Banging my head against the (proverbial) wall…yet again

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Banging my head against the (proverbial) wall…yet again

by Kimberly Spering, MSN, FNP-BC - March 29, 2010

Provided by Clinician 1

There have been a lot of news articles about the lack of physicians in primary care...and a few that have mentioned how we Nurse Practitioners and Physician Assistants can fill the role for a “medical home” for thousands of patients. Of course, there are many detractors who bemoan that we mere “assistants” and “nurses” do not have the training or experience to do such a job. Yet we know that multiple studies prove we are competent providers for primary care.

Many of us may have been involved in teaching NP or PA students over our career. I have precepted many students over the past 20 years...the first 10 for two ADN nursing programs, the last 10 for multiple NP programs...and I taught as an adjunct clinical faculty member for three years prior to that. Many of my NP students excelled, were motivated, and were representative of the profession in the best way possible. Some of my students were just so-so…

And then...on the flip side, I had a few students who made me cringe. And I hoped and prayed that they will NOT be representative of the REST of us who really DO know what we are doing…

So...what the heck makes a “good” student?

Is it the willingness to learn? Textbook acumen? The ability to adapt? Flexibility? Politeness? Charisma? Astuteness? All of the above?

YES!

It’s not only all of these characteristics, but mostly, it is the ability to CRITICALLY THINK! Put the pieces of the puzzle together, come up with a diagnosis and treatment plan, and go for it!

C’mon...let’s face it. When you do what we do, 90% of our diagnoses (rough average) come from a history. Our physical assessment affirms our suspicion much of the time...diagnostic testing confirms it SOME of the time, but our ability to ferret out (I like the phrase “being a detective") the issues is the REAL key to what we actually DO.

I once had a student...she was very nice, good with patients.

She could NOT put two-and-two together without a map. Complete with step-by-step direction from me...all while having multiple prior clinical rotations in Family Practice, Internal Medicine, and Geriatrics before stepping into my office.

After multiple weeks of banging my head against the proverbial wall, I posted my frustrations with this particular student to a bunch of NP friends I know. As a result, I had been advised by some people (whom I consider great mentors)...DROP HER and get remediation ASAP. While I respected them greatly...and would have done so in a flash...it was not just up to me, but my boss as well. I tried like heck to give her the benefit of the doubt, and we kept her on...but my patience wore thin. She had not yet seen any of my “usual” high-risk Internal Medicine patients...just the low-risk cough-and-cold variety patients for “sick” visits.

She had the clinical lecture didactic the prior semester for management of the health issues: diabetes, hyperlipidemia, hypertension, etc. Hadn’t yet had to “manage” these issues with me in practice, mind you. Lord knows what she would have come up with, since she couldn’t choose an appropriate antibiotic therapy for a prolonged sinusitis...but I digress. The other issues that were missed included failure to appropriately examine patients, misunderstanding pathophysiology, lack of knowledge about medications, and generally, not making connections between which tests to order and how to interpret them. She saw only about five patients per day...and I still fell behind trying to catch her up.

Was I once this naive? I really don’t think so. Remediation came and went. We did not pass her clinically, as we felt she did not meet criteria set forth by her program. Her instructor asked us, would we be willing to keep her at the office through the rest of the semester? We were not. Enough energy and time had been expended. She was intimidated by the environment, and we all agreed that she would do better elsewhere. I felt bad...but I wanted her to have a chance to succeed with someone.

The questions I asked myself were: What more could I have done more to help her? I’m not really sure, since the first ten weeks had not enlightened me...despite my prior teaching experience. As a working NP, I did not feel it was my responsibility to teach her the basics of clinical practice...even though I tried. Oh, I tried.

Interestingly, some of the postings from my colleagues (some of them being recent graduates) stated that I needed PATIENCE in dealing with students. Um...ten years ago, I would have FAILED my rotation, had I been like that. Or maybe failing is no longer acceptable in academia. I would have deserved it, too.

I love teaching and precepting students, and I hope to do it for a long time. However, if we are to be considered skilled clinicians, right up there among our physician colleagues, we had better hold up our end of the bargain. If we as NPs (and PAs) are to be recognized as ably-practicing providers, we’d better be able to cut the mustard…

Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA. Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings. She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs. She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health. She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.

The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

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Comments Add Your Comments

frustated PA-S (Manchester, NH)	on 12 Jun 2010 at 4:48 am

What if your program (PA) didn't teach you several clinical skills because it's their philosophy that you teach yourself (they actually don't have a clue what the hell they're doing) Also, how are we expected to learn from preceptors who can't stand PA's (outright tell us that), and who only let us shadow? If this is acceptable PA education then I picked the wrong profession

Luz Sarmiento-Giordano PA-C (Bethesda, Maryland)	on 04 Apr 2010 at 11:00 am

I understand where Kimberly is coming from. She sounds like a very caring health care provider. Sometimes it is NOT the preceptor but the student. I have precepted PA students for over 10 years. I don't think there are a lot of students as Kim describes out there, but as preceptors it is our obligation to try our best and teach them. Then take a step back and realize IF the student is just not ready to move forward. Yes some students do need more time to learn, but not at the expense of our patients. It sounds to me like this student needed to repeat several of her rotations, but everyone just felt bad for her and moved her along. I think that is wrong. She will eventually graduate and make us all look bad while she acclimates to the job and learn on the job, what she should have learned as a student.

