student with a shockingly low-credit program

[db_pavnp]

So you aren't concerned about the 20k hours MDs get vs the 1-2k midlevels get, but you ARE really worried about the 1.2k to 2k difference between PAs and NPs?

[sk732]

In his defence, he's concerned that this person will be let loose with a licence and practicing ON THEIR OWN.  Even when I was "on my own", I always had established back up by my SP or back up SP and they were looking over my shoulder whether I knew it or not.  If something got missed or mucked up, I'd hear about it...not so much in this case.  Even in the ED I work in, where we have 3 NP's rotating through, they're restricted to the minor treatment area and have finite guidelines on what they're allowed to see age and acuity wise.

 

The problem I see with a lot of this trying to out educate each other is this - you want to produce a clinician, have a clinical degree - when I start my Master's at U Nebraska, it's a clinical concentration with a bit of fluff on health policy and scientific writing and such...as opposed to lots of fluff and little clinical stuff.  Some of these schools are likely being controlled by the Dept of Graduate Studies so require a huge amount of mentally challenged, useless crap in order to qualify for a Master's/PhD level degree.  PA/NP are clinicians, not Health Care Admin gurus (though some like to be, and that's ok).  Make the degrees clinical and useful out of the gate.

 

$0.02 Cdn

 

SK

[EMEDPA]

20K HOURS? how did you come up with that? I will give you 2500 hrs for ms3, 1500 hrs for ms4(it's a cake year) and 3000 hrs/yr for 3 yrs for residency. that's 13,00 hrs total for folks with no prior medical background. the 80 hrs/week really only applies for the internship in most specialty residencies, after that the schedule is a bit more than a regular job for most, say 50 hr weeks (the exception being surgery). many PA/NP folks have > 10,000 hrs before they even step in a classroom. a current theory says you are an expert with 10,000 hours in a specialty. that makes a doc an expert when they graduate and a typical PA after 4 years or so of practice in a full scope job (I'm assuming a min of 2000 hrs of training in school, many of us did more).

[db_pavnp]

13k vs 20k alters my point not an iota.  It strikes me as ridiculous that a PA would stand up and suggest that it is SHOCKING that an NP be trained as a semi-specialist in 1100 clinical hours compared to a PA as a semi-generalist in 2000 while MDs grind out 13,000 hours.  Like there is some magic line that is suddenly crossed between 1100 and 2000, the difference between SHOCKING incompetence and a fully functional provider.

 

You guys are as militantly weird as the nurses you spend so much time worrying about.

[Febrifuge]

The only thing I ever characterized as "shocking" was the number of clinical hours per semester. I stand by that.

 

As for the rest, it's nice of Mercury00 to have dug in to the fine details, and it seems to back up my impression that, speaking in terms of graduate programs in general and clinical training in particular, programs like this one really don't seem to require (what seems to me to be) very many hours. Whether they should, or need to, would be up for discussion, or so one would hope.

 

I find it interesting that the argument has now shifted to MD vs PA, and the argument that if PAs are okay to practice with so many fewer hours than MDs, there should be no problem with NPs being another jump down in the total hours. I don't buy that logic, and sk732 explained why. PAs have oversight, collaboration, and usually a formal or informal OJT training period. Sometimes they do residencies. If we go all the way back to the beginning of the thread, my worry is that in my state, there is ZERO required physician oversight for NPs, so a brand-new graduate from a program such as this one can literally go out and practice in a manner exactly like an MD, who has 13x the hours of training. Let's compare apples to apples here, please.

[EMEDPA]

not even the most militant pa says new grad pas should practice solo without oversight, yet this is just what a new grad np with 1/2 the training can do. that is why folks are talking about it. everyone here has worked with good and bad pas and nps, folks we would trust our families to and folks we wouldn't. I think any new clinician(pa/np/md/do) needs some oversight for a few years before striking out on their own. the docs have this built into residency, the pas have it legislated, leaving the nps to do what they feel best. hopefully most do the safe thing and find a good mentor to work with for a few years before opening an office of their own. that's all we are saying here.

[Febrifuge]

EMED has it exactly right. This isn't meant to be an attack on a whole profession, or even an educational system, and it's certainly not an attack on any individuals. It's recognition that what's required in NP training, when compared to the training other clinicians get, seems like it stands out for being less robust.

 

And especially considering the significantly greater level of freedom NPs have once they're done, it seems a little weird to me, with my background and my frame of reference, that they get less preparation before they are able to go out and immediately do more.

 

And I really do think the 150-hour clinical rotation thing is a good example. Maybe we should ask everyone here what they learned in the first 100 hours of any given clinical rotation, compared to what they learned in the last 100 hours of that same rotation. I know for me, if I'd stopped my Internal Med rotation after 150 hours, I wouldn't understand heart murmurs or anti-hypertensives. If I'd stopped after 150 hours of Surgery, I would barely know how to wash my hands properly.

