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Preceptorship with a Nurse Practioner?

Discussion in 'Medical Students - MD' started by InDocNito, Oct 15, 2009.

  1. InDocNito


    Oct 15, 2009
    Hello all.

    I am a lowly and inexperienced M1 at a school in the United States.:whistle:

    My school has a 2 and 1/2 month mandatory preceptorship program and I was just assigned to a Nurse Practitioner as my preceptor.

    Now, I believe that NPs are a valuable part of the healthcare team and I do not have feelings of superiority in regards to them. However, NPs and MDs clearly has different educational experiences and occupational responsibilities, and as a student training to become an MD, I sort of feel like I should be learning under an MD. I'm concerned that under an NP, I won't be getting the whole picture of what a doctor does and that it will somewhat hinder my opportunities for networking/future potential summer experiences/whatever.

    However, I acknowledge that at this point in my education, I know nothing, and that it's possible I misunderstood the point of a preceptorship. I'm sure, strictly clinically, my experience under an NP will be fine.

    So give it to me straight, internet: Am I justified in my complaint, or do I need to get over it and enjoy my upcoming preceptorship?
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  3. sylvanthus

    sylvanthus EM/IM/CC PGY-5 Physician 7+ Year Member

    Sep 9, 2008
    Wow, I would be a bit frustrated also. After all, don't NPs follow the whole "nursing model" or are they already the equivalent of physicians?
  4. Taurus

    Taurus Paul Revere of Medicine 10+ Year Member

    Jul 27, 2004
    Yeah, you should definitely ask for a reassignment if you can. NP's follow protocols and can't get into detailed discussions with you regarding physio, path, diagnosis, and treatment. It really is a world of difference when you discuss patients with an MD vs. NP. You're paying a lot of money to be in medical school. You shouldn't let them shaft you.
  5. Jolie South

    Jolie South is invoking Domo. . . Physician Moderator Emeritus 10+ Year Member

    I think it really depends on what they're asking you to learn from your preceptor and who your preceptor is. I worked with an awesome nurse practitioner this summer in internal medicine. She was very thorough and I learned a lot about the physical exam from her. Honestly, she functioned very similarly to her MD partner, who I also worked with. Granted, it was outpatient and she didn't see super complicated patients. Those basic patients though are probably the best patients to see at this stage in the game.

    If your preceptorship experience is anything like mine, what you're supposed to be getting out of it is time practicing basic skills on real patients. You're not expected to be good and the process of just doing the steps that you've been taught in class is exercise enough. You likely won't be discussing differential diagnosis or management anyways because it'll be way over your head. And to be quite honest, some of the MDs I have worked with as preceptors haven't known the in depth pathophys on things either.
    Last edited: Oct 15, 2009
  6. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

    May 30, 2001
    Gone Walkabout!
    If you are an M1, you are likely not doing more than observation of day to day activities. You can learn some physical diagnosis techniques but you can't actually learn the practice of medicine from an NP. They can and do function more than just following protocols as they have diagnositic capabilities but you won't learn to function as a physician from an NP (nor would you expected to learn this as an M1).

    See if you can pick up some history and PE skills. Otherwise, you won't get much out of this experience.
  7. shiftingmirage

    shiftingmirage 10+ Year Member

    Sep 2, 2007
    My school has a similar thing, but it lasts for 2 years, and we do follow docs.

    While I understand where you're coming from, the purpose of the course is not diagnostics, at least not as a M1 in the first term. Things you should take from the experience: doctor (or nurse) - patient relationship, history taking, vitals, listening for heart sounds, breathing, looking in ears, noses, eyes. If you as a 2 month old med student can do it, a nurse can too. In your position, you can learn a lot from everyone. When we learned how to give injections, nursing students taught us.

    Also, I bet the nurse has more time to spend with you than a doc would.
  8. URHere

    URHere Physician PhD 10+ Year Member

    Nov 20, 2007
    Whether this is a good situation or a bad one will really depend on the particular NP. I'm doing a preceptorship in a family medicine clinic this year, and I generally spend about 1/4 of my time with a NP. She has her own patient pool, and fits in very well with the clinic physicians.

    When I work with her, it's true that she isn't always able to answer all of my nerdy science questions. However, she often gives me the chance to do more things independently. Perhaps she just doesn't understand the level of relative incompetence that comes with an MS2, but either way, I appreciate the responsibility. Also, in my experience, NPs have also been more willing to discuss possible diagnoses with students and genuinely consider their feedback. So, I guess my point is that you shouldn't just assume that an NP would be a poor preceptor. Instead, maybe you could ask her if she would mind if you occasionally worked with her MD colleagues too?
  9. LadyWolverine

    LadyWolverine 10+ Year Member

    Aug 17, 2004
    Hiding in your closet
    This is what I find objectionable about precepting under and learning from NPs as a medical student - discussing diagnoses and treatment plans is one thing, but the student should have a very clearly-defined level of responsibility, ESPECIALLY at the M1/M2/early M3 level. Nothing should be asked of the student that the attending preceptor cannot handle him or herself.

