How to deal with abusive rotations?

[Afib]

Hello all, I'm a PA student and I have heard a horror story regarding rotations which I would like to get your opinion on and how to deal with it:

 

• Student was put into a busy clinic and was expected to see over 25 patients a day
• Student was treated as an employee without pay (AS IN EXPECTED TO SEE AS MANY PATIENTS AS POSSIBLE TO MAXIMIZE REVENUE FOR THE CLINIC)
• Student was not taught anything and just expected to work (no feedback given, no guidance provided when requested)
• Student emailed clinical coordinators asking for help but the student was ignored
• Student was told to do certain in-office procedures with minimal (none) education and guidance

To me that seems like a dangerous situation. How are you as someone still in training expected to see over 25 patients a day on your first day, getting less than 10 minutes for each patient and not receiving any education at all. What's worse in my opinion is that the clinical coordinators (the people who are supposed to help us in situations like these) just ignore any request for help. What would you do in this situation if no one in your own program will hear you out?

[dchampigny]

Hello all, I'm a PA student and I have heard a horror stories regarding rotations which I would like to get your opinion on and how to deal with it:

 

• Student was put into a busy clinic and was expected to see over 25 patients a day
• Student was treated as an employee without pay
• Student was not taught anything and just expected to work 
• Student emailed clinical coordinators asking for help but the student was ignored
• Student was told to do certain in-office procedures with minimal (none) education and guidance

To me that seems like a dangerous situation. How are you as someone still in training expected to see over 25 patients a day on you first day, getting less than 10 minutes for each patient and not receiving any education at all. What's worse in my opinion is that the clinical coordinators (the people who are supposed to help us in situations like these) just ignore any request for help. What would you do in this situation if no one in your own program will hear you out?

 

 

If you have a problem with the bolded bullet, you've grossly underestimated the rotational year. You should treat each rotation as if you were a PA working there. Get there early, stay late, learn everything you can. You accomplish this by working hard, seeing patients, and asking for feedback. A rotation spent with a book in your nose is a rotation wasted. You are supposed to work hard. Now if the student is seeing patients and not consulting with a preceptor, that's illegal. But if the student is seeing patients, making plans,etc and consulting with the preceptor in an active way, that's a really great thing! You can learn something from every patient and despite seeing a lot of patients a day, it's a great way to learn.  

 

Clinical coordinators are busy. They're coordinating more than just 1 student. I'm not sure how big your program is, but in my opinion, the ball is in your court. The clinical coordinator is not on site with you making sure that you're "being taught enough". It's up to you to respectively ask a preceptor for guidance if you feel it is lacking. "Hey, I'm having some trouble with the work up of causes of fatigue. Could we review a patient we saw together?"

 

The only REAL problem I see is in the last bullet point. Sometimes preceptors can forget what rotation you are on (e.g. they may assume you are comfortable suturing a wound). Again, being assertive and telling the preceptor that you've only done it once or twice, or never have done it before, is completely reasonable. Pretending without adequate supervision or otherwise is unprofessional and dangerous. 

 

Keep the lines of communication open and you should be fine. Being politely assertive is useful. 

[Afib]

Thanks for your 2c. I agree with you that we are to treat it as a job and of course, hard work is always the name of the game. However, I think it should be clear that students are not there to help the clinic become profitable again and filling in as free labor. We are there as students first. Do you disagree? 

 

Our class size is about 30 students roughly and there are about 5 clinical coordinators (so 6 students to a coordinator). They themselves are not didactic professors who have anything else going on so I don't see an excuse for them not to follow-up with clinical year students. 

 

 

 

....Now if the student is seeing patients and not consulting with a preceptor, that's illegal...

 

Well that was sort of the case because the preceptor would not take the time to interact with the student at all. 

[Statko]

Bring your specific, objective, documented complaint to your clinical coordinator via email. This is not the time to bring up a "greatest hits" compilation of all your classmates' issues.

Follow up with a phone call to your clinical coordinator.

If you don't hear anything back in 24 hours, contact your program director and cc your clinical coordinator on the email.

