Jennifer Lotter, PA-C, is a physician associate at the National Heart, Lung, and Blood Institute at the National Institutes of Health (NIH) in Bethesda, Maryland, and serves as chair of the NIH’s Nurse Practitioner/Physician Associate Scientific Interest Group.
“How did you learn hematology?” is a very different question than “How did you learn to be a good clinician?” The difference comes down to the distinction between learning the science of hematology versus learning how to be a practitioner of said specialty.
This year marks a milestone in my physician associate (PA) career: 10 years practicing as a PA and nine years specializing in hematology. Now, with a decade under my belt, so also begins the arduous process of board recertification. I am part of the first cohort eligible for the new format of the American Academy of Physician Associates board recertification exam (PANRE-LA), which takes a minimum of two years to complete and encompasses all areas of general medicine.
It feels silly to say, but it was surprisingly satisfying to get the one hematology question that has come up so far correct without having to use a reference. Somehow this one question is supposed to be representative of my entire career as a PA, encompassing years of knowledge and hard work. It was both reductive and humbling.
What I’m realizing is that no matter how we approach testing practitioners’ medical knowledge, the most important part of my education — the clinical rotation — is increasingly at risk. There’s a large and growing shortage of clinical sites and preceptors despite a surging number of certified PAs, drawing nearly universal concern from the programs that educate emerging practitioners. My recertification process is both a reminder of what has taught me the most important skills and lessons of my career and an opportunity to pay those lessons forward in support of a much-needed re-investment in PA clinical education programs.
My PA career is, and continues to be, nourished by my relationships with not only a network of exceptional hematologists but also the connections I’ve developed meeting and treating hematology patients. As I take my boards for the second time, I can’t help but think back to the beginning of my PA career when I was a wide-eyed student and new grad eager to get my feet wet in a field I was passionate about. Where would I be now without hands-on, real-world experience?
Unlike the core rotations in PA clinical education, such as those of emergency medicine, surgery, and obstetrics, hematology is an elective clinical rotation, one that a student must seek out. Although PA fellowships after graduation are gaining popularity, they are not required to practice, and a clinical rotation may be the only direct opportunity for students to gain patient experience in specialty care. Unfortunately, the increasing demand to place an ever-growing number of health care students, combined with the lack of available clinical rotation sites and preceptors willing to teach, is creating a barrier to this important training opportunity.
The number of PAs entering the workforce is rapidly growing. The National Commission on Certification of Physician Assistants 2023 annual report noted a 75.2% increase in board-certified PAs in the past 10 years, with more than 207,000 PAs having earned board certification since 1975 and 178,708 who were certified at the end of 2023.1 There is no sign of demand slowing down, and according to the Accreditation Review Commission on Education for the Physician Assistant, there are currently 309 accredited PA programs, with potentially 352 PA programs to be accredited by 2027.2 Despite observed growth in programs and their enrollment over the last decade, program leaders have indicated that the number of available clinical rotation sites and competition for sites is a limitation of the enrollment capacity in their programs.
Research has found that a staggering 95% of PA educational program directors are moderately or very concerned about the availability of adequate clinical training sites.3 However, the shortage of clinical rotation sites is not exclusive to the PA profession. In a comprehensive 2013 Clerkship Survey developed and administered by four organizations that grant health care degrees ― the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the Association of American Medical Colleges, and the Physician Assistant Education Association ― at least 80% of respondents in each discipline were concerned about the number of clinical training sites. One of the key factors influencing the ability to develop new sites was the training and orientation of preceptors.3
How do programs address clinical site shortages when health care providers are already suffering from time limitations and productivity demands? There is an emerging trend in clinical education to incentivize preceptors and preceptor sites. In 2019, more than 50% of PA programs indicated that they were paying fees to clinical sites and preceptors in exchange for the clinical training of students.4 Other non-monetary incentives used to compete for sites include faculty positions, professional development opportunities, library access, and public recognition. Alternative precepting models have also been proposed to help fill the gap, including simulation, standardized patients, and artificial intelligence and virtual reality, as well as an expansion of telehealth interactions.5 Is trading interpersonal interactions with technology the answer to the preceptor shortage?
Preceptors are critical to help students transition from the classroom to the practice environment, to learn how to conduct an exam and work as part of a team. Experienced clinicians have an essential role in passing on knowledge to the next generation about how to deliver quality care to patients with complex diagnoses, including fostering problem-solving and decision-making skills. However, the teaching goes both ways. As my PA students and I find ourselves studying for our boards at the same time, I’m reminded that hematology is so much more than a question on an exam and that, in reality, we are teaching each other how to be good clinicians.
Jennifer Lotter, PA-C
Associate Editor
References
- National Commission on Certification of Physician Assistants. 2023 statistical profile of board certified PAs: annual report. April 2024. Accessed May 6, 2024. https://www.nccpa.net/wp-content/uploads/2024/05/2023-Statistical-Profile-of-Board-Certified-PAs5_3_24.pdf.
- Accreditation Review Commission on Education for the Physician Assistant. Entry level accredited programs. Accessed May 6, 2024. https://www.arc-pa.org/entry-level-accreditation/accreditation-process/accredited-programs/.
- Physician Assistant Education Association. Recruiting and maintaining U.S. clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. Accessed May 6, 2024. https://www.paeaonline.org/wp-content/uploads/imported-files/Recruiting-and-Maintaining-U.S.-Clinical-Training-Sites.pdf.
- Physician Assistant Education Association. By the numbers: program report 35: data from the 2019 program survey. 2020. doi: 10.17538/PR35.2020.
- Kayingo G, Gordes KL, Fleming S, et al. Thinking outside the box: advancing clinical education in an era of preceptor shortage. J Physician Assist Educ. 2023;34(2):135-141.
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology, the NIH, or the U.S. government unless so stated.
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