Is Clinical Precepting a Lost Art?
Over the past two decades, our changing health care environment has increased both interest in and the need for NPs and PAs as providers. Nursing and PA educators have responded by significantly increasing class sizes. This, in turn, has led to a greater demand for quality clinical preceptors. The preceptor/student relationship is at the very core of the growth and development of NP and PA students. Most clinical preceptors are unpaid volunteers, despite the fact that the time they spend teaching students can lengthen their workday and decrease their productivity as clinicians.
The other day, I was shocked by the response from a potential clinical preceptor for our students. He asked, “What’s in it for me?” Now, I realize that the daily demands of clinical practice are quite overwhelming. With admissions, emergencies, and complications, not to mention the daunting business aspects of managing a practice, even the most skilled and efficient clinicians are seriously challenged. That’s certainly one explanation for the response I received.
But perhaps there’s another explanation. Could it be that the insidious commercialism or deprofessionalism of medicine has changed clinicians’ attitudes? Do we have a new generation of providers who either by choice or by burnout have become jaded and given up on the “pay it forward” philosophy? Tell me it ain’t so.
Even under the best of circumstances, time is a major factor in the clinician’s world. It would be an understatement to say that clinical preceptors who have volunteered to train a PA or NP student have their work cut out for them. Still, I would hope that this potential preceptor’s self-serving question is not a typical response. And yet, to be frank, I keep hearing similar comments. There is even a movement afoot for group practices, hospitals, and HMOs to start charging for precepting a student to recoup lost revenue. Word is that this will soon become standard practice.
Could it be that precepting will soon become a lost art? Is it realistic to think otherwise? Is there anything that could possibly replace it? If we assume that paying for clinical rotations is inevitable, do we ignore it and avoid it as long as possible? Or do we jump in now and try to create the best deal possible for our students?
Of course, entering into a financial contract with a preceptor brings a new level of obligation for both parties. There is also the worry that the cost of future clinical rotations may roll over into increased tuition for students.
I can’t help but think back (yes, it was another century) to my student days and the dedication demonstrated by physicians and NP and PA preceptors. They all wanted to give something back to their profession for the benefit of their patients and society as a whole. They all spent the time needed to make sure the student received the best experience possible—and all of this without asking for compensation. What has changed over the years?
It’s true that clinical preceptors today often don’t have the means or the workload with which to create an ideal environment for student learning to take place. In fact, they may have no control over that if they are employees or contractors. In a perfect system, clinical preceptors would have less work to do themselves and more time to prepare for the teaching process. Unfortunately, that is not a realistic expectation in today’s health care system.
Educators feel that precepting students exemplifies the highest principles of clinical education. Clinical preceptors must be confident in their clinical and teaching skills and generous with their time. Perhaps learning how to better utilize their time will enhance the precepting experience.
An article entitled “A Five-Step ‘Microskills’ Model of Clinical Teaching” was published in the Journal of the American Board of Family Practice in 1992. This article formed the basis for what became known as the “One-Minute Preceptor” approach to effective clinical precepting, and it has been modified and changed over the years. In general, this model offers the following tips for efficient instruction:
1. Get a verbal commitment from the student to an aspect of a case. Ask questions such as “What do you think is going on with this patient?” or “What other diagnoses would you consider in this setting?” The act of stating a commitment pushes the student beyond his or her comfort level and makes the teaching encounter more interactive and personal.
2. Probe for a rationale. Determine if there is an adequate rationale for the student’s answers to your questions. Encourage an appropriate reasoning process.
3. Reinforce what was done well. Positive comments should focus on specific behaviors that demonstrated knowledge, skills, or attitudes that you value as a preceptor. At the same time, it is important to tell the student what areas need improvement in as specific a manner as possible.
4. Teach a general principle. Take the information and data gleaned from an individual learning situation and apply them as a broader concept to other situations.
5. Provide closure. Time management is a critical function in clinical precepting. This final step serves the very important function of ending the teaching moment and defining what the role of the student will be in the next precepting opportunity.
Busy clinical preceptors have welcomed this strategy. The problem with clinical precepting, some say, is that too much time is spent on the nonteaching aspects of preceptorship and the whole process isn’t structured to facilitate effective teaching.
While precepting students can be an enjoyable activity, there are pitfalls that can be anticipated and perhaps even avoided to enhance the experience. Paulman, Susman, and Abboud, editors of Precepting Medical Students in the Office (2000), make the following suggestions:
• Don’t agree to precept a student when you are overcommitted and stressed.
• Don’t hesitate to discuss mutual expectations for the preceptorship.
• Don’t try to teach too much.
• Don’t have students just follow you around. Give them specific tasks to do while you see other patients. This tends to stimulate and vitalize them.
• Don’t make assumptions about your students’ knowledge.
• Don’t assume that documentation by students is adequate or appropriate.
• Avoid subtle putdowns of a student in front of the patient.
• Don’t hesitate to mention issues that are a source of significant annoyance. (For example, a student’s behavior, dress, or personal hygiene may cause irritation or frustration. Deal with it early on.)
With the number of NP and PA students on the rise, there is a greater need than ever for more qualified and dedicated preceptors. If you are not currently a clinical preceptor, I hope that you will consider calling your local NP or PA school and volunteering. If you are already a preceptor, thank you. And let us know what can be done to make your experience better.
I would love to hear from you on the issue of clinical precepting. Please e-mail me at PAeditor@qhc.com.