Study of Prior vs No Prior HCE?

[mktalon]

I was wondering if there has been any studies done as to how important or effective prior HCE is in educating new PAs and then when the new PA-Cs go out to practice. We all have our stories and anecdotal evidence based on our own opinions and experiences. But has there been studies done to show any objective correlation between how well a PA-C practices / PANCE pass rate / school attrition rates and how much and what kind of previous HCE was had by individuals? With schools putting less and less emphasis on HCE (so I have heard), I am wondering if something of this kind is in order.

[YaelS]

I'd love to also see this research break down exactly what aspects of prior HCE seem to result in the most successful outcomes. Coming from a relatively less "medical" background but one that stresses a high degree of critical thinking, I'm very curious about this. Is it skill in performing medical procedures? Comfort level with patients? Ability to think critically and independently? I'm often asking myself these questions when evaluating my own background.

[mktalon]

Wow, I honestly thought this would attract more comments.

[Just Steve]

One of the folks here named David Carpenter PA-C posted up a study I believe was done by the AAPA. I don't have all the details at the tip of my fingers but what stood out in my memory was that PAs with health care experience and PAs with no previous health care experience evened out in patient satisfaction surveys after they had worked as a PA for 2 years. I don't recall the survey breaking it down by type of experience or any of that.

 

I remember reading the post shortly after I joined the forum so maybe around last December?

[mktalon]

Thanks Just Steve, I'll do a search for that study!

[just419]

I would also be extremely interested in seeing a study in that area, especially with all the debate of the "quality" of PAs being produced by programs that do not require tremendous amounts of HCE. Prior to PA school, I only had experience shadowing and as a volunteer EMT, but I do not feel the lack of HCE (army medic, etc etc) has impacted my ability to practice whatsoever, especially in my chosen specialty. The only real benefit it gave me was to feel comfortable communicating with patients in stressful situations, and to take a proper history. From my own experience, PA school is taught under the assumption that the student has no prior HCE. The way the history and physical is taught, from making clinical decisions based upon the patient presentation and history.

 

I'm also curious to see what different schools consider proper HCE. I know for a fact that some schools do consider EKG tech and phlebotomist as experience, despite that these are subjects covered extensively in didactic year of PA school.

[winterallsummer]

Requiring HCE for PA school is not just about giving a PA a running start. It's a way to measure if someone is serious about wanting to work in health care, to see if someone can handle the stresses of working in a hospital and dealing with sick patients, to see if you can juggle school and work at the same time.

 

I wonder if there is any link between how competent a PA is based on the grades they made in their undergrad, or based on how good their LORs were, or how high they scored on the GRE.

 

Basically the point isn't that if you lack HCE you won't make a good PA. Just like seeing if you can make good grades, volunteer, etc, it is another way of seeing who "deserves" to be a PA and who does not.

[Just Steve]

There is a learning curve with any profession, at any level. From the fry cook at McD's to the CEO of Igotyourmoneynowwhat company. This goes the same for medicine. The brand new EMT basic will make more mistakes than the salty EMT Basic, the new medic will flounder where the seasoned medic will skate. The new grad with no previous HCE will still make basic mistakes where the PA with prior HCE has already made those simple mistakes and has learned from them, thus giving the prior HCE provider a jump on their co workers in the learning curve

 

Conversely...the new (insert level of care provider) will make mistakes that are typically fairly benign. They typically goof on simple thing that in the end, don't really change patient outcome. They are running cautious and conservative until they get their legs underneath them. The seasoned/salty (insert level of care provider) may run a bit more aggressive. They tend to be more bold in their decisions, bolstered by the bravado of years of experience. When these care providers make a mistake, the consequences may be much more severe.

 

Of course, this is all opinion/anecdotal.

[coloradopa]

I was wondering if there has been any studies done as to how important or effective prior HCE is in educating new PAs and then when the new PA-Cs go out to practice. We all have our stories and anecdotal evidence based on our own opinions and experiences. But has there been studies done to show any objective correlation between how well a PA-C practices / PANCE pass rate / school attrition rates and how much and what kind of previous HCE was had by individuals? With schools putting less and less emphasis on HCE (so I have heard), I am wondering if something of this kind is in order.

