Quality of student rotations

[Boatswain2PA]

Those who are adamant about independent practice rights for PAs should consider this thread.

[ALC0313]

I think most PA's can relate to having at least one rotation that wasn't quite up to par, but that's very different from this situation where a PA student is graduating without having even one full rotation in general medicine. She also told me that her OBGYN rotation was all GYN so her clinical coordinator told her to log any patient encounter that involved contraception as a 'prenatal visit.' Since she didn't get to do any OB during her OBGYN rotation she is spending her elective in our office to get that exposure. Thankfully she said the clinical coordinator is leaving after this year. So many red flags! I hope this situation is an outlier in current PA education but I'm not so sure...

[cg02186]

For those asking about the latitude of rotations  our program had it set up as 11 rotations. 9 are core and 2 are elective.  Our program was unique in that ours is I think the only program in the nation that requires every student to have an Ortho rotation. So along with the tradition "core" rotations we have Ortho and our Internal Medicine is split into an outpatient rotation and an inpatient rotation since there is a big difference.  Because I had pediatrics, IM outpatient, IM inpatient, and Ob/Gyn I felt like it was fine for my "family practice" to be at an urgent care as I had my fair share of Diabetes and HTN in other rotations.  Because Ortho was already required I was able to do a second Ortho as an elective and a second ER as an elective.  It really helped with jobs because if I was applying to an ER position I had: 2 ER, Urgent Care, 2 Ortho, and Critical care (Inpatient). They were all impressed and helped in getting ER offers as a new grad. Same applies to Ortho.

 

Also, as a side note, almost all of the students did their FP at a family practice clinic. I had 0 interest in working primary care and they knew that and figured for what my career goals were, Ortho and maybe ER, urgent care made way more sense.  It didn't impact me in anyway as I still did great on the PANCE and our program as a whole had 100% first time pass rate for back to back years  

[amwillaert]

11 hours ago, AnneFL said:

I think most PA's can relate to having at least one rotation that wasn't quite up to par, but that's very different from this situation where a PA student is graduating without having even one full rotation in general medicine. She also told me that her OBGYN rotation was all GYN so her clinical coordinator told her to log any patient encounter that involved contraception as a 'prenatal visit.' Since she didn't get to do any OB during her OBGYN rotation she is spending her elective in our office to get that exposure. Thankfully she said the clinical coordinator is leaving after this year. So many red flags! I hope this situation is an outlier in current PA education but I'm not so sure...

Not good and certainly should not be the norm. We (very occasionally) have a student receive what we consider to be inadequate OB experience on their OB/GYN rotation (often with new sites or new preceptors who just don't quite meet the mark despite education about requirements beforehand). An appropriate response to this would be to supplement the rotation (perhaps during an elective) using hours at a site where they are sure to obtain the appropriate experience. It makes all PA programs look bad when programs choose to skirt the rules like you mention above, but I don't think it is very common thankfully. 

[DizzyJ]

20 hours ago, AnneFL said:

I think most PA's can relate to having at least one rotation that wasn't quite up to par, but that's very different from this situation where a PA student is graduating without having even one full rotation in general medicine. She also told me that her OBGYN rotation was all GYN so her clinical coordinator told her to log any patient encounter that involved contraception as a 'prenatal visit.' Since she didn't get to do any OB during her OBGYN rotation she is spending her elective in our office to get that exposure. Thankfully she said the clinical coordinator is leaving after this year. So many red flags! I hope this situation is an outlier in current PA education but I'm not so sure...

I had the same experience.  Aside from watching one C-section, my OB/GYN was all GYN.  I had no desire to go into OB, but I think I should have had the experience I deserved (and paid for). 

[CAAdmission]

The problems PA program run into is mainly due to a piss-poor response form PAs becoming preceptors. They just don't give a damn. To anyone on this thread bitching about the quality of clinical rotations who is not a preceptor: in the words of William Wallace, put your head between your legs and kiss your own arse.

 

[Gordon, PA-C]

Med schools, PA schools, NP schools, nursing schools, and every other kind of health professions school out there has zero business opening a program unless they can GUARANTEE good clinical rotations.  That means you either pay clinical preceptors directly or you have an ironclad agreement worked out.

I always laugh when I hear about PA programs opening in rural country towns with 50k population that has nowhere near the patient base to provide adequate preceptor skills.

