Clinical Year Overview – Admissions 2019

– [Melinda] This is Melinda Blazer, Director of Clinical Education at the Duke Physician Assistant Program. Today I’ll be giving you an overview of the clinical year. The clinical year begins in July following a summer break at the conclusion of the pre-clinical phase of training. Students will begin
with the bridge course, which is a two-week-long
course to transition students from their didactic to
their clinical training. Our clinical rotation blocks will begin in late July and run
one full calendar year, including 11 clinical rotations and one non-clinical rotation. Seven of these are required courses which we’ll review in just a moment, students will also participate
in two elective courses and then you’ll see here
that students will also have an opportunity to
do at least one rotation in a medically underserved area, and this was really developed
out of the sort of mission of Dr. Stead, who
developed our PA profession with a desire to improve access to care, and the Duke PA program still feels like that’s a very important
role for physician assistants and for students to
experience over the course of their training, and
it is something that we have maintained as a requirement
within our curriculum. Students are also required to do a minimum of two rotations out of the Durham area to expand their experiences
and their opportunities for practicing with
diverse groups of patients and in diverse settings. Students will participate
in the Duke graduation in may with a MHS degree
conferral in September, and students complete the
program a year after starting the clinical year with
the Senior Seminar course in late July with a
program completion date typically in Early August. This is a list of the
required clinical courses. You can see that Internal Medicine and Primary Care are both
eight weeks in duration comprised of two four-week blocks. Internal Medicine is oftentimes done in two different clinical settings. Many students will do both an
outpatient internal medicine and an inpatient internal
medicine experience. All students will have
a minimum of four weeks in the inpatient setting. Primary care experiences
are working with family medicine providers in an
outpatient clinical setting, and students are typically
placed in the same site for an extended eight-week rotation. General Surgery course
involves opportunities to practice with general
surgeons in the preoperative, intraoperative, and
postoperative care settings. And Emergency Medicine
takes place in the Emergency Medicine Department working
with EM-trained physicians and APPs. Our Pediatrics course,
four weeks in duration, is based in the outpatient
setting, doing primary care, pediatrics, and Women’s
Health is also four weeks in duration, maybe in
a variety of settings but primarily in the outpatient setting where students have
exposure to prenatal care and routine well woman care. Labor and Delivery may
or may not be a component of women’s health depending on the site. Behavioral Medicine is
our final required course and it is also four weeks in duration. We’ve a variety of behavioral
medicine clinical sites and students have an
opportunity to practice and may be placed in a
variety of different settings with opportunities to have exposure to a variety of different
behavioral medicine conditions within those courses. And then we have the
Evidence-Based Medicine Two Course which is the non-clinical
course during the clinical year and it’s four weeks in duration. It continues training learned
during the Evidence-Based Practice One Course in
the pre-clinical year. Students have the opportunity to research a topic that is interesting to them and do a literature search
and analyze that data and then at the conclusion will present a presentation to their
peers and a group of faculty as well as create an abstract
based on their research. Quality Improvement Content is also a significant component of this course and students will be engaged in a quality improvement project
during their four weeks. There’s a variety of
clinical electives available to students and I think this
is one of the real strengths of coming to a large
academic medical center. Students have the opportunity
to select two electives both four weeks in
duration, and our program is able to offer a variety
of exciting electives, over 60 options and growing,
from things that are common in terms of medical
and surgical subspecialties like cardiology and orthopedics and hematology oncology,
to things that are unique and special to Duke,
opportunities in genetics or clinical research or
pediatric CT surgery, as well as a variety
of medical, pediatric, and surgical subspecialties
throughout the medical center. For those of you who are visual learners, this is an opportunity for you to see what sort of a snapshot
the entire clinical year looks like pictorially, and you’ll note that unlike the pre-clinical
year where sequence of courses happens
consistently for all students in the clinical year, we
see students having courses in a variety of different orders, so this is just one example
of what a student schedule may look like, but it
will vary for all students depending on their
individualized course schedule. Duke partners with, the
Duke PA program rather partners with the Duke
Health System to administer about 45% of our clinical rotation sites and then we have close
affiliations with other hospital systems across
the state and out of state to support ongoing
high-quality student rotations, so the Duke Health System
comprises the main Duke Hospital as well as a Durham community hospital called Duke Regional Hospital,
