Issues in PA education

[SocialMedicine]

What are the big issues/problems in PA education today ? Try and avoid the degree issues (masters, cert. etc).

 

1) One would have to be post graduate programs. They seem on the rise. They seem necessary for PAs to keep advancing and maintain versatility in careers as PA practice and specialty grows.

 

2) Quality of preceptors ....  are all preceptors created equal ? Do we need to do more to ensure the right people are educating future clinicians. I was approached by two PA programs who know little of my clinical acumen to be a preceptor in the last 1-2 years.

 

What other ideas come up ?  Especially concerns over didactic year ....  research/thesis issues .... mentorsgup ...

[EMEDPA]

more and more I am hearing that PAs on rotations are being expected to watch and not participate. that is not a quality rotation. pa students on rotation should be treated exactly like med students. no one is paying big bucks to shadow.

[EMEDPA]

I think many students on rotation are also getting the short end of the stick when  it comes to procedures. I know new grad pa students who have only sutured once or twice, never reduced a fx, never done an ingrown toenail or I+D, etc.

a new grad pa should be able to work ambulatory care fp or urgent care with an sp or senior pa available and do most of the procedures required in those situations.

I think EVERY program should require acls and pals, not have them as optional.

[tunafish]

more and more I am hearing that PAs on rotations are being expected to watch and not participate. that is not a quality rotation. pa students on rotation should be treated exactly like med students. no one is paying big bucks to shadow.

I think this is a huge issue! At least it was my number one factor as to where to apply. I do not know how a hole in the wall uni run out of business park office complex can produce good clinicians if they are not associated with a large academic hospital/als. I also do not understand how a regular not connected PA student can find a good rotation himself. Finally, there are tons of very good clinicians working in the state of the art facilities, but it does not mean they are good teachers.

I am surprised that PANCE pass rate concerns students more.

[SocialMedicine]

You can pass the PANCE and have poor clinical skills. Perhaps a cinical/oral component to the exam is in order given concerns with education. Yea I have no idea how some of these small schools are going to train PA's. It will be a disaster for patients. What issues do PA students complain most about to you guys ?

[EMEDPA]

"back in the day" to get out of PA school you had to pass exit exams which consisted of oral, practical, and written tests then take a week long pance that included 3 written exams(core knowledge, primary care, surgery) and take 3 practical exams.

there is talk of bringing the practicals back as the med students now do a practical as part of the usmle.

as far as "what do students complain about". the #1 thing I hear is bad preceptors/poor rotation sites. a friend of mine currently in pa school just finished a 6 week inpt medicine rotation in which she only did 3 pt h+ps....the rest of the time she shadowed a doc. as a pa student I rounded on several of my own pts/day and presented them at rounds every morning and afternoon. pretty much all my rotations were like that.

[AREID]

I think this is a huge issue! At least it was my number one factor as to where to apply. I do not know how a hole in the wall uni run out of business park office complex can produce good clinicians if they are not associated with a large academic hospital/als. I also do not understand how a regular not connected PA student can find a good rotation himself. Finally, there are tons of very good clinicians working in the state of the art facilities, but it does not mean they are good teachers.

I am surprised that PANCE pass rate concerns students more.

I think pance pass rates concern students because if they do not pass, they do not practice; regardless of how good of a clinician they are. It's an understandable fear

 

 

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[GetMeOuttaThisMess]

"back in the day" to get out of PA school you had to pass exit exams which consisted of oral, practical, and written tests then take a week long pance that included 3 written exams(core knowledge, primary care, surgery) and take 3 practical exams.

there is talk of bringing the practicals back as the med students now do a practical as part of the usmle.

as far as "what do students complain about". the #1 thing I hear is bad preceptors/poor rotation sites. a friend of mine currently in pa school just finished a 6 week inpt medicine rotation in which she only did 3 pt h+ps....the rest of the time she shadowed a doc. as a pa student I rounded on several of my own pts/day and presented them at rounds every morning and afternoon. pretty much all my rotations were like that.

