Is 2 years enough to become a competent clinician?

[EMEDPA]

nope, but there should be. the marker of a quality program should not be pance scores it should be evaluations done by sp's (or senior PAs) of first yr competence.

this would clearly show those with more hce require less sp involvement in cases.

I have worked with PAs for over 25 years and can always tell who had prior experience and who did not. those with experience are comfortable in health care settings, know the language of medicine and know how to think on their feet. many non-hce new grads look like lost kids their first yr or more in practice and are constantly checking EVERYTHING with their sp and other senior PAs on the service. some questions are ok and appropriate. not knowing the basics is not. a new grad should not require spoonfeeding, just some direction.

[EMEDPA]

. Question becomes about time management/efficiency: What would make you a better clinician in 5 years time?.

there is no reason you can't do school and part time work at the same time. I graduated college in 4 yrs with all pa school prereqs done AND accumulated several thousand hrs of paid hce during the same time period. I worked 26 hrs/week as an er tech during the school yr and 60 hrs/week during the summers.

[GatorRRT]

Methinks it hasnt been done because it wouldn't be in the best interest of programs to have enrollment drop. A sad truth.

[EMEDPA]

yup. also hard to do the study and "blind" the SPs and senior PAs doing the evaluations. it would be fairly obvious right from the start which grads were from which groups.

you could look at productivity as a single indicator but then you would also have to control for level of difficulty. a tough study to do.

[Teasip]

The delay: He was a new patient and I saw him for the leg pain, determined it was sciatica. Treated, then in follow up (second visit) he was better. Third visit: symptoms back, after his trip to California, where he was completely symptom free, I saw him again, used the medrol dose pack and discussed the next step was MRI. He has diabetes, so didn't use medrol at first visit, and then we also discussed the diabetes as at this visit. The final visit was when the pain came back so severe it disabled him for a few hours, and i ordered the MRI. We are rural, so the length of time between visits is part of the reason for the delay, as he lives 45 miles away in another time zone, and it represents some of the challenges working in isolated places. Even getting appropriate care is a challenge and he now gets his chemo/radiation in a different state.

 

Gotcha. It was always a tough sell to our clientele (especially high profile celebrities, including professional athletes) that even if subjective symptoms have resolved BUT you still exhibit evidence of motor deficit from nerve root compromise, then you are still a potential surgical candidate due to the progressive decreased likelihood of return of normal motor function as further time goes by. The Medrol concern certainly makes sense in the diabetic but as with everything else we deal with, it comes down to risk versus reward (and it isn't always crystal clear which to go with). FYI, one of the modifications that we went to based on cost for name brand Medrol was to taper prednisone 60-40-20 mg. over a nine day window. This time window also mimics the duration of action of an injectible corticosteroid such as Decadron without the minimal risk of complication (infection, striking a nerve, sterile abscess, etc.).

[Contrarian]

What I have always found troubling and indicative of the misguided "2 yrs makes me safe and ready/competent" notion is the regular posting of new threads by new grads selling all of their books and study material simply because they passed a 300 question multiple guess exam (PANCE).

 

Its like they are saying...

'I passed the program and answered 300 questions... so I know everything I need to know.

There will be NO need to review regularly, NO need to read daily. Even though I had no previous HCE, memorized enough medical terminology and acronyms in my first semester to get me by, and graduated with averge grades, I can sell all my books because that short 2 yrs of exposure fully prepared me to be responsible for peoples lives.'

[Timon]

What I have always found troubling and indicative of the misguided "2 yrs makes me safe and ready/competent" notion is the regular posting of new threads by new grads selling all of their books and study material simply because they passed a 300 question multiple guess exam (PANCE).

 

Its like they are saying...

'I passed the program and answered 300 questions... so I know everything I need to know.

There will be NO need to review regularly, NO need to read daily. Even though I had no previous HCE, memorized enough medical terminology and acronyms in my first semester to get me by, and graduated with averge grades, I can sell all my books because that short 2 yrs of exposure fully prepared me to be responsible for peoples lives.'

 

i would suspect a new grad should approach their first 5 to 6 years of practice the same way a new grad physician would. Meaning continuing their studies for some years after graduating while practicing. Then they take the PANRE and continue to keep themselves updated on new techniques, research and etc. Is that the proper way to go about this? I ask after seeing family members during their early years as physicians and I would suspect PAs wouldn't be exempt from this regardless of the fact we are "supposed to hit the ground running."

[Guest JMPA]

Cost ALWAYS has a place in EVERY medical discussion. The fact that we have not done that for years is why we have the problems we do now.