    My very first M3 rotation was family medicine. My MD preceptor's vacation week fell during my month at her clinic, and as a result, for part of my rotation I was "unofficially" re-assigned to her NP colleage (the clerkship director did not know about it as my MD preceptor did not mention it to him), who worked mainly out of a different clinic affiliated with a local hospital. That 3-day period was the most terrifying experience of my entire M3 year. This was a woman who had been an RN for 20+ years before going back to school for her NP, and had now been a nurse practicioner for several years. After explaining to her that this was now only my third week of clinical clerkships, she proceeded to ask me for pointers on the abdominal examination of a patient who, in retrospect, may have had something seriously wrong. Soon after, she asked me what antibiotic I thought she should prescribe to someone with a puncture wound and surrounding skin infection. Later that day, I was asked about the mechanism and side effects of Clomid before she prescribed it to a woman complaining of infertility. She asked me these questions not to "pimp" me, but because she herself had a knowledge gap and was uncomfortable with her own clinical judgment and decision-making, and she somehow thought that, because I had completed two years of medical school, I had a legitimate answer. We didn't discuss my Dx and Tx, with her then modifying the plan and providing teaching points, as I've done in all of my other rotations. On the contrary, she was asking me, the THIRD-YEAR MEDICAL STUDENT, for "advice" about how I though she should do the job she was allegedly prepared to do. That whole 3-day period was filled with episode after episode of me being thrust into very uncomfortable positions. There was no teaching, there was no pathophys, there was very little discussion other than her messy assessments which she threw together based on God-knows-what, and her reliance on homeopathic treatments, which really raised my hackles. I felt it horribly inappropriate for a preceptor who was supposed to be on-par with an ATTENDING MD to be asking a newly-minted 3rd-year student how to manage her patients. As a matter of fact, I was so upset by this entire experience that I went directly to my clerkship director and told him about it. He was furious and agreed that placing me in this position was completely inappropriate. He spoke to my preceptor about the incident once she returned from vacation, and I guarantee you that no student from my institution will be precepted by a nurse practitioner again on family medicine under his watch.

    An anecdote, certainly. But my point is that a medical student should not be put in this position. Furthermore, I have NEVER felt this way under any of my attending physicians. Certainly, the "mock" role of history-taking and physical exam followed by coming up with an assessment and plan is invaluable, and students should present their entire HPAP as though they were the attending doctor making the decisions. But the bottom line is that the student has no real responsibility for clinical decision-making. That is what the attending is for - to provide the experience, the confidence, and, most importantly, the KNOWLEDGE to make proper observations, diagnoses, and treatment decisions for patients.

    The bottom line is that you are learning to be a physician, and paying a lot of money to do so. You should be taught by physicians, not by nurses. Nurses are our colleages and should be respected as professionals, but they are not trained in the same way that we are. A nurse cannot train you to be a doctor any more than a dentist or physical therapist could train you to be a doctor. Nor does a doctor have any place training a student how to be a nurse or a dentist or a therapist. Can they teach you something about certain aspects of health care? Certainly. But you are in medical school to learn how to practice medicine, not to learn how to practice nursing. As such, you should be learning from a doctor. If you want to learn to be a nurse practitioner, the you should go to NP school. In my experience, I was uncomfortable with the situation, and I said something. I would do it again in a heartbeat. As a matter of fact, I wish I had said something sooner.
    Last edited: Oct 15, 2009
  10. Rendar5

    Rendar5 10+ Year Member

    Nov 12, 2003
    To the OP: you are not justified in your complaint. You need to get over it and enjoy your preceptorship. If you were more advanced in ur training, then you would be justified in your complaint.

    You are an M1 and the school is assignig you to an NP that it knows and trusts to teach its students and if it hears back that she's not goo,d then it'll change it's mind. But this is different from the above situation (which I agree with is objectionable and should have been complained about). The above situation the school was not aware and did not trust that NP to teach its students. Furthermore, you're an M1, not an M3. You will not be taking care of patients, you will not know diagnostics, you will not know clinical presentations of illness. What you are going there to do is to learn history taking a nd perhaps physical examination. An NP can do that just as well at your level as an MD. While the nursing model is definitely different, it shares similarities in terms of history-taking and basic physical exam.

