NP preceptor

[Slack3r]

So maybe I'm wrong, but pretty sure my MEDICAL SCHOOL clerkships should be precepted by DOCTORS not NURSES.

Am I overreacting here? Anybody else had a similar experience?

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[GUH]

So maybe I'm wrong, but pretty sure my MEDICAL SCHOOL clerkships should be precepted by DOCTORS not NURSES.

Am I overreacting here? Anybody else had a similar experience?

I think @sylvanthus did. I asked my school and they said that they wouldn't allow it, thank goodness.
You won't find any medical student here who disagrees that the clinical teaching of medical students should be led by physicians.

 

[mimelim]

As with everything, it depends on the NP. There are a lot of NPs that I would prefer managing interns/medical students over certain MDs who it would otherwise fall on.

On average, your NPs are going to know a crap ton more than a new clinical medical student. Whether they went to medical school or not is largely irrelevant. Good preceptors/teachers are good preceptors/teachers. Especially when you talk about stepping into the clinical teaching realm, things are not as cut and dry as the last couple letters after your name.

Should NPs be doing an MD's job? No. But, I don't think medical education is solely an "MD's job". I had PhDs, PharmDs, nutritionists, MDs, DOs, PAs etc teaching me as a medical student. I learned more about how to be a good resident my intern year from our service NP than I did from any of our faculty. Did I learn any surgery from her? No. Did I learn any book knowledge? Not really, maybe a little. But, how to function in a clinical setting, even as a relatively advanced intern? Nobody was better.

Likewise, when I was an MS4 on an away rotation, there was a PA that essentially ran the minute to minute management in the SICU. I would rather have him teaching medical students than any faculty that was around for certain things. Managing every last bit of education, probably not. But, certain had a role to play.

I don't think precepting a single clerkship if it was FM/IM/etc. is that crazy or bad just on virtue of them being an NP.

 

[GUH]

I don't think precepting a single clerkship if it was FM/IM/etc. is that crazy or bad just on virtue of them being an NP.

Why stop with a single clerkship then? What is the importance of having physicians teaching future physicians?

 

[mimelim]

Why stop with a single clerkship then? What is the importance of having physicians teaching future physicians?

You really don't see the importance of having physicians being a part of medical student education? You need that explained for you? There are aspects of medical education that it would be inappropriate for non-MDs to teach because they are the ones with the experience in those areas to teach it.

As the rest of my post explains, which you have cut out, NPs can certainly play a role in medical student education. Often times, they, like PAs, PharmDs, nutritionists, etc. are the best person at a particular institution to teach students particular things, whether it be a single pre-clinical class, how to function in the clinical setting or even something as broad as family medicine practice. There are plenty of terrible MDs out there as preceptors. Quick polling of the 3 other residents in our break room right now and we universally agree that we'd rather have an interested NP preceptor for an MS3 rotation than many of our MD preceptors we actually had in medical school. There are many clerkships that are not amenable to having an NP as a preceptor because nobody functions in that field the way that an MD does and it makes no sense for them to be a preceptor. An educator on the service, yes, but not as the preceptor.

Clearly medical schools would prefer to have MDs teaching and precepting everything, for some reason this one decided not to. Usually when these kinds of things happen it is a reflection of the incredibly poor MD options available to them. I would be thankful that the school was willing to break from the inertia and have an NP preceptor rather than the likely alternative, a really ****ty MD preceptor.

 

[Psai]

Yes I would rather not have a terrible preceptor but I still think it's completely inappropriate to have an np teaching medical students over a physician. You're paying to learn how to become a doctor from doctors. If you aren't learning from doctors, you need a refund because you aren't getting the full value of your education. I'm not saying that they have nothing to offer or that they can't teach but mid levels just don't have the same experiences or knowledge base and they don't perform the same functions. You don't see me teaching nurses how to do their job

 

[mimelim]

Yes I would rather not have a terrible preceptor but I still think it's completely inappropriate to have an np teaching medical students over a physician. You're paying to learn how to become a doctor from doctors. If you aren't learning from doctors, you need a refund because you aren't getting the full value of your education. I'm not saying that they have nothing to offer or that they can't teach but mid levels just don't have the same experiences or knowledge base and they don't perform the same functions. You don't see me teaching nurses how to do their job