as well the community hospital in Raleigh,
Duke Raleigh Hospital. There’s also numerous
Duke clinics and a network of primary care clinics we refer to as Duke Primary Care in which
our students spend time. We have close affiliations
with the VA hospitals both here in Durham as well
as in the Asheville community through which our students spend time, and we have students who
may have an opportunity to partner with or to experience rotations within the Wake Med Health System which is a large private hospital in Raleigh. Students may have, who express
interest and or may have the opportunity to do rotations at Womack Army Medical Center which is on Fort Bragg down in Fayetteville area, we
also have close partnerships with Novant Health across
the state of North Carolina and Sentara Healthcare, which is located in the eastern part of the
state and the southern parts of Virginia, so students
may rotate there as well. We also have partnerships
with some unique hospitals across the country including
St. Jude’s Children’s Research Hospital, Hurley Medical Center, and Norwalk Hospital. There are several out
of state opportunities and these do continue to grow and develop. Currently, Virginia is the
only out-of-state location where students may be assigned
to their clinical rotation sites, all of the other ones listed here, opportunities within
Connecticut, Michigan, Tennessee, Montana,
Oregon, New York, Florida, and Maryland are opportunities
for site-specific rotations where students
may choose to opt in. And these are considered out of network, in which students would
be required to provide their own housing and transportation for these experiences. These oftentimes reflect
unique opportunities for students such as the
rotation in Memphis, Tennessee at the St. Jude’s
Children’s Research Hospital or the site in Oregon
which is at a healthcare for the homeless clinic,
or the Maryland location which is a newly developing
clinical research elective at the National Institutes of Health. One of the really great things about Duke is that we partner not just
with academic medical centers and hospitals across our state, but also with a variety of
other practice settings, hospital-based clinics,
community health centers, urgent care facilities,
health departments, and I think one of the
really rich benefits of this experience is that by the time a student has completed their training with our program, they’ve
had an opportunity to practice in most of these settings and so they have a sense
of where they really belong in terms of a setting
which is I think often equally as important as
identifying the specialty that is going to make them happy and have a high quality of life for
them as a practicing clinician. We also offer global
health electives here, we currently have six
countries where students may have the opportunity go
for a global health elective. These rotations aim to provide students with valuable cultural and
medical learning experiences in foreign settings. We do know that the availability
of these clinical sites and the ability to accept students to them does vary from year to year. This is another experience
where cost for travel and housing is at the student expense, however students may submit
educational related travel expenses for global health opportunities to the Office of the
Registrar for increased amount of student loan allotment
to help support funding for this and students for
whom that might be needed. We also have opportunities
for limited students to participate in longitudinal
primary care offerings. These are a small handful
of clinics or communities across the state in
which a student may elect to a primary care
pediatrics and in some cases women’s health or behavioral
medicine rotations all within one community
or all within one site, depending on the location. We review with students the
availability and the options, opportunities for these and then there is an application process for
students who are interested, though it is important to
be aware that there are a limited number of these spots each year. In terms of preparation
for the clinical year, our team works hard to
partner with students beginning in their
pre-clinical phase of training to ensure that they are well prepared and eager to enter their
clinical phase of training. We’ll provide introductory
informational sessions in November of the pre-clinical year, and then in January, students will meet with their clinical coordinator,
so students will maintain their faculty advisor
throughout both years of the program, but they
will also be assigned a designated clinical coordinator in the second year of the
program and that’s really your person who you wanna share
what you’re interests are, your learning needs and preferences, and that’s sort of your go-to person to help support your
clinical phase of training. Our team will work really
hard to support students in their overall structure and learning throughout the clinical
phase of their training as well as in preparation for it. We ask that students submit
preferences which includes applications to global
health or the longitudinal primary care rotations
as well as submission of their elective requests
at the end of January, and then our team
diligently works to create a large clinical schedule
which is typically released with preliminary schedules
in April and May. No matter where you attend PA school, you will learn the
importance of flexibility in the clinical phase of training. Our program as all programs relies heavily on preceptors across the country to support the ongoing
