Are paramedic precepting/evaluations of paramedic “students” too subjective?

Replies to This Discussion

Permalink Reply by Chance Gearheart on August 6, 2009 at 9:08pm

1) The practice of paramedicine is primarily based on anectdote and tradition at this current time. We're doing better in falling in line with scientific studies and better practices, but it will always remain this in some capacity. The judging of paramedic students will be based on this as well, and based on the preceptors perception of how well they perform based on how they were taught and the accepted standards of the service or facility in which they do their clinicals.

2) As far as I know, there are NO programs that base their success or failure of paramedic students by the word of a single preceptor alone. And if they do, they open themselves up for significant legal risk. Also, AFAIK, Nursing Interns are evaulated the same way by their preceptors. However, if you have a significantly low score on a paraemdic preceptor, it does warrent some investigation.

3) I believe the Center for Accredation of Allied Healthcare Programs has guidelines for EMT-Paramedic Preceptors: http://www.caahep.org/documents/ForProgramDirectors/EMSP%20Final%20...

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Permalink Reply by Rob Robbins on August 6, 2009 at 9:28pm

Chance, you wrote in item 2: "As far as I know, there are NO programs that base their success or failure of paramedic students by the word of a single preceptor alone. And if they do, they open themselves up for significant legal risk. Also, AFAIK, Nursing Interns are evaulated the same way by their preceptors. However, if you have a significantly low score on a paraemdic preceptor, it does warrent some investigation."

Is there as "standard" of how many preceptors a student can go to throughout their 720 hours of field internship. Or is this at the discretion of the college? Private trade schools dont offer "degree's", but some are affiliated with colleges. I know of one person that was failed from their internship and was unable to graduate with her class and earn the AS Degree in EMS. She already has a BS degree, but wasnt able to complete her AS in EMS with out completing her field internship. Its just unsettling to me!

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Permalink Reply by Chance Gearheart on August 6, 2009 at 9:40pm

Not every college follows the hours required options, Rob. Mine, and many in Tennessee, follow the patient-contact model.

As far as the clinical evaluation criteria for students, by regulations they have to be approved (atleast at the college I went to) by both a committee consisting of the State EMS representitive, a representitive of each of the major ambulance companies/fire departments in the service region, the program medical director, and the Tennessee Board of Regents. The sheets we have are very clear in the criteria they have to use in grading us, and they are taught that as well in a class - We cannot just go to a paramedic and ride, or go to an ER and work, they have to have been through a three day class. We also ride at multiple services, so we have multiple preceptors as well. Anything graded as below average or failure level must be sent to the preceptor along with a detailed reason for doing so. We actually have a review committee they go through before any decision is made.

Something very unsettling about that program to me too, when one preceptor can be the basis of a pass or fail for that student. What exactly was the issue the preceptor had with her?

Rob Robbins said:

Chance, you wrote in item 2: "As far as I know, there are NO programs that base their success or failure of paramedic students by the word of a single preceptor alone. And if they do, they open themselves up for significant legal risk. Also, AFAIK, Nursing Interns are evaulated the same way by their preceptors. However, if you have a significantly low score on a paraemdic preceptor, it does warrent some investigation."

Is there as "standard" of how many preceptors a student can go to throughout their 720 hours of field internship. Or is this at the discretion of the college? Private trade schools dont offer "degree's", but some are affiliated with colleges. I know of one person that was failed from their internship and was unable to graduate with her class and earn the AS Degree in EMS. She already has a BS degree, but wasnt able to complete her AS in EMS with out completing her field internship. Its just unsettling to me!

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Permalink Reply by Rob Robbins on August 6, 2009 at 10:02pm

She has zero experience in a 911 system. Prior to paramedic school she worked as an EMT for a private company doing just interfacility transfers. She graduated number one in her class and was very successful in her clinicals. When she began her field internship, she entered into a whole new world for her that, as you know, requires "scene" management. Granted I wasnt there, but from what I read she was where she should be at 420 hours respecting the fact that this was all new. At 420 hours she was told that she had failed, and will fail at 700 hours, and basically told her she was waisting her time trying to crendential as a paramedic when there was no reason to continue the internship because, "this may just not be for you".