I think that this is incomplete. Nobody is expecting an NP or any single preceptor to teach you how to be a doctor. Heck, I don't think most people are under the illusion that medical school teaches you to be a doctor. Education comes from educators. This isn't an apprenticeship. It is school. Thinking that the only people worthy of teaching medical students are physicians is problematic. How can you possibly judge that they have no roll because they have less experience or knowledge base, therefore they shouldn't play a roll in medical student education? There are highly competent NPs/PAs in many big hospitals. Do they take the place of a physician? No. Do they function as an extender, not a provider at their core job? Absolutely. But, can they effectively teach medical students and in some situations residents? Absolutely. Anyone that disagrees with that clearly has not spent enough time in a well functioning hospital.

The only question with regard to a student's education is can the educator teach them something that will further their education. Medical education isn't a bunch of classes that you take and you become competent. It takes years of experience and education coming from a lot of different angles to get a good education. People that fixate on the last two letters, and can't imagine a world where they have to be taught by people with less education then them are in for a rude awakening in the clinical world.

 

[Tired]

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[alpinism]

Other than being assigned to one NP for 2 days during my outpatient GYN rotation I haven't had any directly serve as a preceptor.


Trust me, that was bad enough.

 

[normtheniner]

I think that this is incomplete. Nobody is expecting an NP or any single preceptor to teach you how to be a doctor. Heck, I don't think most people are under the illusion that medical school teaches you to be a doctor. Education comes from educators. This isn't an apprenticeship. It is school. Thinking that the only people worthy of teaching medical students are physicians is problematic. How can you possibly judge that they have no roll because they have less experience or knowledge base, therefore they shouldn't play a roll in medical student education? There are highly competent NPs/PAs in many big hospitals. Do they take the place of a physician? No. Do they function as an extender, not a provider at their core job? Absolutely. But, can they effectively teach medical students and in some situations residents? Absolutely. Anyone that disagrees with that clearly has not spent enough time in a well functioning hospital.

The only question with regard to a student's education is can the educator teach them something that will further their education. Medical education isn't a bunch of classes that you take and you become competent. It takes years of experience and education coming from a lot of different angles to get a good education. People that fixate on the last two letters, and can't imagine a world where they have to be taught by people with less education then them are in for a rude awakening in the clinical world.

I agree with this. There is definitely value to learning from non-physicians. I learned more of the "bread and butter" of Ob/Gyn when I worked with the midwife on L&D which was totally unexpected. I've had other similar situations like that throughout medical school. I think the important thing is to be able to recognize quality teaching and not care so much about if its an MD/PA/NP/RN that is the teacher -- they all have something to teach us to an extent.

 

[Kaustikos]

Okay,
So even if the NP isn't directly responsible for your evaluation, you need to think twice about how you act around them. Especially if they work closely with the attending evaluating you. Believe it or not, but the attending may ask the NP about you. God forbid you made a bad impression because you didn't think they had a say in your eval when they do. Because the NPs and nurses and all staff do have an impact.
Besides that, why are you so against an NP working with you? Seriously, suck it up. You'll be doing it for the rest of your life and guess what? They can impact your career as a physician, too.

 

[Kaustikos]

God, I read what mimelim posts and how people respond and I want to stab my eyes. He's right about what he is saying but I guess you're not getting it.

I look at it this way:
I worked with an NP almost exclusively for one rotation. The attending is there on occasion but busy elsewhere. It's awesome because I'm doing procedures and taking care of patients with the guy. I learned a lot about clinical medicine (things residents or books don't teach you). I had fun.
End of rotation meeting with attending that he asked me to come to is him telling me about the great things the NP said about me and how well I managed things when he wasn't there.
I thanked him and talked to the NP about it and he told me what he said. He made some white lies about how I was the one managing patients by myself. I couldn't believe it but I realize what it means: if you show people some respect and work with them as a team, you'll find it pays off. Doctors are smart and know medical students try to "be their best" when they're around. Which is why it's in their interest to ask other people before evaluating you. It makes sense. Not just in my example but what if you rotated with this famous doctor hoping to get a letter and you barely interacted with him? Wouldn't you love it if the staff/residents/etc were used by that attending in evaluating you and it ended up benefiting you?

 

[mimelim]

Even an NP who is capable of teaching their limited area of expertise is not qualified to assess a student's professional growth and progression. I have learned much from mid-levels, but they should never serve as a primary preceptor judging your overall performance.