PA attrition rates are historically less than 5% so it would be hard to find any data there. The PANCE has been studied.

 

This study from the IPAP program found that HCE was a negative predictive indicator on passing the PANCE:

http://www.paeaonline.org/index.php?ht=action/GetDocumentAction/i/124197

 

There is a paper by Crovitz from 1973 in the Journal of Medical Eductation that looked at the Duke program from 1965 to 1973 and found that length of HCE was not a predictor for passing the program.

 

In this paper HCE was not predictive of passing the PANCE

http://www.paeaonline.org/index.php?ht=a/GetDocumentAction/i/105129

 

There is another paper published in the mid 90's that basically says the same thing.

 

There is a paper by Opacic in Allied health that shows a positive but insignificant correlation between HCE and self sufficiency in clinical experience.

http://www.ingentaconnect.com/content/asahp/jah/2003/00000032/00000003/art00004

 

If you believe its true that schools are putting less experience on HCE (remembering the plural of anecdote is not data) then presumably the PANCE pass rate should have gone down if there was a link. There are a couple of things to remember. No study has shown a correlation between passing the PANCE and HCE. The early Duke study showed that among the original students the amount of HCE was irrelevant which appears to be backed up by IPAP. If you look at the CASPA data students still have experience. The number reporting no HCE was under 5% and the number reporting under 1000 hours was less than 25%. While the average number of years of HCE has gone down in the last 5 years, the amount of students without HCE at all really hasn't changed and remains quite low. Bottom line on HCE is that it might have a non-statistical impact on self-confidence during clinicals. Most students will have some, so if you are applying its good to have (never good to be an outlier). It has no real advantage in passing the PANCE or anything else.

 

Requiring HCE for PA school is not just about giving a PA a running start. It's a way to measure if someone is serious about wanting to work in health care, to see if someone can handle the stresses of working in a hospital and dealing with sick patients, to see if you can juggle school and work at the same time.

 

I wonder if there is any link between how competent a PA is based on the grades they made in their undergrad, or based on how good their LORs were, or how high they scored on the GRE.

 

Basically the point isn't that if you lack HCE you won't make a good PA. Just like seeing if you can make good grades, volunteer, etc, it is another way of seeing who "deserves" to be a PA and who does not.

 

If you look in PAEA and search for PANCE you will find a number of papers about indicators for passing the PANCE. GRE and GPA remain the best indicators. PACKRAT is good for identifying those who are "at risk" (although there have been no studies to show that intervening here helps). Among demographics being Female and being young are also positive predictive indicators for passing the PANCE.

[mktalon]

coloradopa thank you so much for the info and the links.

[JasonD]

Personally, I believe the HCE requirement is used primarily to weed out applicants, not to make better practicing PA's or increase PANCE pass rates.

[Acebecker]

We did a bit of surveying on this as part of our didactic year (learning to collect and analyze data). We ran a few correlations regarding years of HCE and confidence levels on a Likert scale. We also correlated type of HCE with the same confidence scale. As it turned out, there was no correlation between years of HCE and confidence regarding medical decision making, but there was a statistically significant difference between types of experience and higher level of confidence and the type of HCE. People who had previously been in pre-hospital emergency medicine work were much more confident than other types if HCE. That said, our n was about 80 and our methods were those of fledgling statistical analysts. Take it with a grain of salt, but I think it does confirm the anecdotal thoughts about PA students - those who have faced the harder questions before and been the in-field decision makers have an easier time adapting to the new role as a PA.

[Acebecker]

We ran correlations between all types of HCE represented by students in our class to level of confidence making medical decisions during didactic year. I fully grant you that there are many many variables that could explain why pre-hospital EMS folks said they were confident on the Likert scale. If memory serves, there was also a group of Emergency Department workers (ER techs and the like) who also had a mild correlation with higher levels of confidence. At any rate, the things I've mentioned are far from definitive and may be dismissed if you like. I just thought it was interesting data, not necessarily highly meaningful.