 

Not every murmur needs to be chased down.

 

Remember, even life has a defined value. VSL (value of a statistical life) is somewhere between 5 and 9.1 million dollars. Which is how we calculate whether a new technology is worth it. IOW, if you could save 10 people by using a new technology, but it would cost more than 100 million dollars, than it is not worth doing. If you could save 10 people and it would only cost 40 million, than it is likely worth doing. In economics, these discussions occur all the time. Sounds callous....but life does not have a limitless value.

 

Cost always matters.

if it was your child i wouldnt do a workup

[Contrarian]

... [brevity edit]... Is that the proper way to go about this? ... [ brevity edit]...

 

Yes... but how does one do that if they sell all their books and review material the day after they get their PANCE results back... ???

[EMEDPA]

i would suspect a new grad should approach their first 5 to 6 years of practice the same way a new grad physician would. Meaning continuing their studies for some years after graduating while practicing. Then they take the PANRE and continue to keep themselves updated on new techniques, research and etc. Is that the proper way to go about this? I ask after seeing family members during their early years as physicians and I would suspect PAs wouldn't be exempt from this regardless of the fact we are "supposed to hit the ground running."

a lot of this really depends on the field a new grad goes into. if it is a primary care field or em it is a lot easier to stay abreast of material needed to be prepared for panre.

if you go into a surgical or medicine subspecialty field it is much harder as you are mostly exposed to urology or derm, etc

I generally recommend folks go into a primary care field or urgent care/em right out of school unless they are sure they want to spend their entire career in surgery or the subspecialty of their choice. if you go straight into endocrinology(for example) it is hard to retain all the stuff you learned in school about peds, obgyn, psych, etc

if you work in primary care or UC/EM, every day and every pt is prep for panre.

[WanderlustPA]

There are doctors that aren't competent clinicians. A couple years ago my mother was mis-diagnosed as having a back issue that was causing pain in her leg, when in fact she had a torn meniscus. Good thing she went for a second opinion. From what she said about the first doctor, he didn't seem to really care or listen to her. I imagine the time it takes for one to be competent is different for everyone, and for some it may never happen. Let's face it, some people are incompetent in life in general! ;)

[Gordon, PA-C]

There are doctors that aren't competent clinicians. A couple years ago my mother was mis-diagnosed as having a back issue that was causing pain in her leg, when in fact she had a torn meniscus. Good thing she went for a second opinion. From what she said about the first doctor, he didn't seem to really care or listen to her. I imagine the time it takes for one to be competent is different for everyone, and for some it may never happen. Let's face it, some people are incompetent in life in general! ;)

 

That's true, but it is also irrelevant. More clinical training/experience doesnt GUARANTEE anything, but its a better standard than nothing.

 

Some providers will be incompetent even if they have 25 years of HCE or do a residency that lasts 10 years. That doesnt mean that clinical experience/training is irrelevant.

[physasst]

if it was your child i wouldnt do a workup

 

Well, that's making it rather personal. I would ask however, if you were her provider, is it necessary? I do that now with every one of her providers, if they say yes, I don't second guess them. I don't manage my families medical conditions, but I do try to shield them from the healthcare industry as much as possible.

 

We had a visiting cardiologist not long ago give rounds. He discussed a young 19 year old male who was very, very fit and presented for a sports physical. The patient had a murmur, so underwent TTE, there was thought to be some wall motion abnormalities, but it wasn't conclusive, so the patient underwent a functional study. Apparently, there were some ECG changes noted, and the patient was admitted to the ICU. Eventually an EP cards guy saw the ECG and dismissed the patient as it was nothing more than a normal variant.

 

This cardiologists advice to our whole audience? Don't even listen to hearts on asymptomatic healthy patients who present for a physical. It's a waste of time, and all you are going to do is find a bunch of benign murmurs for that rare, once in a blue moon real one. Now, he said, that changes if the patient is having symptoms. Shortness of breath, fatigue, etc. But asymptomatic....he thinks we're wasting our time and money.

 

Last night, there was a good show on CNN, "Rescuing Healthcare". It was interesting how Nissen, a top cardiologist at Cleveland Clinic advises against coronary stenting with the exception of patients having an acute MI. He said it's not proven to extend life, improve life, etc. Only to make interventional cardiologists rich.

 

The point is not that we should NEVER do testing, or that all testing or procedures are bad....not at all. The point is, that we all as providers are also keepers of the money, and that we have not only a moral obligation to care for our patients, but a financial obligation to spend their money wisely. How we reach that balance is of course the difficult thing. Cost always should be in the providers mind. It should not overrule everything else, but it shouldn't be neglected either.