Using the excuse that "other options were poor" is unacceptable. If the options are that poor, the rotation should not exist.

Random MDs by the same standard are 'qualified to asses a student's professional growth and progression'. Once again, I don't know what being an NP or an MD has to do with the ability to assess a student. Secondarily, my arguments are far more from an education standpoint than a 'judging' standpoint. I couldn't care less about who is 'judging' or 'grading' as a seasoned midlevel, just like a senior resident is more than capable of fulfilling that position.

When I have seen similar situations to this, albeit not as a primary preceptor, an NP/PA/whoever was the best option and was a GOOD option. Saying, "Only MDs are qualified to teach and evaluate medical students by virtue of their MD." is incredibly elitist and simply wrong.

 

[Tired]

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[Tired]

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[sylvanthus]

I think @sylvanthus did. I asked my school and they said that they wouldn't allow it, thank goodness.
You won't find any medical student here who disagrees that the clinical teaching of medical students should be led by physicians.

Yup had an RN as a preceptor on surgery. Im sure the thread has gone down in SDN history. Ahh well, ended up fine.

 

[WinslowPringle]

So, at my school, the term "preceptor" is only thrown around on two rotations when we rotate with an FP doc in the community and it's one-on-one. In that context, I would be very upset if I were pawned off on an NP as a preceptor.

However, there are multiple inpatient services in which we'd round with an NP and the NP would have opportunities to teach the med students. I was fine with that because I'm here to learn whatever I can from whomever I can and it was clear that the NP=MD agenda wasn't being pushed. Slightly less cool on ER when I was told to 'staff' patients with the NP - that did show up on my course eval primarily because I had been assigned to an MD staff who just didn't want to teach.

 

[styphon]

As with everything, it depends on the NP. There are a lot of NPs that I would prefer managing interns/medical students over certain MDs who it would otherwise fall on.
On average, your NPs are going to know a crap ton more than a new clinical medical student. Whether they went to medical school or not is largely irrelevant. Good preceptors/teachers are good preceptors/teachers. Especially when you talk about stepping into the clinical teaching realm, things are not as cut and dry as the last couple letters after your name.

I completely agree. While a MSIII may have more science/theoretical background than a practicing PA/NP, their experience and clinical knowledge will far outweigh the medical students. It would make sense that this applies in any clinical situation: ER, outpatient, inpatient.

But I do think the medical student should also have some direct contact with a physician - for the main reason of seeing what an attending physicians day is in the specific field (considering this influences future career choices).

 

[Goro]

Completely untrue. I don't need an MD or DO degree to assess a student's ability to give a case presentation or interact with a patient in an OSCE assessment.

Even an NP who is capable of teaching their limited area of expertise is not qualified to assess a student's professional growth and progression. I have learned much from mid-levels, but they should never serve as a primary preceptor judging your overall performance.

Using the excuse that "other options were poor" is unacceptable. If the options are that poor, the rotation should not exist.

 

[Tired]

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[Psai]

Doctors should be trained by doctors. It's really that simple.

 

[Goro]

There are areas where non-MDs can assess medical students. That was my point.

Do you need an MD to assess whether an MSIII is performing at the level expected of him/her on a clinical rotation? Do NPs pass/fail the students at your school?

 

[Tired]

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[Goro]

pre·cep·tor
(prĭ-sĕp′tər, prē′sĕp′tər)
n.
1. A teacher; an instructor.
2. An expert or specialist, such as a physician, who gives practical experience and training to a student, especially of medicine or nursing.

I'm viewing my prism through #1, while you're through #2. And that's totally fine!

I don't disagree. Perhaps I'm misunderstanding how others are using the word "preceptor."

 

[Nasrudin]

pre·cep·tor
(prĭ-sĕp′tər, prē′sĕp′tər)
n.
1. A teacher; an instructor.
2. An expert or specialist, such as a physician, who gives practical experience and training to a student, especially of medicine or nursing.

I'm viewing my prism through #1, while you're through #2. And that's totally fine!

The term is typically used as shortened for clinical preceptor. At least in medical training. I agree with Tired. You can't train someone to a do a job you haven't done. In general academics we learn from phd's or for other educational exercises we listen to a lecture from whoever. But in the sense that the OP meant it, using NP's is another step in the wrong direction for our training.