Mine was as yours was.  It was a major state medical center and we were treated no differently than the medical students.  Daily rounds, labs, H&P's, overnight call, fighting for deliveries with the medical students, etc..  We were suturing in the ED and doing our own phlebotomies.  The only rotation that I had that was worthless was when I returned back to my home area from the distant program and I spent a six week rotation/elective right before graduation with an internist who had been one of our first year instructors (he was a 3rd year IM resident).  Sat primarily in his office reading journals each day for the entire period and didn't learn a darn thing.  Daily commute in a large metropolitan area was 60 miles approximately round-trip to sit in his office.  I don't recall ever walking into an exam room with him to see a single patient.  That being said, I was at a county hospital recently in L&D for another matter and there were no students, except for one med student who on his way out the door and saw that a patient that he'd been following all day was about to deliver, after 5 p.m. on a weekday in the non-high acuity L&D.  That was unheard of in my day.

 

All this being said, it isn't just the PA student who are getting ripped off.  Two med students were on a peds rotation at a high acuity children's ED this past summer and no one was assigned to them or showing them around.

[generalfluff]

Just to chime in, my program takes a whole mix of students, a handful from a 3+2 track and the rest with bachelor degrees and HCE. The director shares the concern of students not knowing enough patient care and all that, and he's far too strict to think that HCE (being unstandardized) covers it either. What they did for us then was give earlier clinical experiences through the program, instead of straight didactic for a year, then being thrown to the wolves in rotations.

 

Three to four weeks at the start of the program, we started doing H&Ps on patients at a nearby hospital, then we had to present them to our clinical supervisor at the end of the day. You learn some common differentials, labs, and procedures relating to that case. You get a faculty member assigned to you who is a practicing clinician. Every H&P (ROS, PE, DDx, Tx and all that) you write has to mimic what they might have in practice, and is judged as such.

 

At the start of the second semester of the second year, we begin shadowing moving on to preclinicals right away. Just this week, we had to send resumes for the prospective preceptor we'd get for this experience. It gets done once to twice a week. You start shadowing early on, then running H&Ps, and practicing procedures right off on real people. As with the patient rounds, you present cases (and log it to some computer system for ARC-PA, don't ask) to the clinician preceptor. Suffice to say, the system has worked quite well so far for our relatively young program. All our seniors have told us that the clinical year is actually the relatively more relaxing portion of the program, just because you got to learn and practice it over time during the didactic year.

 

The logic of integrating patient care gradually from start to finish works not only to get the student comfortable but to show the relevance of what is being learned.

Inadvertently perhaps, graduates get too much into procedures that plenty have consistently taken up jobs in surgery and critical care.

[SHU-CH]

We operate in a similar fashion to the post above - we try to get students into a clinical environment as soon as we can.

 

One of the biggest issues facing PA education nationwide is a lack of clinical preceptors. This issue is a constant topic of discussion and concern at every PAEA meeting I have been to. The fact of the matter is that we need more PAs to step up and serve as preceptors for PA students. The push to increase the number of medical school seats will marginalize PA students in favor of medical students. We need PAs to step up and work with PA students. The physicians just do not care anymore. They are all focused on the bottom line.

 

I am aware of one facility where the med students frequently follow the PA around because the doctor could not be bothered with them. At the same time, this facility will not allow PA students in the department.

 

PAEA and AAPA are trying to work on incentives to increase interest in precepting, but it needs to come down to this: we care about our profession, and we want to see it grow and thrive. 

[Gordon, PA-C]

more and more I am hearing that PAs on rotations are being expected to watch and not participate. that is not a quality rotation. pa students on rotation should be treated exactly like med students. no one is paying big bucks to shadow.

 

Med students dont do jack clinically on their rotations.  They just shadow/watch stuff and that's it.  Lets not pretend that med students are out there intubating, putting in central lines, scripting meds, or doing anything meaningful.  Hell at my program the PA students were the ones getting their hands dirty becaues we had actual clinical experience and the MDs trusted us to do a lot.  Med students on the other hand are a bunch of bookworms who know a lot about organic chemistry but are way too scared and incompetent to actually be useful in the ER, ICU, OR, or clinic.