What's unsettling is she is very smart and per her evaluations was progressing, maybe not as fast as perhaps someone with 911 experience, but nevertheless progressing as she should have with only 420 hours of experience in the 911 system...and now being in charge. I just remember in 1982 when I was in my internship at 312 hours I took a nose-dive, but recovered on my 17th shift and was successful at 480. This was a time that at hour 2 if your preceptor failed you you were out...period! I am just stumped on this one and wish I knew more.

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Permalink Reply by Holice Meeks on August 6, 2009 at 11:05pm

Think I have been subject to the same school, think we would have come out better following the hours instead ?

Chance Gearheart said:

Not every college follows the hours required options, Rob. Mine, and many in Tennessee, follow the patient-contact model.

As far as the clinical evaluation criteria for students, by regulations they have to be approved (atleast at the college I went to) by both a committee consisting of the State EMS representitive, a representitive of each of the major ambulance companies/fire departments in the service region, the program medical director, and the Tennessee Board of Regents. The sheets we have are very clear in the criteria they have to use in grading us, and they are taught that as well in a class - We cannot just go to a paramedic and ride, or go to an ER and work, they have to have been through a three day class. We also ride at multiple services, so we have multiple preceptors as well. Anything graded as below average or failure level must be sent to the preceptor along with a detailed reason for doing so. We actually have a review committee they go through before any decision is made.

Something very unsettling about that program to me too, when one preceptor can be the basis of a pass or fail for that student. What exactly was the issue the preceptor had with her?

Rob Robbins said:

Chance, you wrote in item 2: "As far as I know, there are NO programs that base their success or failure of paramedic students by the word of a single preceptor alone. And if they do, they open themselves up for significant legal risk. Also, AFAIK, Nursing Interns are evaulated the same way by their preceptors. However, if you have a significantly low score on a paraemdic preceptor, it does warrent some investigation."

Is there as "standard" of how many preceptors a student can go to throughout their 720 hours of field internship. Or is this at the discretion of the college? Private trade schools dont offer "degree's", but some are affiliated with colleges. I know of one person that was failed from their internship and was unable to graduate with her class and earn the AS Degree in EMS. She already has a BS degree, but wasnt able to complete her AS in EMS with out completing her field internship. Its just unsettling to me!

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Permalink Reply by Holice Meeks on August 6, 2009 at 11:09pm

That is scary, why would a program allow one person that much control. People by nature are falable and make mistakes. One would think that there would be a system of checks and balances...

Rob Robbins said:

She has zero experience in a 911 system. Prior to paramedic school she worked as an EMT for a private company doing just interfacility transfers. She graduated number one in her class and was very successful in her clinicals. When she began her field internship, she entered into a whole new world for her that, as you know, requires "scene" management. Granted I wasnt there, but from what I read she was where she should be at 420 hours respecting the fact that this was all new. At 420 hours she was told that she had failed, and will fail at 700 hours, and basically told her she was waisting her time trying to crendential as a paramedic when there was no reason to continue the internship because, "this may just not be for you".

What's unsettling is she is very smart and per her evaluations was progressing, maybe not as fast as perhaps someone with 911 experience, but nevertheless progressing as she should have with only 420 hours of experience in the 911 system...and now being in charge. I just remember in 1982 when I was in my internship at 312 hours I took a nose-dive, but recovered on my 17th shift and was successful at 480. This was a time that at hour 2 if your preceptor failed you you were out...period! I am just stumped on this one and wish I knew more.

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Permalink Reply by JB Wallace on August 12, 2009 at 10:49am

Please see Field Training Officer: Tips and Techniques for FTOs, Preceptors, and Mentors, by Bruce Nepon and Barry Eberly; Jones and Bartlett Publishers, 2008. This is an outstanding book and it objectifies criteria for evaluating performance in the field. I can't say enough good things about this manual!

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Permalink Reply by Skip Kirkwood on August 12, 2009 at 11:06am

1. The field practice of EMS is a subjective art. You can't objectively evaluate something that is inherently subjective.

