this always blows my mind....

[EMEDPA]

Today I precepted a 2nd yr family med resident on I+D of an abscess. they had never done one before...how is that possible? 2 yrs of clinicals in med school and 1+ yrs of residency and never done a simple I+D? you can't get out of pa school without doing a ton of them....

ditto ingrown toenails, digital blocks, suturing, abg's, venipuncture, etc...why do I have to teach these to licensed physicians? not that I mind, I'm just wondering how they missed those things along the way....

[primadonna22274]

Medical education does not include a lot of procedural skills instruction. I led an IV & venipuncture lab last winter for the 2nd/3rd year med students at MCG...this was the FIRST time the med school had tried doing this. It was pretty awesome as it was me, a family doc and 4 2nd-year PA students (2 EMTs) who taught the med students how to start IVs. :)

[primadonna22274]

Forgot to mention, a strapping young man (after 3 attempts on the IV model and finally being successful!) looked at me and said "this is the most useful damn thing I've learned in medical school yet." :)

[EMEDPA]

All the medics in my pa school class were also paid to teach the ms3's at hahnemann how to start IV's one afternoon. I think they gave us 25 bucks each for a 1 hr procedure lab.

[marilynpac]

You have to quit thinking that all instruction is like yours. I sutured only one time during all of my rotations. Most docs used the staple gun b/c of time constraints. In the ED the same story. Treat-em-n-street-em. Oh, I only did one I&D also.

[EMEDPA]

How did you get out of pa school suturing only once?

Didn't you suture in the er and on surgery rotations?

I think my experience with suturing is fairly typical. All of my students suture 3-44x/day x 5 weeks...i sutured on 4 rotations( em, surgery, peds, em elective).

And I+D's...several/week x 5 weeks. I precept for 3 programs and they all have required procedures logs with min #s to pass a rotation. I think the min # for simple proceedures is around 5. they have to start iv's and draw blood as well. I set them up with the nurses for those. they do abg's too.

[marilynpac]

Yes emed it's changed. Not only that being rural vs city also makes a big difference. As I said in ED and surg rotations they used the staple gun and they still do. I know that for a fact. I've had my IV training through my nursing work and have never done ABGs that goes to lab. The docs do very little procedures in their offices b/c of time constraints.

[EMEDPA]

You can't staple someone's face, over a joint, on hands, etc

i staple scalps, forearms, upper arms and thighs...and that's about it...this is, by the way, the standard of care in emergency medicine...staple someone's face and you get a big lawsuit....how about closing the vermillion border...with a stapler...i think not....most lacs in the ed are not amenable to a stapler because of location(hands, knees, faces...)

[medic25]

I'm also amazed that it's possible to make it through an ED and a surgical rotation and only suture once. The stapler has its place (e.g. scalp lacerations), but the vast majority of wound closures in an ED are going to require suturing unless the ED you rotated in stapled finger lacs, facial lacs, etc. As a PA student I used to sew constantly, and now our PA students rotating through the ED now usually get first dibs on most wound closures, I&D's, etc, and get more than enough opportunities to sew.

[Hemegroup]

My official Emed preceptor (a PA) never let me suture once, she was a complete control freak. All the other Docs and PAs there did let me, thankfully, so I got to suture a few times (was quite good at it too, if I do say myself).

[EMEDPA]

m25. thanks for the confirmation....

[EMEDPA]

in our busy trauma ctr the only suturing done by docs is when they suture in a chest tube or central line...we do 99% of all closures and once in a blue moon call in plastics or ent( I have done it twice in 10 yrs at my current job) for things like pit bull bite to face of 3 yr old girl with no normal landmarks(nose, lips, etc) recognizeable. aside from this we do all the faces, lips, ears, etc

I have personally sutured up several colleagues(docs, pa's, nurses, techs) kids

[marilynpac]

There you go Heme, control freaks in a very very rural area...the truth is we had almost no ED rotations way back then so we were put in the way outback. There just wasn't a lot going on then and I was only there for a total of 14 days!!!

[EMEDPA]

how did you have a 16 day er rotation? hasn't the paea standard always been at least 1 month? we have np students who do 1 week em rotations but not pa's...they all do 4-6 weeks and many come back for an elective...

[EMEDPA]

heme- all 3 of my em preceptors( em, peds em, em elective) pretty much let me grab and work up anything in the rack and do any procedures I wanted to. sounds like you got short changed. my trauma preceptor let me put in chest tubes, intubate, etc

[medic25]

My official Emed preceptor (a PA) never let me suture once, she was a complete control freak. All the other Docs and PAs there did let me, thankfully, so I got to suture a few times (was quite good at it too, if I do say myself).

 

I hope you let your faculty know about this. You are there (and paying good money for it) to learn how to be a practicing PA, not to stand with your hands in your pockets and watch somebody else practice; that's called shadowing. My pet peeve is when a student sits back and doesn't pursue the chance to perform procedures; if you don't jump in and try these procedures, you'll never get to master them.