[Hemegroup]

Well, I spoke to my SP about this who asked me to bring the child back for him to double check simply for my own peace of mind. He laughed when I told him about the reactions here, stating that a grade 3 blowing murmur would have been a different story but that since I was concerned (due to your egging me on) he'll do a second listen. I asked him when it will stop that others could make me doubt myself and he said that he couldn't tell me. I guess if and when he confirms that there was no murmur, then you'll be satisfied. I don't think this conversation was necessarily a bad thing, but ventana does have a history of attacking so I'm glad to see that at least this time he was civil with his suggestion. My SP did say that unless there was some type of obvious murmur on auscultation that an echo would not be necessary.

[Contrarian]

... My SP did say that unless there was some type of obvious murmur on auscultation that an echo would not be necessary.

 

Yes... until the supoena arrives, bites you in the azz and he shoves you under the bus... !!!

 

WE are NOT Physicians. Let them be cavalier while we continue to practice to the local/normalized "standard of care."

Which is what we WILL be evaluated against should it come to that...

When it changes... you change what you are doing.

[Hemegroup]

Yes... until the supoena arrives, bites you in the azz and he shoves you under the bus... !!!

 

WE are NOT Physicians. Let them be cavalier while we continue to practice to the local/normalized "standard of care."

Which is what we WILL be evaluated against should it come to that...

When it changes... you change what you are doing.

 

Okay, and that's all fine and well, but what if I was working rural solo? I guess in that case then the only answer is do the best you can and hope for the best outcome. ACTUALLY, that's where the electronic with recording capability could come into play, so that you can send the audio to your SP for confirmation. I didn't go for that option but I would have if it was that type of work situation.

[PACProvider]

What should the public, physicians, hospital management and insurers conclude from these discussions? There are two schools of thought here. One school, the experienced masters with most experience and credibility, argues that PA schools produce less competent graduates if those newly minted PAs did not have prior HCE. The other school, a growing minority of younger, less experienced PAs and adcoms, argue that PA schools produce graduates of suitable competence to begin work as supervised clinicians without prior HCE. If there is a growing trend toward admitting students with lesser amounts (or no prior HCE), then these two groups are working at odds with one another to the overall detriment to our profession. That is to say, if physicians, hospital management and insurers subscribe to the view articulated by the experienced cadre that argues that the absence of prior HCE produces incompetent practitioners, then wouldn't one conclude that these groups should come to rely less (and hire less) PA graduates? It would seem that one group here actually does harm to another group.

 

Before we make definitive conclusions based on our individual judgment and experience, I wonder if research would produce a more reliable (or interesting) result. Again,I emphasize the importance of national leadership that shapes the messaging for each and every PA. The RNC does this for Republicans. The DNC does this for Democrats. Perhaps it is time for us to have our talking points consistent.

[medic25]

This cardiologists advice to our whole audience? Don't even listen to hearts on asymptomatic healthy patients who present for a physical. It's a waste of time, and all you are going to do is find a bunch of benign murmurs for that rare, once in a blue moon real one. Now, he said, that changes if the patient is having symptoms. Shortness of breath, fatigue, etc. But asymptomatic....he thinks we're wasting our time and money.

 

As the father of a child with congenital heart disease, I would hope that those in pediatrics don't subscribe to this advice. My daughter was a healthy, asymptomatic 4 month old when her diagnosis was made, allowing for early surgery. If her pediatrician had waited until she was symptomatic before listening to her heart, she would likely have faced a much poorer long-term prognosis.

[physasst]

As the father of a child with congenital heart disease, I would hope that those in pediatrics don't subscribe to this advice. My daughter was a healthy, asymptomatic 4 month old when her diagnosis was made, allowing for early surgery. If her pediatrician had waited until she was symptomatic before listening to her heart, she would likely have faced a much poorer long-term prognosis.

 

He was referring to older patients, I don't think, at least from what I can remember him talking about, that he was referring to infants or toddlers.

[Teasip]

Yeah, but it's missing that blue moon that bites you, and more importantly, the patient. How could one possibly sign off on a letter of medical clearance for whatever without listening to the heart? That one would be indefensible. It's one thing to miss something that doesn't matter (strep throat nowadays) as opposed to congenital CV disease. I guess we shouldn't look for coarctation of the aorta either. On a side note, I'm amazed at the CV folks that don't assess for fem bruits pre/post line placement/removal assessing for aneurysms induced by intimal separation during insertion. My, how things have changed.

