Rotation Expectations of Students Vs Preceptor

[SedRate]

I wanted to reach out to the forum community for insight and guidance regarding preceptorship. I apologize for the long-winded post which doubles as a vent session. Thank you

I've had some issues with  students recently who have entitlement issues and poor attitudes. There seems to be an expectation that I hold their hand, answer all of their many questions, lead them through their entire rotation without any critical thinking or attempt to try on their own first, accept their excuses, not ask them to look up things, and that somehow I owe them something. Did I just have a bad batch or is this a glimpse of the next generation of PA students? I am in the Western part of the US where things are a bit more casual compared to the East. 

I set up my expectations from the get-go and gauge their skill set and confidence initially by "pimping" them or giving them various tasks. I will also show them how to do things a couple of times initially because obviously they all start at different levels and with different experiences. My rotation is an elective surgery rotation and I do expect that students already have the basics down such as suturing, note-taking, gowning, H&Ps, Rx writing, etc. I have made this clear to the program I precept students for. But the majority of students blame their lack of preparedness on "bad" prior rotations where they just merely shadowed and "did nothing" or lack of teaching by the program, and some students will actually cop an attitude when I point out their lack of preparedness and/or challenge/push them. Some haven't practiced their sewing, reviewed anatomy for a case, looked up preop labs, etc, you name it. I find it unprofessional and BS that they seem to blame everything else but themselves. As a student, I remember reviewing for each case, looking up labs, practicing at home, etc. I didn't rely on my preceptors to teach me medicine, that was what first year didactic and studying were for. I expected preceptors to help me hone my skills and give me opportunities to gain experience, not do my learning for me. And that's what I try to do with my students. 

I feel like it's my role to push them beyond their comfort zone and give them an opportunity to function as a "real" PA with my direct supervision to guide them, just as I experienced as a student. I know everyone learns differently, so I try to tailor my preceptorship to each student. With that said, I also expect that students take responsibility for their education and actions. I'm getting tired of dealing with the bad attitudes and excuses. 

I have had many other providers, my SP, and nurses tell me I'm patient and a very good teacher. I've reached out to past students who are now working, and all have thanked me for pushing them and appreciate the experience with me. I am tough but not malicious. I do have high expectations. I like precepting for my alma mater and enjoy teaching, but the stress and aggravation is starting to weigh me down. 

Any advice, encouragement, thoughts or suggestions?

[rev ronin]

I would write up these expectations and make sure the program delivers them to the students before arrival.  Then, if students aren't meeting the rotation expectations, counsel them appropriately, then fail them if they're not working hard.  I was on the other end of an expectations disconnect in one rotation, and it did suck, but I didn't blame anyone, and worked through it, and got a 'satisfactory' from it.

[SedRate]

Thanks for replying, Rev. I plan on developing something like that so I appreciate your suggestion/support.

[mgriffiths]

For one of my rotations, my preceptor had a list of items to review before stepping foot into the hospital (surgery rotation).  He expected me to know these items cold and the first day was almost constant "pimping" on these items.  I know I took the list seriously and studied and did well that first day.  I know some of my classmates took it as a joke.  No one I know of failed the rotation, but I do know the difference was our experience.  I loved the rotation, I was given the opportunity to close regularly, was given more and more responsibility throughout the rotation; while some classmates felt largely ignored.  I have always assumed the preceptor used the first day as a gauge for how much work he was going to put in, based on how hard we worked before showing up.

I plan to do similar once I begin precepting.  I am 17 months out of school, and almost 1 year at current job.  I feel that 1 year is a minimum benchmark to even think about precepting - but I've already had several schools contact me asking.

[SedRate]

48 minutes ago, mgriffiths said:

For one of my rotations, my preceptor had a list of items to review before stepping foot into the hospital (surgery rotation).  He expected me to know these items cold and the first day was almost constant "pimping" on these items.  I know I took the list seriously and studied and did well that first day.  I know some of my classmates took it as a joke.  No one I know of failed the rotation, but I do know the difference was our experience.  I loved the rotation, I was given the opportunity to close regularly, was given more and more responsibility throughout the rotation; while some classmates felt largely ignored.  I have always assumed the preceptor used the first day as a gauge for how much work he was going to put in, based on how hard we worked before showing up.

I plan to do similar once I begin precepting.  I am 17 months out of school, and almost 1 year at current job.  I feel that 1 year is a minimum benchmark to even think about precepting - but I've already had several schools contact me asking.