[EMEDPA]

the first 40 hours is "where is the bathroom" and "what is everyone's name"....:)

[Mercury00]

For the record, I'm not a PA. I'm still debating medical school versus a PA program.

 

And as EMEDPA and Febrifuge have pointed out, the reason why requiring less than 1100 clinical hours is so problematic is because in many states, NPs are allowed to practice independently upon graduation. Can you honestly say that someone is adequately prepared to be an independent medical practitioner after only 1100 hours? That is what I meant by "shocking." If PAs were allowed to practice as independent clinicians immediately after completion of their programs, I would have the same concerns (despite the fact that the average PA program requires almost double the average clinical hours of NP programs). 1100 or 2000 hours just aren't enough to prepare someone to be a fully autonomous provider.

[EMEDPA]

you know there are still msn/fnp programs in independent states that require 500 hours total, right? programs with mostly online didactics and rotations arranged by the students....the increase in clinical hours at some DNP programs amounts to a doubling of clinical hours vs programs with min hours. Definitely a step in the right direction. I would be in favor of practice autonomy for both PAs and NPs after 10,000 hrs of experience (including clinical rotations in school).

[UpRegulated]

Can you honestly say that someone is adequately prepared to be an independent medical practitioner after only 1100 hours? 

 

On paper, that is theoretically possible for NP's.  Now go find one that has ever done it - just one.  I'm not talking about some NP working in a "Low T" clinic, or some boutique "medical" weight loss clinic, I mean an NP working to full scope, 100% independently, day one out of school...say in Family Practice.  There is no such thing as an NP that works 100% independently in specialty.  We can talk  paper theory all day - just show me where it has actually happened.

 

Allow me to briefly add - with limited time to respond to other posts - that anyone here that is a non-nurse has a very limited understanding of how BSN prepared nurses are trained in undergrad.  Where PA's are often being taught how to take a proper blood pressure their first semester of graduate school, nurses have mastered that skill their first semester of undergraduate.  Tons of other skills and didactic knowledge that is 100% relevant to being a provider is also taught in undergraduate nursing.  At some point, I'll go point-by-point as to what undergraduate nurses are taught compared to PA's students at the graduate level. There is a reason PA's get more clinical/credit hours as compared to NP students -- they need them.

[EMEDPA]

pretty sure many/most PA students learned to "take a blood pressure" and "other skills" when they were paramedics, resp. therapists, RNs, medical assistants, ER techs, etc before pa school....paramedics, RTs, and yes, nurses learn about their specific job duties before they go to grad school. sure, they know parts of a H+P, a bit about labs and coming up with a ddx, but  it's very different being a clinical provider at the NP or PA level than being a floor nurse on med/surg. also, remember that a significant # of new NPs today never practiced as nurses outside of maybe 700 hrs of training for the 1 yr bsn if they went straight through a 3 yr direct entry program after a bs in nutrition or something. PA clinical training is also longer because we do rotations in more than a single field. while an fnp might do 500 hrs in FP, a typical pa student (say me) might do the following:

surgery 600 hrs

internal medicine 300 hrs

ob gyn 300 hrs

psych 300 hrs

 em (required) 300 hrs

peds em (300 hrs)

FP 500 hrs

em elective 500 hrs

total > 3000 hrs in 54 weeks of full time clinical rotations in 4 states.

[LT_Oneal_PAC]

Between the subject line and the original post, this thread cannot be saved and should be deleted. The OP characterized the program as a 150 hour doctoral level nurse practitioner program generating a clinician and that is not the case at all.

He stated, albeit with dates, that it was for a semester, which is accurate.

[cinntsp]

 

 

Where PA's are often being taught how to take a proper blood pressure their first semester of graduate school, nurses have mastered that skill their first semester of undergraduate.  

 

We spent about a half hour on this.

 

 

 

There is a reason PA's get more clinical/credit hours as compared to NP students -- they need them.

 

This is greatly overstating the value of being a nurse prior to becoming an actual shot-caller.

[EMEDPA]

I think it is fair to say that any high level prior HCE is of great value to a PA or NP student as it provides a solid foundation upon which to learn how to be a provider. I don't know that anyone could prove that rn was better than rt or medic,. but all of these are better than most other things.

[sk732]

Some personal experience with some programs - both BSN and NP...both on physical examinations.  I was helping a friend study for their upcoming physical exam final and was looking over the study notes.  For abdominal exam, it was considered more important that these trainee nurses listen for a renal artery bruit than learn some basic things, like what rebound pain was and how to elicit it, or where Rovsing's and McBurney's points and signs are and what they mean.  This was from a very highly regarded university program.  A friend of mine was asked to go an tutor a class of NP's on physical examinations because they weren't being taught to a level required of a primary care provider.  Same university.  All classes in physical exam were NOT taught by people who should have been teaching them - physicians and either specialist types like ortho, or physio for the MSK, internal med or cardiology for heart murmurs, etc...they were taught by RN's, most who weren't even specialist CRN's.