[Guest Paula]

We operate in a similar fashion to the post above - we try to get students into a clinical environment as soon as we can.

 

One of the biggest issues facing PA education nationwide is a lack of clinical preceptors. This issue is a constant topic of discussion and concern at every PAEA meeting I have been to. The fact of the matter is that we need more PAs to step up and serve as preceptors for PA students. The push to increase the number of medical school seats will marginalize PA students in favor of medical students. We need PAs to step up and work with PA students. The physicians just do not care anymore. They are all focused on the bottom line.

 

I am aware of one facility where the med students frequently follow the PA around because the doctor could not be bothered with them. At the same time, this facility will not allow PA students in the department.

 

PAEA and AAPA are trying to work on incentives to increase interest in precepting, but it needs to come down to this: we care about our profession, and we want to see it grow and thrive. 

I had my first student this last Aug/Sept as a preceptor.  I had some guidance and did pre-prep before the student came.  I would have liked more preparation or formalized training on how to precept.  I think the student got a fairly good experience and I tried to have her do as much procedures as possible that presented to our FP clinic.   I care about our profession and will continue to offer to be a preceptor.  I can only handle one student a year.....it is a lot of work!!!!

 

In retrospect now I see areas where I can improve on how I precept and the posts here are helpful.

 

PAEA and AAPA can energize PAs to precept when they step into the future and start advocating that PAs as more than assistants. 

 

I found during my rotations in 2003-04 that some docs did not care or have time for PA students, some did and were good at precepting...it was a mixed bag.  I also found when starting practice that the docs expect you to know and did not want to mentor or provide much OJT.  

[SHU-CH]

PAEA has created a publication for clinical preceptors with "how to be a preceptor" type info - please contact a nearby PA program and they should be happy to get you a copy.

 

Done properly, having a student should not add too much more work to a practice and they should work with increasing independence as a rotation progresses. In a busy outpatient office for example, maybe they would start by seeing every third or fourth patient which they would present to you when you catch up to them. Patient education and PA student education can often be accomplished simultaneously, and patients will usually appreciate - and possible be impressed - by seeing you in a teaching role.

 

A good preceptor makes a student a little uncomfortable at times. Instead of telling a student what to do, ask them what they think they should do and then guide and correct prn.

 

In the end, we all had great preceptors and bad preceptors in school. The trick is just to model the behavior of the great ones! Even if you can only take a couple of students a year, it is very important to the future of our profession.

[EMEDPA]

I have taken students for over 15 years. I try to let them do as much as possible but check their work and teach them new procedures along the way. I have an H+P form I have them use (as the hospital does not let students enter info on charts.)

it looks like this:

Student History and Physical

Chief  Complaint:

Relevant HPI:

 

Relevant ROS

Relevant PMH/FH/SH/Surg. HX:

meds/allergies:

Abnormal VS:

Directed Exam

 

Differential DX/Medical Decision Making (What is the worst thing this could be?)

 

workup:

Xrays/diagnostic imaging

Labs

Send out labs

Treatments:

IV’s/Meds/Splints/etc

Assessment/DX:

Plan:

RX

Follow up

 

day 1 I show them around, introduce them to staff, then hand them a chart and say "here you go". they usually spend 30 min with someone with a cold or similar minor complaint then we critique the experience and I say "good job, next time do it in 15 min", etc.

for procedures I watch them do stuff they already now how to do and have them watch me once do new things. I talk them through stuff like regional blocks and reductions at the bedside. I try to push their comfort level a bit by having them see sicks folks with undifferentiated complaints. I will see anyone they get lost on. I always see every pt at least once before they leave. I ask programs to send me students with significant prior hce and an interest in em or urgent care. I want to teach em, not basic concepts folks should know before starting pa school. I usually assign a topic of the day the day before( "let's talk about epidural abscesses tomorrow") and we discuss that during down time, review ekgs and xrays, etc

[Just Steve]

Problems with education today?  The belief that a person with no experience can enter a program and then graduate with enough competence to hit the ground running and not require a residency or prolonged OJT period. 