supervised clinical practice of PA students in the
clinical phase of training and we know that sometimes
unexpected things happen and rotations may get
canceled, so we do stress that these are preliminary schedules. Our hope is that they
remain intact but we do know at some point they will have
to change for some students and we appreciate students’
flexibility in that. And as I mentioned
previously, the clinical year starts in mid-July and it
will finish in late July of the subsequent year. So the transitional course
that we talked about, Bridge: The Path to
Patient Care is two weeks in duration, and it is really
focused on skills-based, case-based learning and
review to prepare students to enter the clinical environment. Students will participate in
advanced cardiac life support training during this
time as well as training for electronic health
records and other sort of onboarding and training modules
for the clinical setting and then students will
participate in the SAPA Oath Ceremony to conclude
the transitional phase of their journey. Evaluation in the clinical
year looks slightly difference than in the pre-clinical
year so I wanna take a few moments and discuss that. Given the limited exposure
that PA students have to clinical training
and the condensed nature of our training, we do
have required attendance in the clinical phase of the program and students customarily
will work the same hours as their preceptors and
so that oftentimes means that on outpatient rotations,
that’s more of an eight to five type of thing,
and on inpatient rotations or rotations within the hospital setting that may be longer hours and, and so that’s sort of our expectation within the allotted duty
hours which we review with students in advance. Students do have discretionary days over the course of the clinical year, which they can request for personal time, things like weddings or
travel or interviews for jobs and there’s a process that outlines that. Clinical courses are
evaluated based on preceptor evaluation and for
required clinical courses and end-of-rotation exam. There may also be written assignments as part of those courses
and then all students are required to log
their clinical encounters throughout the clinical year and that is also part of the breakdown for a clinical evaluation. Students also are required
to have a verification of clinical competency
for the core courses and that is outlined for
students and preceptors as they prepare for their transition into the clinical year. The Evidence-Based Practice
Two course is evaluated through the presentation and abstract as we talked about earlier,
as well as the quality improvement project,
and then there are two large practical examinations
or clinical examinations during the second year, and that is the Clinical Skill
Problems exam which occurs just over halfway through
the clinical year, as well as two summative assessments. One is a clinical summative
exam which we call the CPX exam and the other is a written summative assessment and
those occur within 90 days of the completion of training. As I mentioned, logging
of all clinical encounters is a requirement in the
clinical phase of training. Our students utilize a
web-based system to do this, and what that means is
that they can access it from any device that has internet access and they log this in a
de-identified manner. This allows both the
student and the program to have a better assessment
of what learning activities and what patient encounters and exposures the student is having in the
clinical training environment. We find that we use this
as a program for evaluation of student progression
as well as evaluation of clinical sites and program
accreditation standards and students oftentimes will
need this for credentialing after they graduate, so
more and more frequently now we’re finding that students
need to access this data in order to support
credentialing and onboarding to their initial jobs. As I mentioned, students
do participate in at least a minimum of two rotations
which are out of town, and we define that as at
least 50 miles or greater from the Duke PA Program. When students are assigned
to out-of-town housing with the exception of
out-of-network sites, DPAP, so the Duke PA Program,
will support both funding and logistical planning
for student housing, and we do that through
a variety of mechanisms, typically most students
on out-of-town housing are placed within what
we call the AHEC housing which is the Area Health Education Centers of North Carolina, which
are a very close partner and supporter of our clinical
training programs here. We also maintain two apartments,
one in the Asheville area and currently one in the
Williamsburg area for students. There is also support from
the program for travel reimbursement up to a specified amount. We do require because
of the amount of travel, both potentially to distant locations within the clinical year,
and for regular travel to and from clinical sites
each day that students do have dependable transportation,
which means that we do require students to
have access to a vehicle during the clinical phase of training. As I mentioned previously, support funding and logistical support
for housing applies only to in-network sites, so
if students are interested in one of the out-of-network
sites that I spoke about earlier or proposing
an independent study which I’ll talk about in just a moment, then travel and housing
is at the student expense and is up to them to coordinate. So independent studies are opportunities for students to propose elective rotations which are currently not established within the Duke Health System. This does require an application process and approval by the program