Tread carefully: be polite, non-emotional, stick to the facts, ask for a meeting to discuss in person or via skype (if it's a distance rotation). Ask how you should handle your specific issue at the clinic during the time between now and when you meet with your Program.

When you have your meeting, ask what your options are and suggest what you want: to be placed in a new/different rotation, for the clinical coordinator to advocate with you, to arrange a meeting with the site, etc.

Bonus points for verbally acknowledging to program director and clinical coordinator that this is an awkward position for both you and the program.

[Afib]

Bring your specific, objective, documented complaint to your clinical coordinator via email. This is not the time to bring up a "greatest hits" compilation of all your classmates' issues.

Follow up with a phone call to your clinical coordinator.

If you don't hear anything back in 24 hours, contact your program director and cc your clinical coordinator on the email.

Tread carefully: be polite, non-emotional, stick to the facts, ask for a meeting to discuss in person or via skype (if it's a distance rotation).

When you have your meeting, ask what your options are and suggest what you want: to be placed in a new/different rotation, for the clinical coordinator to advocate with you, to arrange a meeting with the site, etc.

Bonus points for verbally acknowledging to program director and clinical coordinator that this is an awkward position for both you and the program.

 

Great points, thanks! I will keep this in mind if I encounter a problem during clinicals. 

[fakingpatience]

Not having guidance from a preceptor is unacceptable on a clinical rotation.  You're there to learn, not be free labor for the company. Not only is it unfair to the student, it is dangerous for the patients.   When I chose my PA program, the most important factor I considered was the clinical rotation; In my mind it's where you put everything together and the real learning happens.  

 

There are standards set by the ARC-PA about clinical rotations;  C4.02 states: 

0. Documentation shows that preceptors are providing observation and supervision of student performance while on supervised clinical practice experiences and that they are providing feedback and mentoring to students. 

1.  

[Afib]

 

Not having guidance from a preceptor is unacceptable on a clinical rotation.  You're there to learn, not be free labor for the company. Not only is it unfair to the student, it is dangerous for the patients.   When I chose my PA program, the most important factor I considered was the clinical rotation; In my mind it's where you put everything together and the real learning happens.  

 

There are standards set by the ARC-PA about clinical rotations;  C4.02 states: 

0. Documentation shows that preceptors are providing observation and supervision of student performance while on supervised clinical practice experiences and that they are providing feedback and mentoring to students. 

1.  

 

I'll admit I didn't do my due diligence when applying and just jumped at the first acceptance I got. I do regret it now... our program is very disorganized and there are students who begin their clinical year without a rotation, with others getting them the day before. Pretty sure that isn't normal? I've heard of programs where students get their rotations early on during their didactic year. 

[UGoLong]

You have no license. You may see patients but a licensed provider must see your patients after you do (or with you.) you cannot perform any procedures without a licensed provider observing and ready to step in. If these rules ate not being observed, tell your preceptor. If they do not follow them, leave politely and call your school.

 

Beyond that, it's fair game. You will encounter good and bad situations and good and bad preceptors. Inform your school but also suck it up and get through the month. Don't second guess where you decided to go to school. You're there; just deal with it.

 

 

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[Afib]

You have no license. You may see patients but a licensed provider must see your patients after you do (or with you.) you cannot perform any procedures without a licensed provider observing and ready to step in. If these rules ate not being observed, tell your preceptor. If they do not follow them, leave politely and call your school.

 

Beyond that, it's fair game. You will encounter good and bad situations and good and bad preceptors. Inform your school but also suck it up and get through the month. Don't second guess where you decided to go to school. You're there; just deal with it.

 

 

Sent from my iPad using Tapatalk HD

I appreciate the advice.  "You may see patients but a licensed provider must see your patients after you do (or with you.) you cannot perform any procedures without a licensed provider observing and ready to step in." Unfortunately this rule doesn't seem to have been followed. The student in question told me they performed procedures without supervision and the clinical coordinators and preceptor there didn't care to address the student's concerns regarding the lack of supervision. I guess the student might be partly to blame since it seems they just dropped the issue and continued anyways. Anyways, this is just one bad experience of the batch, hopefully I won't end up in that situation but I just want to be prepared and know how I should handle the worst case scenario. 