[WanderlustPA]

What should the public, physicians, hospital management and insurers conclude from these discussions? There are two schools of thought here. One school, the experienced masters with most experience and credibility, argues that PA schools produce less competent graduates if those newly minted PAs did not have prior HCE. The other school, a growing minority of younger, less experienced PAs and adcoms, argue that PA schools produce graduates of suitable competence to begin work as supervised clinicians without prior HCE. If there is a growing trend toward admitting students with lesser amounts (or no prior HCE), then these two groups are working at odds with one another to the overall detriment to our profession. That is to say, if physicians, hospital management and insurers subscribe to the view articulated by the experienced cadre that argues that the absence of prior HCE produces incompetent practitioners, then wouldn't one conclude that these groups should come to rely less (and hire less) PA graduates? It would seem that one group here actually does harm to another group.

 

Before we make definitive conclusions based on our individual judgment and experience, I wonder if research would produce a more reliable (or interesting) result. Again,I emphasize the importance of national leadership that shapes the messaging for each and every PA. The RNC does this for Republicans. The DNC does this for Democrats. Perhaps it is time for us to have our talking points consistent.

 

Very well said! I am a part of that younger (although I'm not THAT young) group. I do have life experience, so perhaps that is quite different from someone who goes straight from undergrad to PA school and out to work without any real work experience. I would also like to see some research on it. I don't doubt that someone with QUALITY HCE may be better equipped to hit the ground running right out of school, but within a few years I'd be willing to bet the gap has been completely closed (if even that long). I emphasize the word quality here, because at least from the schools I looked at and some of the accepted HCE, I can't imagine it would make a difference at all. One even said their reason for requiring HCE was so the applicant "showed a commitment to the application process." If research found that experience was statistically significant in performance, then perhaps implementing a one year residency into PA school would allow those without prior experience to still take the PA path. While the PA profession was started as a 2nd career, it is clear that in today's world it is turning into more of a 1st career, or at least a 1st healthcare career, as is the case for me. It doesn't make sense to limit PA school to people who have experience as paramedics or nurses (just two examples). That would severely limit the number of applicants, plus you would get a lot of people going through nursing or paramedic school, not because they want to be a nurse or paramedic, but because they need the experience to get to PA school. That also takes away seats from people who actually want a career as a nurse or paramedic.

[BroncoPAS]

That is to say, if physicians, hospital management and insurers subscribe to the view articulated by the experienced cadre that argues that the absence of prior HCE produces incompetent practitioners, then wouldn't one conclude that these groups should come to rely less (and hire less) PA graduates? It would seem that one group here actually does harm to another group.

 

Keep in mind that this site represents a VERY small portion of the profession and is over-represented by the polar extremes (as is the inherent nature of most internet message boards). The many PAs that I know are very level-headed, rational and intelligent professionals that reflect positively on the profession. Some had little HCE prior to PA school and some had much but they all function at a competent level and most have never even heard of this website...thank goodness.

[Contrarian]

I think a point being MISSED by most of the folks getting their panties bunched up is that the folks answering the question... is actually answering the question as asked by the OP...

 

"Is 2 years enough to become a competent clinician?"

Now their feelings are apparently hurt because they are being told NO it isn't...

 

The folks upset by this don't have any or have very little HCE and therefore have nothing to compare their lack of it to.

 

These folks will eventually catch up... but it will take a while. Meanwhile, these folks haven't seen or heard the little jabs and stabs that may indicate the decline in stature of OUR profession (in the eyes of some physicians) due to the consistent decline in the understanding of the nature of medicine in recent graduates of our 2 yr programs.

 

Again... we REGULARLY have threads here that indicate that many of theses new grads think its over and done with... and that they can sell all of their medical reference and review material, and collect $90k as soon as they get their PANCE results back.

 

Thing is... the answer is still NO ... going from 0 healthcare experience AT ALL to 2 yrs of PA School IS NOT enough to make a clinically competent provider/clinician.

 

If it was... Physician school would be 2 yrs long with no residency required.

 

The idea that having some prior HCE BEFORE PA school helps soften this steep curve a bit and moves someone towards--->>> competence faster should NOT be surprising nor should this be disputed.

 

Its really simple. That minimal 2 yrs of PA school DOES NOT provide competence, it provides exposure and a road map. It's the experience that does this. When that experience comes is really the issue. This is especially so if the new grad touched their first ever real patient the second yr of their PA program.