    I worked with an NP as a MS1 as a preceptor. I would do it again immediately as she was good at what shee did.
  11. Siverhideo1985

    Siverhideo1985 7+ Year Member

    Jun 6, 2008
    For the rest of your career (aka the next 4 years of medical school, 3-8 years of residency and fellowship and the following 20-40 years as a physician) you will be surrounded by, learn from, and work with MDs. You really think its a bad thing to see a different perspective of health care? If I was you, i would welcome the insight into the medical profession from a different angle. Treating sick humans is not, and never will be, the job of a single will work in a team at all times. It can't hurt to know their parts in this.
  12. MsKrispyKreme

    MsKrispyKreme The "Hot" sign is on... 7+ Year Member

    Jun 11, 2008
  13. medInUSA

    medInUSA New Member 10+ Year Member

    Apr 25, 2006
    Wow this is completely absurd!!!!

    I would go to the course director and ask to be reassigned. IF they refuse, take to the dean's office!!! Why should you learn from a nurse? After all they money you are paying, this is ridiculous.
  14. lord_jeebus

    lord_jeebus 和魂洋才 Moderator Physician 10+ Year Member

    Jul 12, 2003
    Although I think it would be ideal to have an MD preceptor for this, I would guess that the focus of this early preceptorship is basic stuff like establishing rapport and taking a basic history - something perfectly within the scope of any NP.

    You should pick your battles wisely in med school - and I wouldn't choose this one.
  15. meister

    meister Senior Member Physician Gold Donor Classifieds Approved 10+ Year Member

    Aug 24, 2004
    You're an M1, it doesn't matter at this point. It's not like you're a new cards fellow stepping onto the wards in July only to find your attending has "DNP" after her name on the white board.
  16. medInUSA

    medInUSA New Member 10+ Year Member

    Apr 25, 2006
    while lordjeebus is right, I would not just give up without fighting.

    Be very polite and dont cause a scene, but i think its still worth asking to be reassigned
  17. Jolie South

    Jolie South is invoking Domo. . . Physician Moderator Emeritus 10+ Year Member

    My school is really hard up to find enough preceptors in outpatient primary care as it is. I think if I had asked to switch they would have laughed at me.

    As another poster above said, this would not be a battle I would pick.
  18. lord_jeebus

    lord_jeebus 和魂洋才 Moderator Physician 10+ Year Member

    Jul 12, 2003
    You don't want to be that med student who thinks he knows more about what and how he should be taught than the MDs that run the curriculum. Even if you're polite about it, getting what you want is unlikely and you will stand out as that guy for a long time.
  19. MossPoh

    MossPoh Textures intrigue me 7+ Year Member

    Apr 24, 2006
    Tally/Willkillya County
    Honestly, after 1 year of medical school you aren't going to have the depth of knowledge to really require an MD/DO. Keep in mind, a lot of the applicable "sciency" questions would develop from your second year. After a year of this crap you are still trying to develop a solid proficiency with doing a basic physical and taking a history. If it were third year then I would be peeved. End of first year, meh, just push through it. I'm sure you'll still have enough to learn about.
  20. SoCuteMD

    SoCuteMD 10+ Year Member

    Nov 28, 2005
    No more rounding!
    I'm sure my school has a hard time finding preceptors as well, and yet they find a board-certified primary care preceptor for EVERY single 1st and 2nd year in the entire school (if I remember correctly where you go to school, my school is much larger and surrounded by many more other medical schools as well). They quickly make accommodations/adjustments for those who find themselves in situations that aren't working.

    To the OP: I would be PISSED and I'd speak up in an instant. You are in medical school, not nursing school. MDs and NPs have a fundamentally different approach to the patient. If you were paired with a PA it would be a different story, as they are trained in the medical model instead of the nursing model and there's a lot you can learn from a good PA. NPs are far more hit and miss (and more miss) in my experience.
  21. badasshairday

    badasshairday Vascular and Interventional Radiology 10+ Year Member

    Apr 6, 2007
    I agree with the above. I would be annoyed to be a 1st year student and be paired with an NP. Nothing against NP's, but dude, you are in medical school. I'd be pissed to even tell my family that my mentor is an NP... they would be like... huh???

    Anyways, it is true what other posters are saying, you really don't know jack at this point. So being paired with an NP won't put you at any sort of disadvantage right now. But still, I just think it really is about the principle of it.
  22. coldweatherblue

    coldweatherblue 5+ Year Member

    Nov 24, 2007

    while it's natural to feel indignant at paying all that money for medical education and being taught by a nurse, I don't think this is a battle you want to fight. If you were an MS3 or above, or even an MS2, then YES it'd be more defensible, but at my institution at least expectations for MS1s in preceptorship were pretty low, basically just "watch, maybe help out on PE, practice history taking, and present a patient every now and then". I'd be pretty upset too if I were you because you deserve to have a physician teaching you medicine, but as a brand-new MS1 if you choose to complain you will basically have to defend why the nurse is not adequately teaching you, which could cause interpersonal problems. The nurse could be quite offended and if you don't have a good case like Lady Wolverine's as to why you're not learning the school will probably take the nurse's side. I agree it's crap and the worst part is that it's a whole 2.5 months! that sucks, but tread very lightly if you decide to talk with administration about this because you don't want to be admonished for "not playing well with others".
  23. ShyRem