[EMEDPA]

in my pa student precepting, probably N= around 100, those with significant prior high level experience stand out from those without. we can skip the basics because they know them and can demonstrate competence and we move right on to adv. topics. some of the other folks never make it out of fast track. my worst student ever had a phd in microbio and zero hce. every single abd pain ddx was" uh, appendicitis or an ulcer". he is not a pa today. I failed him as did his next em preceptor when they gave him a "second chance" elsewhere.

[Sara Wajek]

I would be more interested in a study comparing HCE to job and patient satisfaction.

 

I've been surprised by the number of people that have found out I'm applying to PA school and respond with some comment about how much better they like PAs than doctors, how much more the PA cares than the doctor, how much more time the PA spends with them than the doctor. I've been trying to figure out why this is since we all know PAs don't get any more scheduled patient time than doctors do.

 

I'm not trying to offend anyone and this is just the conclusion I have come to. Doctors generally go straight through school (high school, college, med school) with getting an MD after their name as the goal. They may get some HCE to help them get into med school, but they see it as a stepping stone, a crappy job they need to get through to obtain their goal. They may not realize that the crappy parts of their current job may not completely disappear with their degree. Difficult patients are difficult no matter what your title is. They probably don't take the time to reflect on whether or not this is the right field for them when they're so focused on the goal. Some of them end up loving being a doctor, others end up hating it, but almost none of them can really afford to leave the field. Overall job satisfaction decreases, patient satisfaction decreases.

 

The people that apply to PA school with a ton of HCE probably went into a field of health care and enjoyed it. At some point realized they liked what they saw in the PA field and decided to go for it. I think these students are more likely to ultimately have higher job satisfaction and therefore higher patient satisfaction than students with less HCE. The PA students with less HCE are more like the medical students in that they may or may not love the job they end up with.

 

I know these are broad generalizations and aren't true for everyone.

 

HCE probably has nothing to do with test scores. There are plenty of people in nursing jobs and paramedic jobs that don't have the skills necessary to become successful PAs. I think HCE has more to do with whether or not you really know what you want to do with your life.

[ver]

I'm just starting my pre-pa work while in my original career field (as background...I have a MS+ with about 15 years in my field, which is an operational science field). I'm still working on working out how to get my HCE hours before applying while working and class, but for the record I think experience in any field at a 'lower' level of practice is a good thing before moving upward! So...now trying to focus on the statistical methods...

 

I'm not terribly surprised by the results for a few reasons (IMHO):

 

- The PANCE is an written test. If a student has completed successfully their PA training, they should be able to pass. If there was a clinical 'hands on' portion, one might see a difference between levels of pre-PA HCE.

 

- The stage (again, just my thought from my own field) where the HCE would most come into play is where EM said- reducing the slope of the learning curve in the clinical related courses in the first year and the actual clinical year.

 

To me there is no real way to see just how much of an impact HCE makes is not an easy one. If I had to, I would set up the study this way:

 

1) Admit a portion of X many classes over Y programs without significant HCE.

2) Compare scores of the non-HCE students vs HCE at the end of the first year on their 'hands on' coursework

3) Compare the scores of the non-HCE students vs HCE at the end of their clinical year by course. (ex....does HCE make a difference in the ER, Psych, IM...etc?)

4) Follow the PANCE pass rate at graduation and six years after

5) Incorporate some post graduation statistic (if possible) in misdiagnosis, malpractice, etc.

 

#5 is probably impossible. But if the premise that HCE makes a better PA, that to me is the real test. And honestly, I don't think there is an objective statistical method that can realistically answer the question. People are all individuals and react and learn differently. My guess is that the reason PA programs are reducing the HCE requirement is exactly what these studies say: there seems to be no impact on rates of passing the PANCE.

 

I do think HCE certainly helps and it is a good idea for pre-pa's, but how much of that carries into the PA career 5-10 years down the road, that I don't know. Certainly for some PA's (EMT's into ER PA's, for example) I certainly think it would carry over greatly...but I wouldn't say that for every case. I would say it depends on the HCE and what field the PA is working in.

 

Great find on the papers and a great discussion!