I already send an email to the upcoming student with a list of things I want them to review and practice, similar to your experience. I end the email with, "Be prepared and be prepared to work hard." And then they show up, nope, nothing, nada, just excuses as if my email was a mere suggestion. Perhaps I should be even more strict and have them sit out until they've reviewed said subjects and proved to me that they're ready.

[RuralER/Ortho]

46 minutes ago, Sed said:

I already send an email to the upcoming student with a list of things I want them to review and practice, similar to your experience. I end the email with, "Be prepared and be prepared to work hard." And then they show up, nope, nothing, nada, just excuses as if my email was a mere suggestion. Perhaps I should be even more strict and have them sit out until they've reviewed said subjects and proved to me that they're ready.

Out of curiosity, how are rotation grades calculated for the school(s) you typically work with?

[SedRate]

17 minutes ago, RuralER/Ortho said:

Out of curiosity, how are rotation grades calculated for the school(s) you typically work with?

Pass/fail to my understanding

[eighthnote24]

I would be willing to bet that this is a widespread problem that preceptors are struggling with.  I know at my program, we struggle with this type of entitled/gimme attitude constantly.  I started here in the middle of a class that had already developed this behavior, but for the class starting soon, I plan to address this behavior before it starts. 

I wish we had more preceptors like yourself...unfortunately, many of them either don’t care or don’t understand that we need the students to be held to a higher standard.  Don’t lower your expectations and feel free to let the program know your concerns.

[SedRate]

25 minutes ago, eighthnote24 said:

I would be willing to bet that this is a widespread problem that preceptors are struggling with.  I know at my program, we struggle with this type of entitled/gimme attitude constantly.  I started here in the middle of a class that had already developed this behavior, but for the class starting soon, I plan to address this behavior before it starts. 

I wish we had more preceptors like yourself...unfortunately, many of them either don’t care or don’t understand that we need the students to be held to a higher standard.  Don’t lower your expectations and feel free to let the program know your concerns.

Thank you for your insight and words of encouragement. I will definitely relay my concerns to the school. 

[Guest UVAPAC]

The only thing I would say to keep in mind... At one point we were all students!

There is a huge difference between classroom/didactic work, and rotations with hands on clinical experience.  I learned far more on my rotations than I did reading out of some giant textbook.  

There is a big difference between a student beginning their first rotation, and a student on their last rotation, and I think expectations need to be adjusted.  I always worked hard, asked questions, and did reading at the end of each day to learn/retain information.  I can also say that I was uncomfortable early on (my first rotation was family medicine at a community health center in a very under-served area).  I saw diabetics with HA1C's of 15, people having moderate/severe asthma attacks, STD's including numerous HIV+ patients, blood pressures of 240/130, etc.  I always was willing to go in and do an initial evaluation, but at times it was uncomfortable.

In regards to the initial poster's comments:  Things like suturing and following sterile procedure may be second nature to a surgical PA-C, but to a student who has never been in a surgical procedure before it can be intimidating/challenging.  I think we did a brief lab at our program where we all washed our hands, and put on a gown.  Doing this once in no way makes you an expert.  Neither does suturing on a pigs foot.  

I say as long as there is hard work put forth, and improvement is shown, and an interest to learn... you work with them instead of reporting them to their programs.  

[SedRate]

2 hours ago, UVAPAC said:

The only thing I would say to keep in mind... At one point we were all students!

There is a huge difference between classroom/didactic work, and rotations with hands on clinical experience.  I learned far more on my rotations than I did reading out of some giant textbook.  

There is a big difference between a student beginning their first rotation, and a student on their last rotation, and I think expectations need to be adjusted.  I always worked hard, asked questions, and did reading at the end of each day to learn/retain information.  I can also say that I was uncomfortable early on (my first rotation was family medicine at a community health center in a very under-served area).  I saw diabetics with HA1C's of 15, people having moderate/severe asthma attacks, STD's including numerous HIV+ patients, blood pressures of 240/130, etc.  I always was willing to go in and do an initial evaluation, but at times it was uncomfortable.

In regards to the initial poster's comments:  Things like suturing and following sterile procedure may be second nature to a surgical PA-C, but to a student who has never been in a surgical procedure before it can be intimidating/challenging.  I think we did a brief lab at our program where we all washed our hands, and put on a gown.  Doing this once in no way makes you an expert.  Neither does suturing on a pigs foot.  