 

[Kaustikos]

All this is true (working as a team, etc), and I'm glad it worked out for you. However, you were short-changed in your education.

When you are on clinical rotations, you receive feedback on whether you are progressing to the standard required of a physician. The feedback that you get, both good and bad, assists you in assessing yourself and making adjustments as needed. When you spend all your time with a mid-level who "reports in" to an attending physician, you are not getting the benefit of a trained eye who can help you develop. At best, you can hope that the NP knows the attending well enough to make some kind of rough comparison of you to him. And you deserve better than that.

There are many things we can and do learn from non-physician staff. Feedback from them can be useful. However, you deserve an overall assessment of your performance, which you did not get. I'm glad that this experience was positive for you, but at the end of the day, it did not benefit you in the ways that really matter.

So,
I get your point but you're assuming physicians always give the best feedback towards a student's progress. Or they know how to evaluate a student in terms of becoming a doctor.
After 2 years of dealing with this ****, I'll say you have no idea how crazy and random these evaluations are. Nor how ridiculous.
I'll take the praise and positive feedback over the physician with a Napoleon complex who writes me a scathing failed review for no reason other than their own personal agenda and not an objective assessment. Or a physician who gives me negative feedback because of the shoes I wear in the OR. I'd agree with you if this was posted two years ago and I hadn't gone through the hoops and ladders. Looking back: the people that gave me the best feedback were the ones who didn't just take their own experience with me but also listened to others. Not just in the example I gave but other rotations.
My family medicine preceptor gave me my evaluation at the end. He told me what he would write but then told me what I needed to work on (which wasn't going to be on my evaluation). I honestly think that is the best way to do it. Don't ruin the students chances but also let them know what they need to work on.

 

[Kaustikos]

Completely untrue. I don't need an MD or DO degree to assess a student's ability to give a case presentation or interact with a patient in an OSCE assessment.

Agreed. People seem to think that the best evaluations only come from the attending.
I hope they realize that people talk and the attendings do actually talk to residents and faculty about the students lol

Do you need an MD to assess whether an MSIII is performing at the level expected of him/her on a clinical rotation? Do NPs pass/fail the students at your school?

No, you don't. Like, seriously, people are assuming the NP or PAs working in the academic environment haven't learned how to work with students or how to teach them or what's expected. If I go to a rotation and find out this NP or PA has been working with this attending for 5+ years, you're damn sure I'm going to be best friends with that person. You're basically getting a chance to help make yourself look good. It's the same thing with the secretaries in the departments.
I guess I don't get it. Why is it so hard to be friendly and okay in working with people who work with the person you're trying to impress?
Not to mention the fact that these people do know a lot about the field they're working in. They do enjoy teaching. They just don't like dealing with students who are entitled arrogant bastards who feel they deserve the best treatment possible.

 

[Tired]

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[Nasrudin]

I also feel the pain of clerkship and evals. But that is also aside from modeling behavior and judgment. Clinical work has to be modeled and practiced like learning a martial art. You can learn this from a bad teacher. You just have to not think about a grade and think more about what is clinically effective. I say this realizing that this is the luxury I now inhabit but didn't then.

 

[Kaustikos]

You're mixing up "an evaluation that helped me with my standing/scores" and "an evaluation that helped me grow as a physician."

I feel your pain with MDs who are poor teachers, poor evaluators, poor preceptors. I have had only a few (fortunately) but they were memorably painful and impacted me professionally long after I had left their service. I get the attraction of someone who is "easy" or "nice" or "friendly" when you're in the thick of the pain with horrible MD preceptors.

I don't get too worked up over mid-levels, because in my specialty, they work very well and there is minimal likelihood of the encroachment issues seen in the non-surgical and anesthesia worlds. But I do continue to believe whole-heartedly that we are different. That we have a way of thinking about medical problems that transcends diagnostic algorithms and experience, and is founded on a sense of ultimate responsibility for the outcomes our patients have. Our students, who are plunged into debt pursuing their educations, deserve the benefit of direct precepting by people who have the training and experience both guide their development and assess their progression through the lens of a fully trained and educated doctor.

When the MD teachers are bad, it's a terrible situation to deal with. But the answer is not to find nicer preceptors outside the field.