director and clinical team and as I mentioned, travel and housing is at the student expense. We do request that these
submissions for independent studies be for compelling educational reasons and that the preceptor or
site that is identified is both willing to host the student and that they are willing to
support future Duke students. There’s a lot of effort behind the scenes that goes into developing
these sites and we like to be able to pay it
forward to future classes, that is how we’ve been
able to grow our list of really exciting and
interesting out-of-network sites that our current students
have the opportunity to participate in, is by,
is through this ongoing commitment from independent studies. So students also have
the opportunity to return to the clinic, or excuse
me, to return to DPAP throughout the clinical
year for what we call call-back days, and this is an opportunity that occurs at the end of
some rotations, not all, but students come back to the program for a one- to two-day sort
of educational opportunity and this will include sort
of didactic presentations, professional development opportunities, this is oftentimes time for assessment so we do end-of-rotation
exams on these days, we may also do some of our
other clinical assessments that we talked about. There’s also opportunities
for small group sessions and discussions around things
like cultural competency and health literacy and
things of that nature. And an opportunity to start planning for post-graduation events,
so there’s typically opportunities for residency
and fellowship fairs to learn more about
that, we host a job fair as part of these days,
so really over the course of the clinical year our goal is not only to support students academically, but also to really adequately prepare them professionally for transition
into their future roles as PAs. As I mentioned, Duke
hosts their graduation in May, and we do host, we
do have a large celebration, where we invite family and
friends to come and honor the hard commitment that
our students have worked so hard for. It’s a really special
event and one that I think is really cherished by our
students and our faculty alike. It does occur in May as our
program does not complete until August, students have their degrees conferred in September
and their certificate of completion at the end of August when the program completes,
however this is an opportunity to celebrate with the
larger Duke community and the DPAP family and your
family and friends as well. The clinical year concludes
with the Senior Seminar course. It is comprised of a board review course which is produced by the faculty here and is also an opportunity for students to meet with advisors and
have their exit interviews and talk about their
portfolios that they’ve created over the course of their two years. And this course concludes
with a Certificate of Completion Ceremony
and it’s that certificate of completion that allows students to sit for their PANCE. So to summarize our clinical
year, as I mentioned, it is a full year, includes 10 rotations which is comprised of two electives and seven required courses. Students typically will have
greater than 2,000 hours of direct patient care
experience by the conclusion of their clinical year. We also have a full month dedicated to the Evidence-Based Practice Two Course so students can have some
kind of dedicated brain space to think and to work on that,
while not being distracted by other clinical requirements. Students I think really
benefit from an opportunity to practice and experience a diverse group of healthcare environments, both in terms of setting, inpatient and outpatient, as well as communities, so
within the Durham community and within communities across the state and perhaps in other states,
so that they really have a good sense of what they’re looking for in their first job and where
they feel most comfortable, as well as sort of having a really strong foundational educational
background as well. We believe strongly that your
goal in the clinical year is to focus on learning and patient care and that our job is to
manage the logistics and the housing and so
we take care of that for all of our in-network rotations. Students remain connected
to their faculty advisors, their clinical coordinators,
and our community at large throughout the clinical year through call-back days
and email communication and we work really hard
to empower students to transition effectively
into their professional roles. We do, we ensure verification
of clinical competence through a variety of ongoing
exams, practical evaluations and clinical evaluations
throughout the year, and we hear from our
graduates that they feel well prepared to enter the workforce. We have just some employment data for you as that’s sort of the
endpoint of our journey for students as they
conclude their training here. Consistent with our
mission, we are happy to see that about a third of our class ends up in primary care, and
about a quarter of those are practicing in federally designated underserved areas, and the class of 2017, just over 20% ended up in surgery or surgical sub-specialties
and 10% emergency medicine, and a large percentage
of our students ended up taking jobs in internal
medicine or medical sub-specialty practices. That concludes our talk, and we will look forward
to seeing you here at Duke for your interview
day and answering any additional questions
that you might have about the clinical phase
of training, thank you.

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