 

The good thing HCE of any kind provides is exposure to sick people.  The first thing I had to learn when I started PA school after being a medic for nearly 20 years was what I didn't know - surprisingly, it was a lot more than I realized.  I find a lot of RN's don't really realize what they don't know - even highly experienced ones.  It's one of the reasons a lot of these programs have as few hours as they do - training, experience and knowledge are over estimated.  Don't think for a second that people shouldn't start from scratch when they go into advanced training - why do you think that in medical school, everybody starts out on the same foot, regardless of background?   Everybody then learns what needs to be learned, and everybody unlearns what they think they know but really don't.  If you've got a PhD in biochem, well you should have a lot less trouble with that...pharmacist, well same for dope stuff and some pathophysiology.  But you don't get no buy in.

 

SK

[RealityCheck]

I have stopped taking NP students from the universities around me because they are clinically inept at the time of entry into a preceptorship with me, a PA, in an outpatient clinical setting.

They also have little oversight in my region from the 3 universities in our city.

 

My last two students before I stopped made up their own schedules, showed up when they wanted and stayed only as long as they wanted. They could not present. They did not know how to formulate a differential. 

 

When it takes 25 minutes to get a history on strep throat and this is this person's FOURTH clinical rotation - I am done.

 

She was an ICU nurse with absolutely no professional reason to obtain a DNP but just wanted one. No financial worries, spent more time with her show horses and was generally just going to school to do something since her nest was empty.

 

The other was pregnant and pretty much figured she knew what to do. 

 

Both only needed 80 HOURS of Family Practice to finish their degrees. 80 HOURS in FP - are you kidding me?????

 

One student showed up around 8:30ISH - I start seeing patients at 8. She talked to the staff about knitting and cooking and then got miffed when I was already in a room seeing a patient and "forgot" to come get her. She was an ICU nurse and pretty much thought FPs are overrated and ICU folks are much much smarter.

 

The pregnant one would take off for lunch with her mother and be gone 1-2 hours and return "tired and full" while I had been charting through lunch and seeing a work in. 

 

ZERO WORK ETHIC AND NO SUPPORT FROM THEIR PROGRAM.

 

She also faked her write ups to her clinical supervisor and actually just made stuff up in her write ups in order to use limited clinical knowledge and general laziness to cover for her ineptitude. 

 

Her clinical director did very little once I showed her the false reports and documented her tardiness and lack of interest or attention. They were afraid of the potential litigious outcome or having to confront someone who had no business in the profession at all.

 

So, yes, I got burned and it left a bad taste. My PA students from the state program (yes, I teach there part time) come ready to go. Arrive early, ask questions, ask for feedback, do nighttime research on interesting or just flat weird findings and are eager to learn - yes, 99% of them are happy little sponges who are rearing to go.

 

So, until NP education is regulated with the same tenacity as PA education - I will no longer proctor NP students. My experience has shown me that , at least in my region - they need structure, discipline, and support from staff.

 

So, debate away and NPs can get all over me for this but after repeat situations over a period of 5 years and no support from doctorate level staff at the university - ummm, I'm done.

[Febrifuge]

RealityCheck, it sounds like you are someone I should be talking to, in my quest to make this a good rotation for my student.

 

What I have as a plan so far is to have all my students fill out a brief survey at the start: what's your background and experience, which rotation is this for you, and how would you rate your own skills across a few areas (history-taking, test ordering and interp, DDx, physical exam, etc). Likewise, I want to know if they have areas they believe need work, and anything they want to make sure to learn during the rotation.

 

I'm thinking this will help me focus the very few hours we have, in a case like the one coming up. It will also help me assess how well the student is able to estimate their own strengths and weaknesses, and it should help me with writing feedback and evaluations.

 

Every so many hours, I plan to send them home with a short form to fill out: what's going well, what needs work, what's something new they have learned. And I'll ask them to prepare a few 10-minute talks, on a few key subjects.

 

Behind the scenes, anybody who complains that this is a lot of work will get dinged. What else can I be doing, so as to try and head off the kind of horror-show you experienced?

[EMEDPA]

reality- our last NP student (from a large well known online program) the last week of her last rotation could not identify classic strep throat in an adult as the cause of fever x 5 days. she didn't even examine the throat. she had 2 preceptors, me and an excellent NP from a strong program. we both agreed she needed to fail as this was typical of her progress through the rotation despite both of us offering suggestions for areas of study, etc. apparently she found that too hard to work in around her full time job as a peds nurse. she is not an np today.

her "rotation" with us in em was 80 hrs scheduled at times of her choosing. I don't know how any of her prior preceptors gave her a passing grade when she was their student. I have been very selective about NPs that I precept since then. only folks I already know who ask me personally. mostly er nurses. they all have done fine, but then again they are er nurses, so they know how to work.