I tell all PA students that they should walk away from a program that forces you to scrounge up your own preceptors.  That's a weak program that has zero business being in existence.  It's just one step above a diploma mill IMO

[Reality Check 2]

On 7/27/2017 at 4:42 AM, CJAdmission said:

The problems PA program run into is mainly due to a piss-poor response form PAs becoming preceptors. They just don't give a damn. To anyone on this thread bitching about the quality of clinical rotations who is not a preceptor: in the words of William Wallace, put your head between your legs and kiss your own arse.

 

PA not becoming preceptors is often out of their hands. The more corporate medicine becomes, the less collegial we are allowed to be. 

The corp behemoth I worked for would not let students of any realm CHOOSE their preceptor or vice versa. IF the corp chose the student - based on what criteria I do not know - then they sent an email to a somewhat random provider who might not even want to be a preceptor or might not have an ounce of teaching qualities.

The email would say "Congratulations, John Doe, Medical Student, will be spending the months of June and July with you in your practice. Please facilitate their education"  Unwritten PS - we aren't going to slow down your schedule or change your production quotas or provide you with ONE OUNCE of assistance such as computer access or resources.

A prior multispecialty group I worked with had a complete ARSE of an assistant medical director who told us that we could have students but should abide by Medicare rules and there would be no change in schedules or production. And, by the way - we will NOT provide ANY written guidelines, rules or regulations. BUT, if we don't like something you do - we will punish you summarily. Provided ZERO desire to precept and long term docs and PAs who had precepted pulled out of rotation immediately. The fear of retribution and punishment with a complete lack of guidelines left us bare butt out in the cold hoping not to violate some rule we were not aware of. 

So, I would not blanket a guilt trip on all graduated PAs in the country. More and more medicine is owned by corporate monsters and more and more of us are drones without control of our own schedule or destiny much less the capacity or good will to precept. 

Still - every one who can - should. 

Another vote for some form of PA independence and a continuing vote that corporate medicine implodes and goes away.

[Guest HanSolo]

Surprised not once has accreditation standards come up in this thread. If people are getting terrible rotations and it's damaging the profession, then there should be more stringent standards regulating preceptorship. Most schools likely won't regulate themselves. This is another factor in the argument of "does it matter where you go to school?" 

[sas5814]

"The corp behemoth I worked for would not let students of any realm CHOOSE their preceptor or vice versa. IF the corp chose the student - based on what criteria I do not know - then they sent an email to a somewhat random provider who might not even want to be a preceptor or might not have an ounce of teaching qualities."

 

Too true. I have been precepting students off and on for 20 years. My current (massive corporate) employer won't let us precept because it would slow us down and therefore affect revenue. I have asked several times and was basically told to drop it.

[UGoLong]

Believe me, ARC-PA cares!


Sent from my iPad using Tapatalk

[rev ronin]

40 minutes ago, UGoLong said:

Believe me, ARC-PA cares!

I'd love to hear about a program they withdrew accreditation from because staff were telling students to cheat on their experience logs.  Seriously.

[MT2PA]

On 7/26/2017 at 8:48 PM, amwillaert said:

Not good and certainly should not be the norm. We (very occasionally) have a student receive what we consider to be inadequate OB experience on their OB/GYN rotation (often with new sites or new preceptors who just don't quite meet the mark despite education about requirements beforehand). An appropriate response to this would be to supplement the rotation (perhaps during an elective) using hours at a site where they are sure to obtain the appropriate experience. It makes all PA programs look bad when programs choose to skirt the rules like you mention above, but I don't think it is very common thankfully. 

As a student, an appropriate response would be to identify the faults in the site and cut it short and be placed elsewhere for the remainder of the rotation (and strongly consider dropping the site).  I would be livid if my program forced me to use my only elective to make up for the faults of a site that they sent me to.

[amwillaert]

7 hours ago, MT2PA said:

As a student, an appropriate response would be to identify the faults in the site and cut it short and be placed elsewhere for the remainder of the rotation (and strongly consider dropping the site).  I would be livid if my program forced me to use my only elective to make up for the faults of a site that they sent me to.

It's more complicated than that. Cutting a rotation short (especially if the student is getting good GYN experience but just needs some additional OB experience) would be simple if OB preceptors grew on trees. Because they unfortunately don't, and because OB heavy sites are notoriously difficult to find (not many PAs working in OB), that would put the student at risk of not graduating on time if a new site couldn't be established prior to rotation end. And given that it takes weeks to months to onboard and that the majority of our rotations schedule 6 to 12 months out, the chances would be slim. Thus the compromise of taking a few days from a non-core rotation to supplement. 