I say as long as there is hard work put forth, and improvement is shown, and an interest to learn... you work with them instead of reporting them to their programs.  

Agreed. However, you're misunderstanding my concerns. 

While I don't expect students to be an "expert," I do expect them to know how to perform the basic styles, which suture materials to use, surgery-specific topics, and need-to-knows for an ELECTIVE SURGERY ROTATION. Obviously their final product may not be greatest, but they should know how to do it so when they do perform it, they're not asking me, "How do I do this stitch?" Students can learn/practice this on their own with the help of the many resources out there and then work on it with me in the OR. All students of mine have already done a surgical rotation and so they have all been in dozens of surgical procedures prior. And this is the problem I have. I have students coming in to rotate with me at the end of their training having never written a Rx themselves, don't understand pre or postop orders, not sure how to handle a needle driver or needle, how to gown/glove, etc... And then I find out they haven't even prepared for my rotation at all. And then they blame others or copying an attitude at me when I share my disappointment in their lack of responsibility or preparedness. 

[SedRate]

It'd be different if they said, "I've never done this stitch on real skin before. Can you please show me first?" Or, "I've been practicing but still can't quite get it." SOMETHING! But no. Seems like students don't care to put in the homework and instead want me to spoon-feed them everything. 

[gbrothers98]

Some considerations.

OP is providing a surgical elective experience. Is this an assigned elective or student chosen? The behavior concerns outlined are more consistent with being an assigned rotation (one the student may not be interested in) rather than student chosen. 

While I think there have been good recommendations, the thing that will get the OP the attention sought would be to send a student home. While that may seem a bit much, if there is a significant issue with lack of involvement, then this rant will gain some quick attention when a faculty member has to replace a rotation in the short term.

Would state that the high price tag of PA education has potentially led the profession to this. I recall back in the late 90s, setting up most of my rotation year with preceptors back home, wondering what I was exactly paying the school for when my education was being supplied in two parts by my involvement and my preceptor's level of interest and skills. Fast forward 20 years, when it is commonplace for a comparable PA education to cost 10x more, I would have significant expectations of my preceptors also. To make matters worse, consider the likelihood that students view preceptors as an extension of faculty and assume their tuition dollars are lining preceptor pockets, therefore a student expects some significant one on one hand holding. 

While curriculums do vary, most are still firmly stuck in the information delivery mode. Combine this with years of education spoon fed to students rather than actively seeking out information and lack of initiative is the not surprising end product. The eye opening moment comes during the transition to practice, being responsible for the reality and realizing that the perception held by students was an unsustainable luxury. Rest assured, the involvement desired of those students will bubble to the surface due to workplace necessity and the weak will be separated from the herd. 

Last, PA clinical training is a broken and outdated model. While ARC-PA has set standards, those can be interpreted by a program in order to justify goals and outcomes. Those likely do not match up with a preceptor in a surgical specialty. After reflecting on my 2.5 year stint as a clinical educator, I firmly see the clinical year better delivered by 4 common experiences, outpatient family medicine, inpatient adult medicine, general surgery and EM. Each should be a minimum of 4 months, consider outpatient family medicine for a minimum of 6 months. 1-2 months at a clinical site just does not provide enough time for the breadth and depth required of patient experiences nor does allows for true modeling to occur. Likely the OP could turn around the majority of students assigned given more time with. A few weeks to make an impact is wishful thinking.

George

[SHU-CH]

2 hours ago, gbrothers98 said:

While I think there have been good recommendations, the thing that will get the OP the attention sought would be to send a student home. While that may seem a bit much, if there is a significant issue with lack of involvement, then this rant will gain some quick attention when a faculty member has to replace a rotation in the short term.

That may be a little drastic as a first step without first gettgin the program involved. I would certainly encourage every preceptor to contact the program immediately upon any concern about a student - knowledge, skills or attitude. If negative feedback is communicated back to a program, they should move immediately into some sort of remediation process. It is dissapointing for all parties when a student receives an unexpectedly poor end of rotation evaluation. The rotation might have been a better, less frustrating experience for all parties involved if the issue could have been addressed earlier. Many preceptors do not want to hurt a student's feelings, but they do not do any favors for anyone's career by not bringing problems to light when they still might be fixable.

The timing of this thread is funny - I just had a meetgin with a long-term preceptor who expressed similar feelings. I was just in the process of creating an updated "what preceptors expect" document. I'd welcome any more feedback to create a "top 10" list! 