[acozadd]

My last NP student wasn't able to even accurately identify which bone was the tibia vs. fibula at the end of the rotation, let alone identify the fracture, discuss treatment options, etc. She is a few months away from graduating... She was the only NP student I've had so maybe my experience has been skewed by 1 bad example, but it was scary. I have more confidence in the scribes at my office compared to her. I'm sure her "years of high quality prior HCE" will help her at some point, but it wont be in an orthopedic office...

[Febrifuge]

These horror stories are pretty scary. Maybe I'm still naive and idealistic, but I'm hoping my students will rise to meet some higher expectations, and I'm feeling like it's especially important for me as a preceptor to challenge them. I'm realizing I have been a little bit lazy with the handful of students I have precepted so far, so being more organized and objective seems important.

 

How have programs responded when you give a student a failing mark? Do they accept criticism about how well-prepared the student seems to be, for where they are in their program? I don't want to beat my head against a wall, but I also want to give a student a fair shot at being better than they might have been expected to be in previous rotations.

 

I know the majority of providers in my system simply won't take students at all. I hope I can make something good out of all this before I decide I need to be one of those, but it's possible that day might be coming, eventually.

[EMEDPA]

My last NP student wasn't able to even accurately identify which bone was the tibia vs. fibula at the end of the rotation, let alone identify the fracture, discuss treatment options, etc. She is a few months away from graduating... She was the only NP student I've had so maybe my experience has been skewed by 1 bad example, but it was scary. I have more confidence in the scribes at my office compared to her. I'm sure her "years of high quality prior HCE" will help her at some point, but it wont be in an orthopedic office...

if only she had taken woodshop in high school...:)

[RealityCheck]

After my experiences, I came up with a What to Expect list for any students.

I list my hours and that they are expected to keep my hours.

I put in a written presentation of a common issue and ask that they follow that format.

I had a PA partner in the one office - so he and I would present to each other in the desired format as examples.

The PA program gives me excellent rating forms for everything from appearance, attendance, attitude and then clinical acumen. The PA program even addresses cultural sensitivity and patient interaction including empathy, sympathy and educational ability.

I now ask for their write ups to me printed out and I bleed on them when needed with a red pen - I tell them this will be given to their clinical faculty.

The faculty comes out for at least one on site and goes into a room with the student and watches everything. Somewhat of an eye opener for the ICU nurse who failed to recognize how to treat for atypicals in lung disease and a smoker and who didn't even think of bronchodilators or other adjuncts - absolutely clueless. And, surprise - you cannot do a straight leg raise with the patient standing up and fully clothed…….

 

The ICU nurse I referenced could not remotely understand how one of my peds patients had 2 Moms - she just didn't get it. I had to explain it to her outside the room after the patient left. She had no cultural knowledge. She was rude to the parents in her ignorance. 

 

I also have several transgender patients and that just flipped her lid - she didn't get it at all. Patients deserve better and that contributed heavily to me flunking her. My patients were thankfully gracious and didn't blame me for someone else's ignorance.

 

So, I would actually advise any of us who proctor to use the forms for your favorite PA program and cut and paste and use your own letterhead, etc and make your own assessments and requirements - do not count on the schools to do it for you with an NP. You ARE the preceptor - make it YOUR rotation so you know the student is getting what you expect and has clear understanding of what will be done, tolerated and not tolerated.

[fishbum]

My PA students from the state program (yes, I teach there part time) come ready to go. Arrive early, ask questions, ask for feedback, do nighttime research on interesting or just flat weird findings and are eager to learn - yes, 99% of them are happy little sponges who are rearing to go.

 

 

I'd bet that those students spent the better part of at least a couple of years working really hard taking science classes, entrance exams, and putting together a solid application package specifically just to get where they are. It makes sense to keep working hard after admission. Maybe there's some value in having such a rigorous admissions process rather than a plethora of readily available, user-friendly "education opportunities". 

[Guest Paula]

@Reality Check:

 

Can you send me your format for the presentations you require of your students?

 

I get my second PA student mid-August and it will be a learning curve for me as a new preceptor.  I can use any help and tips you or anyone else has to offer. 

 

I emailed the student today with the hours, and I expect the student to follow my schedule, which is different every day, including a 12 hour day.  On my day off the student is expected to still come in and I have the student set up to do pediatrics with the MD pediatrician. 

 

I'm a bit nervous but excited.  The student is a direct entry student into a PA program.......so a young one...23 years old or so.