This talk of early integration into patient care while in school... here is an idea..how about integration into patient care before they ever start school?  

 

There should not be a former Navy Corpsman, Airforce/Army medic, a paramedic, a nurse, a respiratory therapist that does not have at least one or two schools calling them every few months to get them into a program.  That health care professional should not have to wonder "where I am going with my career"... ever. 

 

Instead, programs cater to the buzz over PANCE rates, admitting super smart and clinically naive students to ensure that PANCE rate doesn't wobble... No one seems to have an issue with it but then at the same time we see a rapid development of PA residency programs and specialty exams... we see fresh grads struggling to find a job...we see a big dip in preceptorship spots.  We stand around and scratch our head thinking "why are things getting more complicated for PA education" but they don't stop to admit that perhaps it's the related to the lack of HCE.  Perhaps docs and senior PAs have tired of dealing with students who don't know which way to point a bevel when they are in their clinical year. Perhaps employers are tired of hiring, then being forced to train over several months, a new grad who has only truly held a needle driver for less than a 100 sutures?  Or never felt what CPR is really like..or talked with real parents about real issues regarding their really sick kids....have developed a bedside manner that allows for rapid rapport development...

 

Non experienced students simply do not have the medical knowledge entering school to come out the other end as a reliable practitioner within a relative short amount of time.  We have already supported this statement with the explosion of residency programs and employers endorse this statement with the growing requirement for experience and/or specialty exams....of which you can't sit for without experience or a residency.  We can either change the 2 year training model and expand it to build in a residency, or change the type of student being admitted.  

 

I know I am probably burning a couple of bridges or at least crawling under peoples' skin with my rhetoric but I am done apologizing. I came into the PA profession after spending 22 years in the trenches.  I worked side by side with an untold number of "para professionals" or "allied health employee" who can run clinical circles around some of these PAs who are graduating. Sure, they can't diagram the Kreb cycle in their sleep or they may struggle with standardized tests but they sure as heck can tell the difference between a snotty kid who has a cold and a snotty kid who is about to run out of steam and crash in front of you. 

[EMEDPA]

agree with above.

unfortunately what is going to happen long term is they will keep accepting folks with low hce, be forced to make programs longer to increase clinical time(see the usc curriculum), then funnel them into residencies.

I am a big fan of residencies, even for experienced folks. I think everyone graduating pa school today should seriously consider doing one. the downside is one year of low salary, maybe in a place you don't want to live. the upside is higher salary for life, more jobs skills and autonomy and a pick of choice jobs.

[True Anomaly]

I agree with most that students have a very disjointed clinical experience, as I'm sure a lot of us did.  I do a modified version of what E does with his students.  I will start out assuming they operate from a relatively high degree of medical decision making, and depending on how they present/how long it takes them to see patients/their skill at differential diagnosis then I will refine either up or down a skill level.  I point them in the direction of a patient to see, give them the vitals and triage note (because that's what I get as well, so it's only fair) and set them off.  When they return, I'll ask them to present and then at the end I ask "What do you think is going on and what do you want to do?".  We have a conversation about differential dx and I will guide them in the thought process, which includes introducing objective ER decision rules or evidence-based practice specific to the ER setting, all the while having them keep in mind that our overall goal is to identify or rule out with a certain degree of comfortability anything life or limb threatening.  My main goal is to get them to learn how to properly think in the ER, because the mindset is different and one that, in my opinion, gets glossed over quite a bit.  Sure, I'll get them some procedures and will precept as needed or show them how to properly do something, but if there aren't any big procedures to be done that day, I'm still going to make sure they leave understanding a bit better how it is to think like an ER clinician.  

 

What I end up finding with this is most students seem surprised that they get this level of teaching on their rotations- so again, what I infer is that not much goes on during other rotations- and it worries me a lot too when I read stories like here about students sitting around an office just reading all day without actually touching a patient.  

