Feeling like a failure

[NP621]

Just in need of some advice. I just finished my first clinical after a few months in health assessments. I just got my review back from the doctor and he basically did not think much of me. I got all good scores on professionalism and inter office relationships, but he said I was lacking a medical knowledge base and felt like I did not engage myself. After I had a bowl of ice cream, I figured that I did not agree with all of his assessment. My question is how can I show him that I am more engaged when he is so busy and basically walks out when I give him my assessment of the patient? Next, I have spent days pouring over medical knowledge and there is so much out there I have become stressed out!! I do have a knowledge base since I have been a nurse for four years, and I was just in assessments. We start disease management in the summer. Where do I start? I feel as though I am following the NP program successfully, but he expects I should know more. I would try and find a different doctor, but Preceptors are scarce. Thanks in advance for any advice ! :)

[Olgelena]

Hi there! I am finishing up NP program and after almost 700 clinical hours, I can assure you, your clinical preceptor will never be absolutely happy with you. Actually throughout my entire clinical experience all I heard was just harsh criticism from MD staff and it got me to think: why? The answer is pretty simple. They are just not used to us and our knowledge base makes them feel uncomfortable. They are used to medical residents, because even 1st years know much more theory than first year NP students. Why? Well they just had 5 years (!!!) of non-stop medical studying, and we had one semester plus countless days of nursing practice that besides analytical thinking involves cleaning up patients and running errands. We enter the healthcare arena completely unprepared and expected to function as residents. Like one of my preceptors said, you are neither fish or fowl, people do not know what to do with you. However even though harsh criticism never ceased, I realized WHY it's important for us to be where we are. Even though I could not answer my preceptor what was renal tubules acidosis and read kidneys as glands on the CT, I knew damn well when my patient was in trouble. I developed that valuable innate sense of emergency from being a nurse which you cannot find in any book. And that was noted and greatly appreciated. Here is how you need to survive this nightmare: just like residents do, jump in and learn. Forgive yourself for not knowing and give yourself another chance to learn. Ask many questions. In every clinical rotation that you are going to have there will be just a handful of common conditions and treatments. Spend finding out first couple of clinical days on what they are and read up. Every time your clinical preceptor points out your knowledge deficit, do not get upset, instead get all the info from him and read about it. Try to read about it right away ( there is never enough time to do it at home). Cheat! Download phone apps (Medscape, epocrates) and look up patients' diagnosis before presenting the case to the preceptor. Do not be afraid to suggest what you think it is, even residents ( especially residents) do not have right answers all the time. And definitely find another doctor, not because previous one didn't think much of you, but because it's a better learning opportunity, some doctors like to teach more than others.

It's unfortunate that they make all of us start clinicals in the assessment course. t's very introductory and doesn't teach you entire SOAP process. Later on, during your other Np courses, you are going to look back and know EXACTLY why you struggled. You just didn't know how to do it right, nobody taught you that yet. Unfortunately your preceptors are never going to adjust to your school curriculum. You cannot come to the Primary care and say, well I learn only how to assess, I don't know how to treat. Preceptors like to use you as additional free labor, and they will make you do the entire process.

Don't get frustrated, we all felt like fools in our first clinicals, it does get a little better. And don't be afraid to take patients: think about them as same patients you treat in the hospital - nothing changed, only its you now wearing a thinking cap.

P.S. I heard that NP preceptors are even harder on the students.

P.P.S Also there is such thing as chemistry with the preceptor; sometimes no matter what you do, you can't get it. Always try to have a back-up preceptor for each semester, so if you feel like things with the other one not going well, you can jump the ship.

[SHGR, MSN, RN, CNS]

I would practice staffing your patients (concise, to the point) so that when you are with your preceptor again you will be able to convey the info quickly. Are you using SBAR format? You might know the stuff backwards and forwards, but you have to get it across.

[BostonFNP, APRN]

This is case-in-point why NPs should precept with NPs, especially in the first rotations. While most MDs are great teachers with a huge knowledge base they don't necessarily understand the NP model of education: medical students have front-loaded education and rear-loaded clinical, if he is used to the medical model, he doesn't understand you have very limited knowledge during your first rotation. I am sure you have lots of nursing experience and you work hard in school and out but the truth is at this point in your ed you are a pre-novice.

A critical preceptor will make you a better provider, so you can be comforted by that. Remember the medical model is much more critical on students.

Take all your feedback as motivation to improve your practice. Shorten your case presentation. Assert yourself. Give a differential and a plan.

[ryguyRN]

I just finished my first clinical semester at a rural internal medicine clinic. I can relate to the OP, I was first with a NP who I was fine with and she with I. But as the semester tension grew in the office when the NP decided she had had enough of the low pay and berated almost everyday by her collaborating physician. She left about half way in the semester and that left me in an awkward spot, so I had to stick it out with this physician for about 90 more hours that I needed. This physician was very intelligent but he was not good at teaching or working well with students. He made the time with him more and more unbearable as the semester progressed as if he wanted to see me fail or drop out and not finish the hours. This semester has been a grind for me as well, just wanted to let you know your not the only one having trouble with docs as preceptors.

[Corey Narry, MSN, RN, NP]

I think it's all part of NP programs not making sure that we have preceptors who are vetted into the teaching role regardless of who it is (physician or NP). It's not about being smart because any random NP or MD we find is not always going to be a good teacher. It takes a certain kind of person to have the patience to be a teacher in a clinical setting. Not everyone is good at it and I've seen NP preceptors who fit the "bad teacher" profile. It would really help if we could standardize NP education so that each school would have a group of academic NP's in clinical practice whose role is to precept similar to how residency programs are set-up. But I know that's not realistic at the pace our NP programs are accepting students.