[rev ronin]

How horrible.  As a preceptor, I see every patient "my" student sees--we share oversight of 2-3 NP and PA students among 5 licensed providers.  If I see the patient with the student, I read it and cosign it.  Students aren't there to add throughput to the clinic; I make sure that they aren't expected to. They make me keep learning and growing, and allow me to "give back" to the profession.

[UGoLong]

Afib,

 

If a student does procedures unsupervised or sees patients without a licensed provider in the loop, your school can be party to legal action. Don't do it! Make it clear that it is not allowed and indicate politely that you can't proceed that way.

[EMSGuy1982]

I am finishing up a rotation in addiction medicine where my preceptor is the owner of the practice. It appears to be that his business plan involves having students rotate through as free labor. The preceptor makes no attempt to create a learning environment, nor could there be one when you schedule 40-50 patients in a 3 hour timeframe. I currently do H&P's that involve nothing more than filling out paperwork and asking questions.. I have been asked multiple times to do duties that fall under the job description of a MA as the clinic is grossly understaffed. Many of my fellow classmates have been through this rotation as well with no changes made by clinical faculty. This is the only negative experience I have had throughout my clinical phase. In a situation like this I just do what is asked and grind it out. I am glad that it's my last rotation.

 

These rotations are out there!

[EMEDPA]

I have not read every post in this thread, so bear with me.

I do agree with what Rev stated above, the preceptor must see each pt and assure competency at each procedure before the student does it independently. Towards the end of a rotation I let students do I+Ds, suture, etc without me in the room after watching me do several and having me observe them do several. I always check the final result before the pt leaves. There will be rotations and life experiences where you are treated like crap. it's part of the process. just keep showing up and sooner or later it will be over. don't let the bastards get you down. keep showing up. smile. do the work you are expected to do. learn from your mistakes. move on.

[thinkertdm]

I actually had an excellent job with a place where there were no MA's.  I had to get my patient from the waiting room, do vitals, do my own POC testing, do my own shots.  It was excellent, because it was more than just processing them through.  Plus, in doing your own stuff- you know its done right.  I had an MA do a throat swab of the tongue.  And one who didn't know how to irrigate an ear. 

[Statko]

I'll admit I didn't do my due diligence when applying and just jumped at the first acceptance I got. I do regret it now... our program is very disorganized and there are students who begin their clinical year without a rotation, with others getting them the day before. Pretty sure that isn't normal? I've heard of programs where students get their rotations early on during their didactic year. 

Afib,

I can't speak to all programs, but this happened at my program when I was a student, and it's happened at the Program I work for (I am not a clinical coordinator). As a student, I didn't have a rotation assigned for internal medicine for the first week of rotations. I was an anxious mess... I had no idea if I would have to move, where I was going, etc.

 

It is getting increasingly competitive for programs to secure clinical rotation sites. There's a lot of students who need rotations and not all providers want to take students, so the sites become very valuable. This is why sometimes students end up in less-than-stellar rotations. That doesn't excuse illegal or negligent behavior in any way. It's in your program's interest to make sure your rotations are safe experiences (for you, the patient, the Program, and the provider!). Programs affiliated with their own university/teaching hospitals tend to have more reliable, predictable rotations. Other programs have exclusivity agreements with certain sites, so this can help with scheduling. I wouldn't say this is the norm, though.

 

In my clinical practice, we had to cancel a rotation last minute due to a staffing issue (we had a provider who was suddenly diagnosed with a terminal illness and we were all covering multiple sites - not a good setup for a student). So it's not always your program's fault, even though when you're going through the didactic year, everything feels like the Program's fault. I've been there, too :)

[Reality Check 2]

There is ZERO excuse in my mind for a rotation site like this to continue to exist.

 

Students deserve better and they are NOT free labor.

 

Many years ago I had a preceptor who LOVED students because he left them alone in his half baked family practice in a semi rural town while he went off to work at his weird right wing church.