Well now you're just being unrealistic.
I find no fault in someone evaluating me if they don't have an MD. Why? Because I'm trying to be a better clinician, which is something that doesn't require someone being an attending. Or physician. If my knowledge base sucks, I'll know and so will the NP. If I don't know how to manage patients, then the physician, NP and even nurses will know. If I can't find my way around a hospital?
Like, where in this realm of 2 years of medical training is it a detriment to be taught by someone without an MD? The NPs at academic centers tend to have a good grasp on what to do in their area. They've seen and dealt with students just as much as the attending.
I honestly feel like people are being too naive and ignorant about the situation. If you're trying to learn and be better, then you need to take what's given to you and make it work. Better to have someone to teach you or make you better than... Nothing

 

[DocVapor]

I'm paying a lot of money for my medical education. I expect my primary source of learning during 3rd and 4th year to be from involved physicians. I certainly can appreciate that NPs and PAs (or PharmD's, RN's, CNA's, whoever) can teach me plenty, and am grateful for any time they are willing to spend with me. They can certainly have input into my evaluations. However, to be punted off to a mid-level for a month is unacceptable. If that happens frequently then the school needs to re-evaluate either the preceptor or even the rotation, as how can an NP, who's own national organization repeatedly states that they practice "nursing, not medicine" teach me medicine?

 

[Tired]

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[Psai]

I don't know why people keep talking about evaluations as if any of those even matter. Clinical evaluations are largely bull**** and I haven't had a single bad evaluation yet besides the "needs to read more" thing that people seem to like to fall back on. The real issue is that you need to learn how to think like a doctor, not how to think like a mid-level. They might know more things than a trainee but it's the thought process that matters

 

[Kaustikos]

Yes, my 6 years as a clinical med student and surgical resident, coupled with my 4 years of fully licensed independent general practice (supervising a couple mid-levels along the way) has left me "naive" and "ignorant." C'mon now...

None of us know what we don't know, and I think that there's an element of that operating for you right now. I hope that in 3-4 years, when you're deep in residency, you've found some mentors who serve as good models for how to think and be like a physician. Based on what you've written, you don't seem to be getting that now. I was miserable as a student, but I was never in a situation where I didn't have role models to learn from, even when they weren't nice people. I hope things get better for you.

Right,
I'm not saying medical students should be taught by NPs all the time. Yes, physicians should be teaching students. I agree completely.
But the reality is you won't be working 1:1 with physicians all the time every day of your rotation in all rotations. I'm saying suck it up and use that to your advantage. I'm not saying its fair. Nor that schools should be okay with it.
But schools are having more and more students in hospitals every year and less direct interactions with attendings. I'm saying I'd just make the most out of it. Learn from the staff and then bitch to the school if you feel as though you didn't get the proper training. Or evaluation.
But if students are looking for a proper or appropriate person of authority to work with, then it's honestly difficult for me to condone the idea of immediately rejecting working with NPs while you're on your rotation. Keep an open mind. That's all.


Edit - I definitely do have great role models. My point wasn't to paint a jaded pessimistic view of my time. And I apologize if that's the impression you got. It was more to show that I have experienced situations where attendings didn't do their job. Who do I complain to about that? No one. lol. The residents loved me but even their opinion or evaluation of my performance was tossed aside and held no weight. Considering I worked with them a lot during that month and learned a lot from them, I would think they had more say in how I performed as a student. Which, they gave me a lot of advice which was helpful.
So, yeah, I'll say the positives do outweigh the negatives. The residents have been some of the most important people in helping me become better. There are also the attending, too. I have a vascular attending I talk to frequently (he even asks me to call him on his cell phone) and has served as one of the few people who've been there when things were horrible. Took the time out if his day to call me and see what was going on.
But anywho, sorry if my post made it seem like I'm calling you naive. I was just giving students an idea of how beneficial people can be regardless of having an MD.

 

[W19]

I am glad that my school does not use NP/PA for the reasons that @Tired mentioned above...

 

[ketosisevangelist]

That's awesome.

 

[cbrons]

As with everything, it depends on the NP. There are a lot of NPs that I would prefer managing interns/medical students over certain MDs who it would otherwise fall on.