2. If we have untrained preceptors, then shame on the schools and the agencies. Preceptors should be trained to do what the school or the employing agency (for FTOs) want them to do.

3. NO! We can't even agree on levels of certification. We absolutely DON'T need another bureaucracy!

The law enforcement community has a generally accepted standard of practice for FTO programs, using what is known as the "Kaminsky method" or the "San Jose" model. It has been in use in EMS, adapted for the EMS community, for at least 15 years. It could be adapted for schools to use for pre-service field time. However, it requires some work. And I've seen very few schools invest much effort or money in to the field internship time for their students. Mostly they seem to want to "get the hours done" rather than to graduate a functional, field ready paramedic. That responsibility has been "transferred" to employers, who now have to pay for longer and longer field training programs.

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Permalink Reply by asysin2leads on August 12, 2009 at 12:51pm

This sounds like much more of a problem with the preceptor, rather than the patient. Obviously he had a beef that she had no experience as an EMT in the 911 system, and he was going to make sure everyone knew the tired old "BLS before ALS" crap. I hope she found a different preceptor and that guy posing as a paramedic is working at Denny's, where he belongs.
If a teacher says "There is no way this student is passing," that says much more about the ability of the teacher, rather than the ability of a student. Give me someone who has gotten good grades n their didactics, good grades in clinicals, and struggling in the field, and I'll show you one with lousy preceptors. I think this is obvious evidence of the need for standards for precepting.

Rob Robbins said:

She has zero experience in a 911 system. Prior to paramedic school she worked as an EMT for a private company doing just interfacility transfers. She graduated number one in her class and was very successful in her clinicals. When she began her field internship, she entered into a whole new world for her that, as you know, requires "scene" management. Granted I wasnt there, but from what I read she was where she should be at 420 hours respecting the fact that this was all new. At 420 hours she was told that she had failed, and will fail at 700 hours, and basically told her she was waisting her time trying to crendential as a paramedic when there was no reason to continue the internship because, "this may just not be for you".

What's unsettling is she is very smart and per her evaluations was progressing, maybe not as fast as perhaps someone with 911 experience, but nevertheless progressing as she should have with only 420 hours of experience in the 911 system...and now being in charge. I just remember in 1982 when I was in my internship at 312 hours I took a nose-dive, but recovered on my 17th shift and was successful at 480. This was a time that at hour 2 if your preceptor failed you you were out...period! I am just stumped on this one and wish I knew more.

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Permalink Reply by Rob Robbins on August 12, 2009 at 5:36pm

Skip you’re obviously a very intelligent person who has perhaps been in management too long, and sadly perhaps, have lost focus of the true objectivity of the science of delivering out of hospital care. Subjectivity is the judgment based on individual personal impressions and feelings and opinions rather than external facts. By definition, an intern/student has X hours to demonstrate proficiency, (e.g., skillfulness in the command of the fundamentals of paramedicine deriving from practice and familiarity; "480-720 hours of practice greatly improves proficiency" cognitive, affective, and psychomotor). Remember Skip this training is academic in practical methodology and cannot be compared to post hiring nor credentialing because the “candidate” is an employee, and the student is a learner in the academic setting….two separate things here.

This burden of the “employer” fundamentally speaking, to train an individual is ridiculous by the mere fact it’s so subjectively psychosocial and the candidate already credentialed. Go to any hospital and you can ask about X doctor and be told he/she is the worse doctor ever to graduate from medical school, or nurse, PA, NP or RT or EKG tech. Nevertheless, you led your question with “is Dr. Smith…..” I will never be convinced or persuaded away from the fact that paramedic training should remain academic.


Skip Kirkwood said:

1. The field practice of EMS is a subjective art. You can't objectively evaluate something that is inherently subjective.

2. If we have untrained preceptors, then shame on the schools and the agencies. Preceptors should be trained to do what the school or the employing agency (for FTOs) want them to do.