[marilynpac]

Mon-Thurs 6a-6p off Fri, Sat, Sun for 1 month, very very rural, tried to get a different one, no other ones open. I think I was the last PA that went there b/c it was just too quiet of a rotation. I saw some from the admin at a conference about a yr later and asked if their still sending students to that rotation. Was told the students just refuse to go so they haven't sent anymore there. I do have to say the nurses there were wonderful and could see how it was lacking and got me on the ems service to help me out, but that was only 1 day. I left early as I was allowed to, called the nurses and asked if I missed anything...of course not.

[EMEDPA]

m25...we have failed several students who refused to do procedures...we had 1 guy who said he was going into fp and didn't need to know that stuff. he was right because he never became a pa....

[marilynpac]

He didn't deserve to be a PA, and good for you, failing students who refuse. Instead putting out skilled PAs.

[primadonna22274]

E--FYI: ARC-PA does not set the "minimum" length of any rotation. It just says that PA programs MUST provide experiences in the core disciplines. In fact, when I was a student it wasn't required to do an EM rotation--could do urgent care instead which I did. Guess what? I always felt weak in handling emergencies until I made myself work EM the past 4 yr. (Rest easy though...ARC-PA has changed the Standards and now specifies that EM must actually be hospital-based. Also, in our ED, docs rarely suture and the PAs do the vast majority of closures...we also rarely call plastics as they're nigh impossible to persuade to come in, although for a case such as you mentioned I'm sure they would.)

how did you have a 16 day er rotation? hasn't the paea standard always been at least 1 month? we have np students who do 1 week em rotations but not pa's...they all do 4-6 weeks and many come back for an elective...

[icthus13]

I think my experience with suturing is fairly typical. All of my students suture 3-44x/day x 5 weeks...i sutured on 4 rotations( em, surgery, peds, em elective).

And I+D's...several/week x 5 weeks.

 

 

Yep, same here...suturing and abcesses all day, every day on my EM rotation. For me it was like 5-6 abcesses/day; suturing was at least that much.

 

I also sutured on EM, surgery, FP (very, very rural--did lots), and OB-GYN. Did ABG's on EM and inpatient IM.

 

And I was in an urban program...I think I got a good experience in general.

[HopefulPA]

I only got to do 1 I&D and Throw 2 sutures in my surgery rotation (mostly staples used). In my ER rotation they let me "watch" an I&D but I did get more suturing (only on adults and nonfacial) a few splinting. If I have decided to do my final 2 month preceptorship in FP or IM that would have been my experience. I also have NEVER done a pap smear period and no pelvics on my OB or FP rotations. I did assist the doc in FP with the pelvics but wouldn't let us do it. On my OB/Gyn I did get to assess for efacement/dilation and deliver some babies but the second half of the rotation was all GYN surgery no clinic days. Thankfully I decided to do my preceptorship in a inner city ER. Pretty much in the Fast Track areas and did lots of I&Ds, pelvics, eye stuff and suturing, however only 2 splints one of which I only assisted ortho in 2 months.

 

You have to remember first you can only see what pts come in with. Also with the lack of preceptors often there are multiple students (med and PA and NP) on a single rotation. I had 3 other students on my team for surgery, OB, FP rotations. 1 other student on my IM and Psych rotations for my ER, Peds and ER preceptorship I was lucky to be the only student but could have easily had other students on the rotations which would automatically equate to less opportunity to do proceedures.

[brookspa]

, da dahhh , when i was a nurse in a small rural, i not the doc ,did most of the suturing...people tend to get to do what they are good at.

[chiaroscuro27]

heme- all 3 of my em preceptors( em, peds em, em elective) pretty much let me grab and work up anything in the rack and do any procedures I wanted to. sounds like you got short changed. my trauma preceptor let me put in chest tubes, intubate, etc

 

I surely hope I'm allowed to get my hands dirty come clinical year. One suture job is not enough! I'm counting on getting preceptors like the ones you had, Emed.

[klb48]

I have to agree that unfortunately not everyone gets an amazing experience on clinicals in pa school OR med school. I got my fill of suturing but only ever did one I&D and it was in the OR and I didn't even get to do it completely by myself because the surgeon was also a control freak and I wasn't breaking loculations up fast enough for him. I've never done an ABG, ingrown toenail, or digital block. I did luck out at one of my elective ER rotations that I set up and get to do a few intubations, one lumbar puncture, and one femoral line. But at my core rotations I barely got to do anything because of preceptors afraid of liability issues or just too controlling over their patients. (didn't do a single pelvic or deliver a single baby during my ob/gyn rotation).

 

EMEDPA- I wish I would have been as lucky to have wonderful rotations like you did! I hope you continue to precept students and let them get their hands dirty! But I do think that a 2nd year resident should have at least done an I&D....something is definitely wrong with medical education if he can go 3+ years in clinicals without doing that.