The Myth of the Tough Preceptor
I had a reputation as a tough preceptor. I was the one that people either sought out because they wanted the challenge; or the one that they avoided. I thought I held students to a high standard, thought I was tough but fair, and thought that any student of mine who passed through my finishing school was eminently ready for the challenges of the profession.
I considered myself the gatekeeper.
My knowledge was sharp; my clinical skills, even sharper. I was supremely confident that there was nothing they could do that I couldn’t fix. I thought that this confidence would trickle down to my students, and they would also become rock stars by sheer osmosis.
This was the same way that I was taught by my preceptors. The preceptors I learned from were looked upon as demigods. They had swagger, they had confidence, and more importantly, they knew the job better than anyone. They seemed to know, almost preternaturally, who would “make it”, and who would not.
Those who made the cut, succeeded, and those who didn’t ended up not staying. And everyone accepted the methodology. I remember one story a preceptor had told me when I was a student. The call involved a sick patient where the student, who was on the verge of going to boards, pulled out the wrong concentration of epinephrine. Didn’t give it; just took it out of the box.
Let’s be honest; as clinical screwups go, this is very low on the totem pole. Any half-assed preceptor could have corrected this and discussed it after the call, and then everyone could go on. Simple. Easy. And except for an after action debrief, nothing much else other than maybe some homework.
But not in this case.
For this preceptor, this was clear evidence that this student “couldn’t do the job.” As they told the story, a couple conversations with the director of EMS, the medical director, and the clinical management, and the student was gone. Dropped from the program.
After almost two years of work, and a not-insignificant amount of money, that was it. On one person’s interpretation, that was it. Sorry, no glitter patch for you. No immortal number to place you on the long line of paramedics, going back to license number 1. Seriously.
It may or may not be true. But the connotation, especially as a student, was there. That was it. Nobody questioned it. Not one person questioned whether or not the preceptor had the knowledge necessary to make that recommendation. Nobody defended the student. And in the late ‘90s, no one understood human factors, the affective filter, and provider stress to the point that this could be chalked up to just a simple error of a loaded-bandwidth brain in a stressful situation.
That’s how I learned about precepting paramedic and EMT students. You had to make it HARD, see? Because if you didn’t, how would they ever race the Reaper for real? Stress was accepted as part of the job. And if you had a “bad” call, like a traumatic fatality or a pediatric critical patient or a pediatric death, the measure of you as a clinician (we didn’t use that word back then) was how soon you could get back in service and handle the next call.
Everything needed to be committed to memory, because looking up a drug dosage or protocol was considered “weak”. You didn’t “know” it.
So, fast forward, and I was now a preceptor of my own. And I was determined that my charges would meet the same standard that I did.
I was lucky. For the most part, my students did very well, and went on to be excellent paramedics, and leaders in their own right. They have presented at national conferences, been published in peer-reviewed journals, and are considered by their colleagues to be excellent clinicians. They are flight medics, educators, and even physicians. I’ve been really happy to see them flourish.
But was their success in EMS because of me being tough, or was it because they were fundamentally excellent, passionate people? What should the role of a preceptor be?
Did my students succeed because of me, or was it in spite of me?
The idea that some of the students I interacted with may not have made it, because of my indirect or direct actions bothered me. And I started to look inward.
I started having conversations with former students, and I was humbled by what I heard.
While it was true that I was considered a strong paramedic, and a good teacher, in other areas I may have been holding them back.
I learned that my bearing, learned in paramilitary organizations since I was 18 years old; made me look professional. But it also made me imposing, and prone to misinterpretation of my mannerisms. It instilled me with a strong sense of acting professional and reserved; but it also made me seem unapproachable and unable to answer questions that some may have never asked.
I found out my dry, sardonic sense of humor was sometimes interpreted as annoyance or sarcasm. And more importantly, I started to learn that I didn’t know HOW to teach. No one had ever trained me to teach students. Nor was I taught how to understand students.
Let me state that again: Our profession actually spends very little time actually teaching the people we expect to train our future professionals, just how to do it. Sure, I had “instructor” certifications. But once below the surface, all of them were really just how the class should go, which slide pack went at which time, and more importantly how to fill out the administrative stuff so the cards and money flowed the right direction.
No actual theory. No actual understanding of how students think; and certainly no education on the affective domain and how important it is to a student’s success. Nothing prepared me for these simple, but important things.
Your students aren’t going to learn if they’re nervous or apprehensive. And believe me, they are. Think about the last time you had to walk into a room with people you’ve never met before, a team; and you have to introduce yourself and start working with them. It’s hard; isn’t it? And you probably weren’t doing it for a grade, or for your future.