As Clinical Coordinators, it's our job to constantly find and develop new sites and preceptors. How else can we make up for the established preceptors who retire, move out of state, change specialties etc? Someone always has to be the first student at a site. And we can set expectations until we are blue in the face, but at some point you have to see how it goes, understanding that it may not always be perfect on the first try. I always notify students if they are a first student at any site and am in frequent communication with them throughout. 

[amwillaert]

15 hours ago, sas5814 said:

"The corp behemoth I worked for would not let students of any realm CHOOSE their preceptor or vice versa. IF the corp chose the student - based on what criteria I do not know - then they sent an email to a somewhat random provider who might not even want to be a preceptor or might not have an ounce of teaching qualities."

 

Too true. I have been precepting students off and on for 20 years. My current (massive corporate) employer won't let us precept because it would slow us down and therefore affect revenue. I have asked several times and was basically told to drop it.

I am sorry to hear this, but unfortunately it is an all too common response from interested (and former) preceptors. It's not as simple anymore as finding an interested preceptor and matching them with a student. There are usually at least 2-3 layers of other individuals above the preceptor who must approve a potential rotation (lead PA or physician in the group, clinic manager, clinical ed coordinator, etc). If any one of those individuals can find any reason why a student shouldn't be allowed in the clinical site (EMR transition, hiring too many new support staff in the next 6 months, the sky is blue) then the request will be declined even if the preceptor is willing. It usually all comes back to money, and the thought that having students will adversely affect productivity and revenue.

[MT2PA]

5 hours ago, amwillaert said:

It's more complicated than that. Cutting a rotation short (especially if the student is getting good GYN experience but just needs some additional OB experience) would be simple if OB preceptors grew on trees. Because they unfortunately don't, and because OB heavy sites are notoriously difficult to find (not many PAs working in OB), that would put the student at risk of not graduating on time if a new site couldn't be established prior to rotation end. And given that it takes weeks to months to onboard and that the majority of our rotations schedule 6 to 12 months out, the chances would be slim. Thus the compromise of taking a few days from a non-core rotation to supplement. 

As Clinical Coordinators, it's our job to constantly find and develop new sites and preceptors. How else can we make up for the established preceptors who retire, move out of state, change specialties etc? Someone always has to be the first student at a site. And we can set expectations until we are blue in the face, but at some point you have to see how it goes, understanding that it may not always be perfect on the first try. I always notify students if they are a first student at any site and am in frequent communication with them throughout. 

 A 'few days' of OB may help a student meet the ARC-PA standards but it's certainly not a replacement.  Either way the student suffers through no fault of their own.  

I'm not saying there's an easy answer, but this just adds to the idea that students are getting subpar clinical rotations.  Another reason for students to strongly scrutinize programs, new and old, for their clinical connections when applying and considering acceptance.

[amwillaert]

3 hours ago, MT2PA said:

 Another reason for students to strongly scrutinize programs, new and old, for their clinical connections when applying and considering acceptance.

Agree 100%

[amwillaert]

3 hours ago, MT2PA said:

 A 'few days' of OB may help a student meet the ARC-PA standards but it's certainly not a replacement.  Either way the student suffers through no fault of their own.  

Was trying to offer a much better alternative than "count your contraception appointments as OB hours" as was mentioned above. Our clinical team is responsible for scheduling over 400 rotations a year, and has to supplement hours maybe once or twice a cohort. The "few days" of OB is because the student has already gotten some OB experience but just needs a bit more to meet our standard. We really do our best :)

[CAAdmission]

On 7/28/2017 at 7:13 PM, Reality Check 2 said:

PA not becoming preceptors is often out of their hands. The more corporate medicine becomes, the less collegial we are allowed to be.

We need to force the issue. This was a conversation I had during the interview process every place I worked. I was taking students.

[rev ronin]

I took students my last position, and my clinic immediately doubled "our" (my) workload: the student was to be scheduled for as many patients as I was.  PA students at that clinic were treated as extra labor that didn't have to be paid... but at least they did get to see real patients with real problems even if it did totally torch my schedule.

Now that I'm working two part-time jobs (FP/Occ Med and Sleep), I really can't take a student for a full rotation.  I'd love to have students rotate with me for A DAY in sleep medicine, but beyond that I'm afraid it would be too much the same thing for 4-6 weeks.

[Boatswain2PA]

On 7/29/2017 at 3:42 PM, UGoLong said:

Believe me, ARC-PA cares!