 

E is going to hate to hear this, but in my neck of the woods I actually see more med students with extensive past medical backgrounds than the PA students I precept.  Like you all, I've had good and bad med and PA students, but as I work at a major academic center with a long-time ER residency program, at the beginning of the academic year we have several excellent 4th-year med students rotate through our system who are applying for our residency program, so THOSE students are the ones who are the most consistently solid- as they should be, since they're basically auditioning for next year.  

[EMEDPA]

doesn't surprise me that ms4 folks heading into EM residencies are sharp and have prior valuable experience. I know a lot who used to be er techs, medics, military, etc.

don't know that the same can be said of other fields like IM though.

[True Anomaly]

Oh, this is the time of year when those great med students start falling off the cliff- everyone who wants to come to our program has already rotated, so now we're getting "the rest"- IM, FP, surgery, etc.  The quality varies from stellar to "Just go home for the rest of the day"

[SHU-CH]

Problems with education today?  The belief that a person with no experience can enter a program and then graduate with enough competence to hit the ground running and not require a residency or prolonged OJT period...

 

Everyone is quick to assign universal value to "experience."

 

I worked fulltime in an ER for a while with a bunch of nurses who seemingly could not stand the sight of blood. Granted, I had come from open heart and had a higher hemorrhage tolerance than most. But the site of every small pumper was ground for alarm. Some of these people had been nurses for 20-30 years.

 

One day I was setting up to put four sutures in a patient's arm. Being a cop, he predictably experienced a syncopal episode which caused one of the nurses to scream "he is passing out!" He then did a couple of those twitches that a hypoxic brain likes to provoke, causing her to scream "he is seizing!" and then fly into some sort of resuscitiation algorithm. Meanwhile I am standing there thinking "Shut up, leave the guy unconscious and let me put four stitches in his arm and then do whatever you want."

 

Some medical experience does not automatically equal good experience. There are nurses who have never made decisions in their careers and combat medics who will be baffled by neonates. There are single parents who know how to deal with being responsible for another person's life and stockbrokers who daily make self-directed decisions under tremendous stress. 

 

It is easier to get a smart person some experience than to make a dumb experienced person smart.

[generalfluff]

Once again, much as prior HCE is valuable, there is hardly any standardization to what HCE anyone gets. If there was some checklist of what skills you should have before getting to PA school, then maybe the "you don't have HCE, therefore you can never be a good PA" argument would have a point. But then again, any reasonably competent school would make sure you will develop these over the program anyway.

 

Think about this.

 

Is it an immediate guarantee that if you worked 8 years as an EMT, you absolutely know everything there is to know with advanced airways? Granting that, how well would that skillset transfer if you worked in women's health, urology, or another specialty for that matter? 

 

Is the program supposed to just think that just because you had that HCE, you're immediately good at it, and should skip all the basics entirely? It's a waste of time in the course right? Since I'm good at it and cannot improve, all my classmates should be like me too. How about that RNFA? He's pretty solid on suturing right? Too bad for the EMT guy then, guess we're skipping suturing skills in class, since he should have had the decency to know everything about it before being in PA school.

 

There's no perfect crossover between any HCE, no matter how good and extensive, with any future PA job, that it should be an absolute requirement. ARC-PA standards, like it or not, don't think every PA job is in just in one field (eg. critical care and emergency medicine). The goal is to train you to have the generalist skill set, a little bit of everything, which does mean skipping things you deem "oh-so-essential" in your specialty that while neat, overtakes time better spent on skills with wider utility that fit the Standards.

 

Last time I checked, there was no recent deluge of poorly trained PAs being let loose on the world by these 'horrible' schools. If you doubt the competence of these "inexperienced" PAs so much, precept. 

 

Nurses eat their young, let's hope physician assistants don't do the same.

[SHU-CH]

Nurses eat their young, let's hope physician assistants don't do the same.

 

That is one thing we do not do now, and I hope we never do. PAs look out for other PAs (and PA students)!