Martin Joyce (Home)	on 31 Mar 2010 at 7:45 pm

HI Kim Thanks for highlighting your experience and your conundrum. I have been a PA for almost 28 years. I Have taught Physical Diagnosis and been a precepter for surgical rotations. I am currentlyworking in cardiac surgery primarily in the OR.I have had to deal with students like you described. I hve tried to say to myself would I want this person taking care of me or my loved one. I think you have to decide if the student is really trying. but sometimes everyone needs a teacher/mentor to inspire them. It sounds to me that you really care about not just patients but about the future of health care. Marty Joyce

el gorrion (colorado)	on 31 Mar 2010 at 5:25 pm

I don't really get the point of the part about the bad student. Everyone knows everyone has bad students. Is Mrs. Spering just griping? Is she also trying to tell us that she thinks she was an awesome student? I wonder if Mrs. Spering ever considered that maybe she and the student had a dynamic that would never work. I also wonder if Mrs. Spering has ever done any real hard self-reflection on how she thinks she was with all of her student experiences? There's a good "Scrubs" episode on this very subject titled "My student" from season 1.

Jane PAC (rural FP in Wisconsin)	on 31 Mar 2010 at 10:24 am

Thanks to both of you for your comments. In particular, the frustration of Kim, obviously someone who spent a lot of time with this unfortunate student and also a mentor who devoted much time attempting to help her. Jared's comment was also right on, that we all are students. As a preceptor for 6 years and PA for 31, I still am learning every day every patient. Thanks to both of you for caring enough to communicate your styles and expectations to your students. Your blogs have helped me to continue pressuring the reticent student to take on more, but the patience to understand those students who learn in different ways. Most of my students have been wonderful but the occasional PAS with a learning disability or expectation to go home early or be handed good grades because of previous experiences, have been issues. Mostly I learn from my students the fact that I will always be a student of medicine and the art of a good history is the key. Keep teaching and learning. However there probably is a point when a year off is appropriate when the preceptor's life becomes too complicated to teach or it doesn't seem fun anymore. Thanks for your comments! Jane

Jared	on 30 Mar 2010 at 11:10 pm

I think half the battle is that most preceptors don't have a clue what to do with students, and many students truely do learn differently, or in different ways, some of which is based on a prior career. I think precepting and preceptors in general, lack a standard of things students in APC training should be doing/seeing. Confidence is another issue that I had as a student. While I was confident in life, my previous career in medicine, and talking with people in general, I didn't have my own sayings, ways of educating patients, and general flow of exams down because I've not seen thousand's of patients like some of you have over 10-30 years in the field. One could say the same of procedures. Sure we can put in sutures or put on casts, the ability of suturing a few times in rotation doesn't prepare you for some types of lacs coming in the real world, some that create uncertainty about the best way to close. I think at best, APC programs job is to prepare you for further/closely guided training in the real world. You get baseline education at best, and a lifetime to continue to learn as you go with the steepest curve right away out of school. Even in my early career, I still feel like I don't know anything on the job, until I've seen is a few times and can recognize it later. And prescribing antibiotics is sort of past experience (we have none as students), combined with EBM recommendations, and of course, your supervising physician influence of what they prefer you use if you're not independent. Working w/ multiple physicians further increases confusion because they too, recommend certain ab use based on their own knowledge which differs amongst providers. All in all, I think its very important for students and preceptors to sit down for 20 -30 minutes before the start of any clinical rotation, and assess each other for desires to learn, procedures to be carefully watched and trained, and general knowledge base about clinical conditions (anatomical/physiological), and where the student is in their learning curve (1st vs 4th rotation) and ability to see patients and critically think alone. I very rarely was asked by my preceptors to develop my assessment/plan, present to them as a 4th yr or medical resident student does. It was almost as if some physicians didn't know what to do with a PA student. Then I did have a great Internal Med preceptor who used me as an employee, seeing consults in the ED for admission, and writing up H and P's as we would in the real world. Of course, he followed up later with the patient and examined them, compared my notes to his findings, and then dictated using some of my written notes in the chart. I did learn a lot of routinely needed skills in that rotation, but my only complaint is that there was no time for great feedback because EVERYONE is so busy, there is no time for teaching anymore. Its a lose/lose situation that needs to be worked on for the future of our profession.