3. NO! We can't even agree on levels of certification. We absolutely DON'T need another bureaucracy!

The law enforcement community has a generally accepted standard of practice for FTO programs, using what is known as the "Kaminsky method" or the "San Jose" model. It has been in use in EMS, adapted for the EMS community, for at least 15 years. It could be adapted for schools to use for pre-service field time. However, it requires some work. And I've seen very few schools invest much effort or money in to the field internship time for their students. Mostly they seem to want to "get the hours done" rather than to graduate a functional, field ready paramedic. That responsibility has been "transferred" to employers, who now have to pay for longer and longer field training programs.

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Permalink Reply by Skip Kirkwood on August 12, 2009 at 5:45pm

First of all, you have no right to judge me, thank you very much. I will appreciate it if you keep your comments professional, and not make uninformed conclusions about why I believe what I discuss.

Candidates for employment, in EMS agencies or hospitals, are not already credentialed. They have a state license, which is not the same as being credentialed to practice in that hospital or EMS system. Bring your NREMT-P and your NC paramedic license to Wake County, and it will take you another 6 months or more to get credentialed to practice in the system. Hospitals call the process "granting privileges" to physicians - same process.

You describe the very flaw I was pointing out (perhaps too long in academia?) - being a paramedic is not about doing procedures and being proficient therein - it is at least 90% interpersonal communications and getting along with patients, families, and co-responders. Please tell me how you objectify (meaning that it will withstand the tests of statistical validation) those? Perhaps the fact that this is NOT part of what our educational programs deliver is why our field training programs have extended from six months, to a year, to...

The physician education process has closed the gap between school and practice with the residency. EMS agencies still have no choice but to hire individuals for whom that gap has not been bridged, the way that "field experience" is structured and conducted today.

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Permalink Reply by Rob Robbins on August 12, 2009 at 6:32pm

Skip, by no means am I judging you and I sincerely apologize if I gave that impression. I honestly think you’re very thought provoking on the topics you address. Furthermore, credentialing is a broad meaning word that I perhaps didn’t use properly. My point is these paramedics are “licensed” “certified” “accredited” “credentialed to enter in to practice because they have graduated and were successful in licensure exams….or what ever you want to call it….to obtain employment with X agency, the candidate needs to be successful in the “accreditation” “credentialing” for that jurisdiction….but in order to get to that, the individual has to be offered employment first at that level of certification. I am still “licensed” in the State of California as a paramedic, but don’t work as a paramedic.

I’ve already attended and was successful academically and met all requirements for state licensure. What I am saying here is that I am concerned that there is no regulatory authority to govern…in true academia you have advisors, and with out my advisors I would have never been successful getting through my doctoral thesis or fellowship…I was a part-time graduate student and a full-time paramedic…Skip I had no idea what I was doing…I was very smart academically coupled with an EMS “fix” the problem and move on mentality….and I can tell you with conviction my advisors and senior fellows were very “objective” which contributed to my success. The point is that we need to be less subjective and more objective. I just don’t feel it’s the place in academics for any one person (preceptor not FTO…two different roles) to be in a teaching role to be telling students that perhaps they choose the wrong college course and that they have been wasting their time and money over the past 18 months….where does the student go from there?


Skip Kirkwood said:

First of all, you have no right to judge me, thank you very much. I will appreciate it if you keep your comments professional, and not make uninformed conclusions about why I believe what I discuss.

Candidates for employment, in EMS agencies or hospitals, are not already credentialed. They have a state license, which is not the same as being credentialed to practice in that hospital or EMS system. Bring your NREMT-P and your NC paramedic license to Wake County, and it will take you another 6 months or more to get credentialed to practice in the system. Hospitals call the process "granting privileges" to physicians - same process.

You describe the very flaw I was pointing out (perhaps too long in academia?) - being a paramedic is not about doing procedures and being proficient therein - it is at least 90% interpersonal communications and getting along with patients, families, and co-responders. Please tell me how you objectify (meaning that it will withstand the tests of statistical validation) those? Perhaps the fact that this is NOT part of what our educational programs deliver is why our field training programs have extended from six months, to a year, to...

The physician education process has closed the gap between school and practice with the residency. EMS agencies still have no choice but to hire individuals for whom that gap has not been bridged, the way that "field experience" is sttructured ann conducted today.

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