[EMEDPA]

15 minutes ago, SHU-CH said:

I was just in the process of creating an updated "what preceptors expect" document. I'd welcome any more feedback to create a "top 10" list! 

at a minimum:

1. student will show up on time(or preferably a few minutes early) for each shift appropriately dressed, sober, and ready to learn.

2. student will understand basics of performing an H+P and have basic procedural skills

3. student will follow up on recommendations from the preceptor. If there is a long discussion, for example,  about abdominal pain ddx, the student should go study that and have a better differential the next time they are asked. ( I had a student years ago who never developed his ddx beyond "an appy or an ulcer". he failed). 

4. student will have an idea of what they hope to gain out of the rotation beyond just passing and be able to answer the question "what would you like to talk about today" if there is some downtime. 

Specific to EM : understand basic ekg and lab principles. know the basics of most ed workups (sob gets a cxr, chest pain gets an ekg and a trop, etc). It would be nice if students knew basic decision rules(Geneva, perc, chad scores, curb-65, heart scores) before  starting the rotation or at least knew of the existence of MD Calc and how to use it. 

(A big part of this discussion as well is preceptor selection- people should not be forced to precept, but instead choose to do so. I enjoy teaching and almost always have a PA or medical student/resident with me). 

[SedRate]

5 hours ago, gbrothers98 said:

Some considerations.

OP is providing a surgical elective experience. Is this an assigned elective or student chosen? The behavior concerns outlined are more consistent with being an assigned rotation (one the student may not be interested in) rather than student chosen. 

While I think there have been good recommendations, the thing that will get the OP the attention sought would be to send a student home. While that may seem a bit much, if there is a significant issue with lack of involvement, then this rant will gain some quick attention when a faculty member has to replace a rotation in the short term.

Would state that the high price tag of PA education has potentially led the profession to this. I recall back in the late 90s, setting up most of my rotation year with preceptors back home, wondering what I was exactly paying the school for when my education was being supplied in two parts by my involvement and my preceptor's level of interest and skills. Fast forward 20 years, when it is commonplace for a comparable PA education to cost 10x more, I would have significant expectations of my preceptors also. To make matters worse, consider the likelihood that students view preceptors as an extension of faculty and assume their tuition dollars are lining preceptor pockets, therefore a student expects some significant one on one hand holding. 

While curriculums do vary, most are still firmly stuck in the information delivery mode. Combine this with years of education spoon fed to students rather than actively seeking out information and lack of initiative is the not surprising end product. The eye opening moment comes during the transition to practice, being responsible for the reality and realizing that the perception held by students was an unsustainable luxury. Rest assured, the involvement desired of those students will bubble to the surface due to workplace necessity and the weak will be separated from the herd. 

Last, PA clinical training is a broken and outdated model. While ARC-PA has set standards, those can be interpreted by a program in order to justify goals and outcomes. Those likely do not match up with a preceptor in a surgical specialty. After reflecting on my 2.5 year stint as a clinical educator, I firmly see the clinical year better delivered by 4 common experiences, outpatient family medicine, inpatient adult medicine, general surgery and EM. Each should be a minimum of 4 months, consider outpatient family medicine for a minimum of 6 months. 1-2 months at a clinical site just does not provide enough time for the breadth and depth required of patient experiences nor does allows for true modeling to occur. Likely the OP could turn around the majority of students assigned given more time with. A few weeks to make an impact is wishful thinking.

George

It is student chosen. 

Thank you for your valuable insight and contribution to this discussion. I agree with just about every point, although I still would like to see the elective option. 

[BayPAC]

I think I was a good student during my clinical rotations... always showing interest and showing up on time. However, it was difficult to study for all my surgery cases given the amount of extra things that I had to do for school. Going to rotation 40+ hours/week, studying for EORE, writing papers/doing homework for online classes... it was just too much! 

[sas5814]

I was military trained so I got to start the day with physical training at 0530 and then go home and clean up for class. :-)

When I took students in FP rotations I always sat down with them on the first day and we talked about our mutual expectations so there were no surprises. One of the things I told them, as I was told, is I don't ever want to hear "I don't know" that wasn't followed by "but I'll find out". I also told them I was really easy to get along with, I wasn't going to ride them because I expected them to be self starters, and I'd fail them in a second as sad as it would make me. My loyalty was to patients, the profession, and the student in that order.