 

I've read NOWHERE on this site that someone has said that PA-Cs with NO prior HCE will NEVER become competent. What I understand being said is that when comparing the performance of the two... the one without experience will be starting from a different set of blocks and be mildly hobbled when the start gun is fired. They will eventually catch up, but it will take a while.

 

One problem is... if you take a NEW GRAD PA and a NEW GRAD FNP and they apply for the same job... in a LOT of places, the FNP will get the nod. Why, because Most of the time, the NEW GRAD FNP will be able to display a level of clinical competence/or comfort that a NEW GRAD PA without any other clinical experience outside of PA school just won't be able to muster.

 

Also I keep seeing IPAP brought up... but IMNSHO, comparing those applicants and their potential patient population to the regulars that apply to civilian programs is like comparing apples and... ummm ...wing-nuts...

 

For you military folks...

Why do you think that the Combat Arms MOS's have such a easier time in Hoooah Schools than the Support folks...???

Previous exposure and experience maybe...???

 

Why was the top marksman in Basic Training consistently the "Country Boy/Girl" who grew up shooting to fill the freezer...???

Previous exposure and experience maybe...???

Now the other folks/trainees in the company would eventually catch up and be just as able with their weapon, but initially... that country boy/girl would SMOKE any one of their "peers" in weapon handling/marksmanship skills.

[pa2007]

Rev Ronin-

How long have you been practicing as a PA?

[Moiraine57]

I think a point being MISSED by most of the folks getting their panties bunched up is that the folks answering the question... is actually answering the question as asked by the OP..."Is 2 years enough to become a competent clinician?"Now their feelings are apparently hurt because they are being told NO it isn't...The folks upset by this don't have any or have very little HCE and therefore have nothing to compare their lack of it to.These folks will eventually catch up... but it will take a while. Meanwhile, these folks haven't seen or heard the little jabs and stabs that may indicate the decline in stature of OUR profession (in the eyes of some physicians) due to the consistent decline in the understanding of the nature of medicine in recent graduates of our 2 yr programs.Again... we REGULARLY have threads here that indicate that many of theses new grads think its over and done with... and that they can sell all of their medical reference and review material, and collect $90k as soon as they get their PANCE results back.Thing is... the answer is still NO ... going from 0 healthcare experience AT ALL to 2 yrs of PA School IS NOT enough to make a clinically competent provider/clinician.If it was... Physician school would be 2 yrs long with no residency required.The idea that having some prior HCE BEFORE PA school helps soften this steep curve a bit and moves someone towards--->>> competence faster should NOT be surprising nor should this be disputed.Its really simple. That minimal 2 yrs of PA school DOES NOT provide competence, it provides exposure and a road map. It's the experience that does this. When that experience comes is really the issue. This is especially so if the new grad touched their first ever real patient the second yr of their PA program.I've read NOWHERE on this site that someone has said that PA-Cs with NO prior HCE will NEVER become competent. What I understand being said is that when comparing the performance of the two... the one without experience will be starting from a different set of blocks and be mildly hobbled when the start gun is fired. They will eventually catch up, but it will take a while.One problem is... if you take a NEW GRAD PA and a NEW GRAD FNP and they apply for the same job... in a LOT of places, the FNP will get the nod. Why, because Most of the time, the NEW GRAD FNP will be able to display a level of clinical competence/or comfort that a NEW GRAD PA without any other clinical experience outside of PA school just won't be able to muster.Also I keep seeing IPAP brought up... but IMNSHO, comparing those applicants and their potential patient population to the regulars that apply to civilian programs is like comparing apples and... ummm ...wing-nuts...For you military folks...Why do you think that the Combat Arms MOS's have such a easier time in Hoooah Schools than the Support folks...???Previous exposure and experience maybe...???Why was the top marksman in Basic Training consistently the "Country Boy/Girl" who grew up shooting to fill the freezer...???Previous exposure and experience maybe...???Now the other folks/trainees in the company would eventually catch up and be just as able with their weapon, but initially... that country boy/girl would SMOKE any one of their "peers" in weapon handling/marksmanship skills.

I think your last example is dead wrong. Some of the best shooters were those with no prior experience, because they listened and soaked up what their instructors had to say like sponges. Some of the worst were the "country boys" who had enough knowledge to where they thought they knew it all, and gaffed off the instructorsThe highest shooter on the range when I went was a guy who had done no shooting prior to rifle range.Practice doesn't make perfect. Perfect practice makes perfect. Bad practice grooves bad habits.Prior experience doesn't necessarily speak to how good you're going to be... On the range, at least.