    ShyRem I need more coffee. Physician Moderator Emeritus 10+ Year Member

    Jun 17, 2004
    Where I hang my hat.
    I also worked with several NPs during my third year, but not for more than a day or so each time. Every time, they would ask me about pathophysiology, ask me about drugs, interactions, other considerations, to read EKGs, when I asked about certain aspects of an musculoskeletal exam I would perform they had no idea what I was talking about. They were clearly uncomfortable having a student who knew more about some things than they did, and had no idea on how I should present patients (nor what to do when I did present on patients). But they did know their patients well, and were very good with time management.

    Considering your preceptorship is for so long, I would absolutely say something and see if I could get reassigned to a physician. But be nice about it.
  24. Rendar5

    Rendar5 10+ Year Member

    Nov 12, 2003
    umm...shyrem, you realize we're talking about an MS1 learning history taking, not an MS3 learning patient care and general medicine/surgery/etc..
  25. Jolie South

    Jolie South is invoking Domo. . . Physician Moderator Emeritus 10+ Year Member

    Hey, I'm not saying that we shouldn't be paired with a MD at all stages in the game. At my school, everyone is. My experiences with a NP weren't school related.

    I just don't know that being paired with a NP is all that detrimental for a MS1 learning H&P skills. As a MS2, I think it would be different.
  26. Non-TradTulsa

    Non-TradTulsa Senior Member - Resident 7+ Year Member

    Apr 17, 2005
    Hopefully, you "got the whole picture of what a doctor does" when you shadowed prior to applying to medical school. And with all respect, I find the prospect that you will shine so brilliantly as a 1st year that you will pick up future networking contacts a bit amusing.

    The purpose of "clinical experiences" in the first year is only to get you around live patients to try to maintain your enthusiasm for medicine while you are stuck in the classroom for the first two years. Your expectations for learning are slim to zero. You'll be trained in elementary physical examination and diagnosis next year.

    Proctoring a first-year student is somewhat like baby-sitting and it's not always easy - I've done it (one concept you need to get used to in medical training: anyone with a year more training than you is potentially going to be assigned to be your teacher at times). If you've been assigned to a Nurse Practitioner, they probably picked that person because he or she is "good" with students and likes teaching. Enjoy the experience of being out in the "real world" and don't get all hung-up on whether you're getting experience from an NP or an MD because, in all kindness, you don't know enough yet for it to make much difference.

    Requesting to be assigned to a physician over the NP is going to be seen for what it is: pure snobbery. At least at my medical school, there is a heavy emphasis now on care teams - nurses, pharmacists, social workers, mid-level practitioners, and physicians - working as a team. A negative attitude toward mid-level practitioners would be a heavy black mark in your first year. I'm mid-way through my fourth year and, while I probably know more medicine than an NP, an experienced NP probably has physical exam skills far superior to mine and I wouldn't be a bit bothered to learn from that NP.
    Last edited: Oct 17, 2009
  27. MexicanDr

    MexicanDr 5+ Year Member

    Oct 11, 2009
    Would it be better if it was a Masters Level Physician Assistant than the NP since PAs follow the medical model?
  28. kidthor

    kidthor meep 10+ Year Member

    Dec 5, 2005
    The purpose of clinical exposure your first two years is really to get you comfortable interacting with patients. So, when you start rotations your 3rd year you won't be totally lost, as was the case in the olden days. I think there's plenty you can learn from an NP in terms of dealing with patients, and clearly you can learn about many common primary care medical issues.

    My first year I was initially assigned to work with a doctor who was completely unpleasant and condescending to me. He was a horrible teacher, and being with him was a painful waste of time. I mention this because you could complain to your school, only to be subsequently paired with someone who doesn't want to teach.

    If your NP is nice and a good teacher... and if you're an M1 with absolutely zero medical knowledge anyway... then be thankful for what you've been given and learn what you can!!!
  29. InDocNito


    Oct 15, 2009
    Thank you for all of the feedback. I talked to my faculty adviser and was told basically the same thing that many of you have said: though there is a difference in the model, preceptoring under an NP will largely be no different than being under an NP at this stage and the point of the exercise this early in is to get some time in a clinical setting interacting with patients. I'll warrant my original thinking was overly ambitious given my lack of knowledge, but hey, you never know until you ask.

    I start later this week and it sounds like it will be a very positive experience for me. :thumbup:
  30. dienekes88

    dienekes88 7+ Year Member

    Jan 21, 2008
    The only thing you have to learn right now is how to establish rapport and make an emotional connection. Some of my classmates had semester long preceptorships with physical therapists.

    Preceptor != Mentor.

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