 

He specifically asked me why I pursued this field as a woman when my place was in the home. And, how did I plan on getting married if I was career minded........ Then asked my religion.................. Seriously - made these comments to my face. 

 

He did NOTHING to teach me and then tried to tell me that all my previous rotations had told me wrong. 

 

I wrote a scathing 5 page letter to our program outlining his chauvinistic, pompous, sexist issues and the fact that I was left ALONE in his clinic for 8 hours each day, 5 days a week and saw him about 10-15 min 3 days a week for 6 glorious weeks. I spent all my time buried in a book learning about the next patient's conditions and meds. 

 

He wrote that I was unenthusiastic and didn't show motivation for family medicine. Meanwhile, I was doing things way out of my league as a student like learning by the seat of my pants about CHF (no internet then, kids) and reading EKGs with another student and calling ambulances and sewing stuff up with less than adequate instruments. 

 

They ditched him the next year.

 

If a program can't adequately vet a preceptor site to ensure student and patient safety then that program needs TO CEASE AND DESIST OPERATIONS.

 

Bad choices, bad medicines, bad education.

 

'nuff said 

[PACdan]

Also, if you're documenting in the EMR (which you should be) and a preceptor is just taking over or copying your entire note; that is fraud under CMS:

 

B. E/M Service Documentation Provided By Students

 

Any contribution and participation of a student to the performance of a billable service
(other than the review of systems and/or past family/social history which are not
separately billable, but are taken as part of an E/M service) must be performed in the
physical presence of a teaching physician or physical presence of a resident in a service
meeting the requirements set forth in this section for teaching physician billing.

 

Students may document services in the medical record. However, the documentation of
an E/M service by a student that may be referred to by the teaching physician is limited to
documentation related to the review of systems and/or past family/social history. The
teaching physician may not refer to a student’s documentation of physical exam findings
or medical decision making in his or her personal note. If the medical student documents
E/M services, the teaching physician must verify and redocument the history of present
illness as well as perform and redocument the physical exam and medical decision
making activities of the service.

[Lauren R]

The advice I would give on this situation is to first reach out to the PA school for assistance and possible relocation.  If that fails, bite the bullet and rise to the occasion.  Everyone is bound to get a challenging rotation.  Take it as an opportunity learn and gain skills.  Keep a positive attitude and remember why you're there and how it is temporary.  Then recommend your school removes this facility as a rotation site, so that no future students are doomed to the same fate.

[roger777]

I actually had an excellent job with a place where there were no MA's.  I had to get my patient from the waiting room, do vitals, do my own POC testing, do my own shots.  It was excellent, because it was more than just processing them through.  Plus, in doing your own stuff- you know its done right.  I had an MA do a throat swab of the tongue.  And one who didn't know how to irrigate an ear. 

Yeah that is the one thing I miss from being a medic. I haven't done any IVs, blood draws or injections since I started rotations and we didn't do any on live subjects in school. Only time I hold a needle is for doing blocks. I've been tempted to ask the nurses a couple times but didn't want to bother them. My understanding is that is considered below our SOP. But I feel like a provider should know how to do everything that ancillary does and I think it would not be hard at all to go through this program and essentially have no real experience in phlebotomy etc.This is another thing I would like about working in a remote location I think.

[fakingpatience]

Yeah that is the one thing I miss from being a medic. I haven't done any IVs, blood draws or injections since I started rotations and we didn't do any on live subjects in school. Only time I hold a needle is for doing blocks. I've been tempted to ask the nurses a couple times but didn't want to bother them. My understanding is that is considered below our SOP. But I feel like a provider should know how to do everything that ancillary does and I think it would not be hard at all to go through this program and essentially have no real experience in phlebotomy etc.This is another thing I would like about working in a remote location I think.

 

 

 

I placed a handful of difficult IVs during my inpatient rotation, and the nurses were always extremely grateful and remembered me for it.   My preceptors also commented how nice it was having someone able to start lines, and appreciated me using my skills, with phlebotomy and trouble shooting patient equipment.    

[EMEDPA]

faking- I did the same on my rotations. lines, intubations,splints,  etc.