As a preceptor, your job is to put them at ease. Lower the affective filter, as Stephen Krashen says.
Wait. Who? This guy isn’t even cited in PubMed.
Let me go back to what I said earlier. I’m not a professional educator, but my wife is. Jennifer teaches high school French. Now, you’re probably wondering what French language has to do with EMS education or precepting paramedic students.
Whether your student is learning a foreign language, or learning how to treat prehospital patients, we actually want the same goal for our students: production.
All the book knowledge in the world is useless if you cannot on produce that knowledge you’re learning on demand.
For Jennifer, she wants her kids to be able to function in a foreign country and be able to get around, ask questions, and generally stay out of trouble.
And if you think of it, that’s really what we want our students to be able to do in EMS, also. Be able to walk in, function as a crew member, ask the right questions, and stay out of the trouble areas. Krashen talks about three affective domain factors that actually hold students back from production. They are:
(1) Motivation. Performers with high motivation generally do better in second language acquisition (usually)
(2) Self-confidence. Performers with self-confidence and a good self-image tend to do better in second language acquisition.
(3) Anxiety. Low anxiety appears to be conducive to second language acquisition, whether measured as personal or classroom anxiety.
We can apply the same thing to EMS education. Students who are motivated to do well, with self-confidence, and low anxiety tend to do better in paramedic or EMT training than those who don’t.
Admittedly, there is a part of this that we may not be able to help. We’re not medic whisperers or therapists. But, there are things we can do to understand that these factors raise a shield in our students and try to keep their effect to a minimum.
Motivate them to be there. Start by introducing yourself, and your partner or team. Since they’re going to be helping the process, maybe even tell them you’re glad they’re here for the day. If you work in a station, offer them coffee or water, and talk to them. Ask them how they’ve been doing in training, and what they feel they need to work on. If they don't say anything specific, ask what roles are they comfortable with on calls. Ask them how familiar they are with the equipment you carry, and offer to show them. Don’t just throw them the keys to the truck as you’re ignoring them and expect them to check the entire vehicle.
We have to give them confidence. Confidence that they’re in a safe space, where they can learn without fear of being ridiculed or put into a bad position by people they need to trust to succeed.
Lower anxiety. Preceptors should be engaging with students, not the other way around. Encourage questions. I actually had a student who related to me that on other units during their field internship that they were limited to three questions per shift.
Three.
You can imagine how that made this student feel. How intimidating that was, and how it basically inhibited them from feeling comfortable for the rest of the shift. Now, think about the damage to their self-confidence, motivation, and anxiety level. Ask yourself this: How would YOU feel? The clinical hours were achieved; but I doubt seriously any effective learning was done there.
How can we ever make better clinicians this way?
If this sounds like you, or you think that this is the way to treat your students, it’s time for tough love. You need to fix yourself or stop taking students.
Period.
You can’t dislike the job or think every call you go on is BS, and expect to be able to teach a student effectively. Part of the job of a preceptor is to be an example for the student to emulate in terms of their professionalism and how they embrace the job. It’s not easy; and if you can’t do it; it’s time to step away. It’s not worth the extra money to be honest. Don’t drag them down.
So how can we make this happen?
Engage your student. I talked about this earlier, but it can’t be over stressed. How your student is handled in the first few minutes will color the entire shift. And to a large extent, those few first minutes will have a huge impact on how the shift will go.
Show them around if they are not acclimated, and be willing to explain equipment and things they may not have seen before. Don’t assume that since they are in field internship that anyone has taken the time to do so. Ask them, you might be very surprised.
Have an honest discussion about what the expectations for the shift are; both yours and theirs. Is there something they want to work on specifically? Are they looking to take on more responsibility, such as a team lead? Do they need procedures, assessment, or hands-on practice with the tools of the trade? This is their time for them to learn, and you are the person who can unlock those things for them.
This is a great time to speak to them about how you like to do things, especially if you work on a steady crew or have a regular partner. Realize though, that just because YOU do it one way, does not meant that your student is duty-bound to follow you exactly. Goals here should be thoroughness and completion of the tasks of patient care in a clinically acceptable manner. You may like to do things in a certain way. If your student does it differently; that’s OK as long as the overall goal is met.
During patient contacts, realize that although YOU may have seen it all, your student may not have. And “the book” is a poor substitute for the real world, or the first time they do a procedure on an actual patient. Don’t expect they will do it smoothly, and expect that you may have to help them or talk them through it.