In some 10 years of taking students I only failed one that was late in their rotations and simply could not arrive at a diagnosis. She would just freeze...... and stare.....

[EMEDPA]

I co-failed (me and the np preceptor agreed) an (online/distance trained) np student a few years ago on her last day of rotations before graduation because she could not diagnose strep pharyngitis as the source of fever in a pt with sore throat and fever...because she didn't look at the throat given a chief complaint of "sore throat and fever x 1 week".  we asked her to go back and figure out the fever and she couldn't.....sad.....

[MedicinePower]

On 4/29/2018 at 8:58 PM, Sed said:

Perhaps I should be even more strict and have them sit out until they've reviewed said subjects and proved to me that they're ready.

This is very confusing. Why would you allow yourself to be a paid clinical staff members of a PA program yet complain about teaching? These students have zero experience in your expert field and therefore require a lot of hand holding.

[SedRate]

6 minutes ago, MedicinePower said:

This is very confusing. Why would you allow yourself to be a paid clinical staff members of a PA program yet complain about teaching? These students have zero experience in your expert field and therefore require a lot of hand holding.

I apologize for the confusion. My original post was long-winded, so I hope my intention didn't get lost. 

I am not paid. And for the record, I'm ok with "hand holding" so long as it's with a student who puts in the effort and has a good attitude. Obviously, they are students who likely know little-to-none about my field and need lots of guidance. I understand that. I actually do enjoy teaching, but only those interested in learning and have a good attitude. I don't seem to be getting much of that lately. I reached out to this forum to make sure I wasn't completely off-base with unrealistic expectations.

[SedRate]

3 hours ago, BayPAC said:

I think I was a good student during my clinical rotations... always showing interest and showing up on time. However, it was difficult to study for all my surgery cases given the amount of extra things that I had to do for school. Going to rotation 40+ hours/week, studying for EORE, writing papers/doing homework for online classes... it was just too much! 

You're saying that students have other things going on outside of my elective rotation?? What?!

Kidding aside, good point. I will remember to keep that in mind.

[SedRate]

3 hours ago, sas5814 said:

I was military trained so I got to start the day with physical training at 0530 and then go home and clean up for class. :-)

When I took students in FP rotations I always sat down with them on the first day and we talked about our mutual expectations so there were no surprises. One of the things I told them, as I was told, is I don't ever want to hear "I don't know" that wasn't followed by "but I'll find out". I also told them I was really easy to get along with, I wasn't going to ride them because I expected them to be self starters, and I'd fail them in a second as sad as it would make me. My loyalty was to patients, the profession, and the student in that order.

In some 10 years of taking students I only failed one that was late in their rotations and simply could not arrive at a diagnosis. She would just freeze...... and stare.....

I function very much like this minus the PT portion... Although that might be a nice way to start off the day.

I haven't failed any thus far.

[MedicinePower]

2 hours ago, Sed said:

I apologize for the confusion. My original post was long-winded, so I hope my intention didn't get lost. 

I am not paid. And for the record, I'm ok with "hand holding" so long as it's with a student who puts in the effort and has a good attitude. Obviously, they are students who likely know little-to-none about my field and need lots of guidance. I understand that. I actually do enjoy teaching, but only those interested in learning and have a good attitude. I don't seem to be getting much of that lately. I reached out to this forum to make sure I wasn't completely off-base with unrealistic expectations.

It sounds like you shouldn't be taking students. A good teacher will meet the student where they are.

[ProSpectre]

1 hour ago, MedicinePower said:

It sounds like you shouldn't be taking students. A good teacher will meet the student where they are.

Seriously? You don't think a preceptor should be able to have reasonable expectations that a student will come prepared to their rotation? Or that they will pre-read on common diagnoses and procedures within that specialty and look stuff up before playing 100 questions with their preceptor? Or that they won't get an attitude with the preceptor when they are taken out of their comfort zone? Or that they will take some personal responsibility when they are told they aren't meeting expectations? 

Of course a student shouldn't be expected to know everything (they are there to learn after all), and they should be able to ask questions (after making a reasonable attempt to find the answer themselves). But what I got out of the OP's concerns is students who aren't taking personal responsibility for their own education, and that is a problem.  

I think the expectations of students mentioned in the original post are perfectly reasonable. I do think maybe Sed should outline his expectations more clearly up front, but nothing he mentioned is unreasonable or suggests that he shouldn't take students.