On average, your NPs are going to know a crap ton more than a new clinical medical student. Whether they went to medical school or not is largely irrelevant. Good preceptors/teachers are good preceptors/teachers. Especially when you talk about stepping into the clinical teaching realm, things are not as cut and dry as the last couple letters after your name.

Should NPs be doing an MD's job? No. But, I don't think medical education is solely an "MD's job". I had PhDs, PharmDs, nutritionists, MDs, DOs, PAs etc teaching me as a medical student. I learned more about how to be a good resident my intern year from our service NP than I did from any of our faculty. Did I learn any surgery from her? No. Did I learn any book knowledge? Not really, maybe a little. But, how to function in a clinical setting, even as a relatively advanced intern? Nobody was better.

Likewise, when I was an MS4 on an away rotation, there was a PA that essentially ran the minute to minute management in the SICU. I would rather have him teaching medical students than any faculty that was around for certain things. Managing every last bit of education, probably not. But, certain had a role to play.

I don't think precepting a single clerkship if it was FM/IM/etc. is that crazy or bad just on virtue of them being an NP.

good to know medical school is useful

 

[mimelim]

good to know medical school is useful

Medical school is useful, but there are two things that are problematic.

#1 They are notoriously inefficient. Most if not all spend 2 years teaching toward a test (Step 1) that while laying the foundation for everything else is quite minutia driven. Others have PhDs lecture even more specifics on a topic that while at it's core is important for medical students to know, understanding the gritty details has zero relevance to future MDs and if there are one or two students that will need that knowledge, they would get it in a future setting anyways. You need to have a pre-clinical curriculum, but schools can go a long way in improving that aspect of student education.

#2 There is a crap ton to learn. You don't start learning to be a vascular surgeon from day 1 of medical school. You have to learn everything about medicine. I'm pretty sure that I learned the pediatric vaccination schedule for Step 2, Step 3, my peds rotation and my peds shelf. Something that if I were to ever need to know, I would google it because I sure as hell don't remember it now.

 

[W19]

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[chipwhitley]

I was precepted by an NP once early in 3rd year because the doctor was away for a couple days. She tried to teach me pathophysiology that was completely wrong. This was stuff that was super basic and even a 1st year medical student would know cold.

When the doctor got back she told me to forget anything the NP had tried to teach me. I noticed a huge difference in the thought process between the NP and the MD. It was night and day. The NP's was incredibly simplistic and formulaic. Learning from that NP would have been disastrous.

 

[chipwhitley]

Medical school is useful, but there are two things that are problematic.

#2 There is a crap ton to learn. You don't start learning to be a vascular surgeon from day 1 of medical school. You have to learn everything about medicine. I'm pretty sure that I learned the pediatric vaccination schedule for Step 2, Step 3, my peds rotation and my peds shelf. Something that if I were to ever need to know, I would google it because I sure as hell don't remember it now.

So how exactly do the NPs and PAs become competent enough with even less education?

 

[mimelim]

So how exactly do the NPs and PAs become competent enough with even less education?

Experience.

 

[W19]

So how exactly do the NPs and PAs become competent enough with even less education?

I would not use the word 'competent' for most NP. They probably learn to follow algorithm. PA is legit though!

 

[W19]

I was precepted by an NP once early in 3rd year because the doctor was away for a couple days. She tried to teach me pathophysiology that was completely wrong. This was stuff that was super basic and even a 1st year medical student would know cold.

When the doctor got back she told me to forget anything the NP had tried to teach me. I noticed a huge difference in the thought process between the NP and the MD. It was night and day. The NP's was incredibly simplistic and formulaic. Learning from that NP would have been disastrous.

Did you tell her that she is wrong?

 

[chipwhitley]

Experience.

So can we just skip the extra school and do it their way? It would save us a lot of time and money.

 

[chipwhitley]

Did you tell her that she is wrong?

I did but she insisted that she was right. I asked the MD later on, and the MD just rolled her eyes and told me to ignore anything that NP tried to teach me. Apparently everyone there knows this person is really incompetent but no one seems to care - which is scary. Clearly some NP schools have very poor standards.

 

[W19]

So can we just skip the extra school and do it their way? It would save us a lot of time and money.

NP might be right when they say physicians are overeducated.

 

[Tired]

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[Winged Scapula]

OK -- opposite situation: I agreed to precept an NP student this summer. Slightly annoyed because she uses my first name in all her emails to me.

 

[Tired]

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