This isn’t weakness, nor is it a sign of a sub-standard student. It’s the hallmark of a person new to an experience that is full of sensory overload. And we need to recognize it and be good with it.
The key to better clinicians is giving them a safe environment to practice under supervision, so that they develop confidence and eventually, entry-level competence. But you can’t have the latter without the former. If you don’t lower their affective filter and address their sympathetic nervous system; you are never going to get them where they need to be. Simply put, they have to be allowed to make errors and fail procedures in a environment of patient safety, because you have to provide the safety.
Obviously, there are limits to this, and as a preceptor you need to be aware when it is time for you as the experienced clinician to step in and take over from the student. This is where the hard work comes in, because you are responsible for the care of that patient. Also, you have to be aware where repeated attempts at a procedure, like an IV for example, may start hurting your student’s self-confidence. It’s a delicate balance. But again, think of the patient and be an advocate.
Following each and every patient care encounter, debrief, debrief, debrief. I can’t stress this enough. Even in a busy environment, there should be time for at least a 2-3 minute hot-wash of the call. If you can do more, great; but this is a bare minimum.
A debrief for a student is a critical event. It’s where they actually get to learn what happened on the call, what they got right and what they missed, how experienced preceptors saw and did what they did, and why. This is where they get the lessons imprinted on their brains in a less chaotic and dynamic environment. It has to happen each time. Ask about what they did; but also, ask them how they felt. Feelings give insight, and you may be able to understand more fully what happened on the call if you know what the student was feeling at that time.
Recognize that on critical calls, or major “firsts” in the student’s training, that they may need some time to process. Your first really sick pediatric, cardiac arrest, or trauma leaves an imprint. As preceptors, we can help to mitigate the potentially harmful effects of these incidents by acknowledging their feelings and helping them to process.
If you’re lucky enough to to be able to go back and follow up on patients, do just that. Talk to the treating nurses, mid-levels, or physicians and ask about what they found. Imaging, labs, and ED level care has strong value in reinforcing why a case went the way it did, or how we can learn for the next one. You can then add to the learning process by giving them information on definitive care and how what they did fits into the spectrum. It also stimulates discussion and further learning. This is where you can stimulate follow-on learning with some articles, peer- reviewed studies, or even podcasts and video casts to reinforce what they just experienced.
If a student asks a question and you aren’t sure of the answer, don't make up an answer because it feels good to you. Use it as a research opportunity and look it up. This is a credibility issue; because you may get away with it for this shift. But they’ll know. They’ll talk. And your reputation will suffer. There’s no shame in finding limitations to your knowledge. Today’s paramedic students are exposed to more evidence-based medicine than ever before. You may even find out something new for your practice. And it may be a confidence-builder for a student to hear honestly from a preceptor, “Nope, never seen that before. Let’s do a deep dive!”
Allow them to have downtime. Constant study or questioning wears people down, and students are no different. If the vehicle is stocked and the admin work is done, students should be allowed to rest their brains. It helps processing and allows for better information absorption.
When you fill out the evaluation at the end of shift, be realistic. What we are striving for with a student is “entry-level competence.” That means: Can they do the job effectively as a brand- new licensed paramedic? Not as a 5-10 year provider; can they handle the relatively uncomplicated calls for service with a minimum of assistance? You should’nt expect a student to be able to handle a really difficult case on their own, we want to see if they can hit fastballs consistently.
Discuss the evaluation with the student, and provide some ideas for them to work on in future shifts. If they didn’t meet the standard, you need to take the time to explain that to them, and you need to give them a way to fix it. Tough love may be needed here; but it’s about the only time you should need it during the shift.
Finally, remember as preceptors, it’s not up to us whether or not someone will “make” it. That’s a decision between students, faculty, and medical directors. Every little turtle may not make it to the ocean; but we have a responsibility to make sure as many of them as possible do. That’s the job of a preceptor. Not a gatekeeper, but someone who can teach how to get over the bar.
I was lucky. Eventually, I attended training that opened my eyes to the realities of precepting, and on self-reflection, I think I’m a better preceptor.
It’s hard. But if you want to improve the profession and leave the place better than when you found it, there’s honestly nothing better in EMS. We just need to do better. Our students deserve it. The patients need it. And if we really want to see lasting change, it will be with the future of our profession.
Steven Krashan and the Affective Filter Hypothesis:
https://www.sk.com.br/sk-krash-english.html
Check out 579 Solutions for preceptor education at:
www.579solutions.com