Sent from my iPad using Tapatalk

Care to extrapolate?

What is ARC-PA doing to FIND and CLOSE programs like this?  Why is ARC-PA allowing so many new programs??

[UGoLong]

In a previous post above, I noted that the ARC-PA (the body that accredits PA programs) cares about clinical rotations and at least two people have asked for more information. Having been part of an audit (as a faculty member, not as part of an inspection team), it is clear to me that they care very much about clinical rotations and the distribution of patients seen and procedures performed. 

From my previous lifetime as an engineering manager (where I did do audits), I would liken at least part of an ARC-PA audit to an ISO-9000 audit. By that I mean that an outside party looks at your written procedures and sees if you really follow them. For example, if a student says something negative about a clinical rotations -- or gets a poor grade in it -- does the program really follow up? Are poor rotations dropped? ("Let me see the records.") A program is supposed to have procedures and the audit team checks to see that you do and then can spot-check to determine if they are just words on a page or part of your actual procedures.

Having a system to track a program's students and see that they get the required experiences is part of an audit. I doubt that this oversight is perfect, in that an individual student might be able cheat without detection and log things they didn't see. On the other hand, does the program review the logs in a reasonable period of time, spot problems, and deal with them? ("Let me see your records.") Could a program systematically cheat and get ALL of their students to generate fake logs? Maybe, but there are some safeguards, including live interviews with clinical students, reviews of faculty site visits, etc. And my guess is that a program willing to be that dishonest in one area of operation would likely have other, perhaps more easily detectable, dishonest actions as well.

So, can an auditor be 100% sure that a program is doing things the right way? Probably not, but they can do a reasonably good job.

As far as why so many new PA programs, I don't know for sure. I had heard that prior ARC-PA leadership didn't feel that they should be in a position of stopping schools from starting them -- it would be restraint of trade. (I don't know anything about how the current leadership might feel.) On the other hand, ARC-PA could make sure (or reasonably sure) that the programs were following the standards. 

There are a lot of transients in the PA program world. Your host university goes through its changes, faculty members come and go, new programs start and have growing pains, while older programs may not keep up with new instructional methods or evolving ARC-PA standards. Nothing stays the same. Nothing.

To the prospective student: do some research and ask questions (respectfully) when you have the opportunity. I know of no system -- in any environment -- that can absolutely guarantee that you will have a good experience with any purchasing decision you might make. The same is true when you consider PA programs.

[CAAdmission]

5 hours ago, Boatswain2PA said:

Care to extrapolate?

What is ARC-PA doing to FIND and CLOSE programs like this?  Why is ARC-PA allowing so many new programs??

ARC-PA has no ability to stop a program from opening if it demonstrates it can meet the standards. As to closing programs, they are very transparent - you can see they have a lot of rotation related concerns:

http://www.arc-pa.org/wp-content/uploads/2017/05/Accreditation-Actions-2017Jan-M-5.10.17.pdf

It's worth noting that the ARC-PA is considering an update to the standards, possibly to the extent of doing a complete re-write. If you have concerns, they will have a comment period sooner of later. Be sure to give feedback.

[amwillaert]

@UGoLong - thanks for writing that detailed description above. Compared to other Allied Health accreditation bodies, ARC-PA has much more stringent standards and better oversight (at least this seems to be the case based on discussions with other allied health professionals in academics who have also been through accreditation). Having just been through accreditation, it is no joke. They look at EVERY aspect of your program top to bottom and it would be difficult (if not impossible) to pass an audit with consistently inadequate clinical experiences. I think part of the issue is what is the average practicing PA considers "adequate experience" is likely different than what is necessary to meet the ARC-PA standard. Some of the standards are quite general and do give programs a fair amount of leeway as to what "counts." If PAs as a whole think they should be stricter then yes this needs to be addressed prior to the next set of standards being released.

[Boatswain2PA]

On 7/31/2017 at 1:22 PM, CJAdmission said:

ARC-PA has no ability to stop a program from opening if it demonstrates it can meet the standards. As to closing programs, they are very transparent - you can see they have a lot of rotation related concerns:

http://www.arc-pa.org/wp-content/uploads/2017/05/Accreditation-Actions-2017Jan-M-5.10.17.pdf

It's worth noting that the ARC-PA is considering an update to the standards, possibly to the extent of doing a complete re-write. If you have concerns, they will have a comment period sooner of later. Be sure to give feedback.

Thanks!