NWCC Preceptorship Program Leads the Way

Northwestern College of Chiropractic created the preceptor program model for chiropractic education in 1977. It was initiated with the purpose to provide final term students an enhanced clinical experience. The Chiropractic Physicians Associate Program (CPAP), now 12 very successful years old at NWCC, has proved to be a vital part of the complete clinical experience for our students.

All NWCC students must complete all of the council on chiropractic education quantitative clinical requirements for graduation, to be eligible for the CPAP elective. The program does not replace any such requirements, nor does it replace required coursework. Owing in large part to a very strong public clinic service, virtually all students complete the necessary requirements prior to the final, tenth term. Currently, more than 95 percent of the students select the CPAP elective. These students are placed in chiropractic offices not only in Minnesota, but across the United States and in selected foreign countries. Since initiation of the program, more than 1,100 students representing almost 90 percent of graduates have taken advantage of this experiential learning process.

Experiential education is learning by doing. The purpose of CPAP is to allow time for the student to experience a "real world" setting outside of the college. The CPAP model was designed so that students would act in the role of associate doctor, under the direction and supervision of an experienced professional role model or preceptor. By having this one-on-one experience, the student extern observes the clinical decision-making process, the role that the doctor plays in managing a private office, and how the doctor relates to home life and to the community. CPAP is a 15 week experience that allows the student a chance to look into the future, to visualize his or her eventual role as a licensed chiropractor, and to have an additional foundation by experiencing a community role model in the approach to primary patient care. It also builds the confidence of the learner by having the opportunity to "put it all together" in a private practice environment.

Greater confidence has been the result of enhanced patient care skills, and by providing more knowledge of practice management methods. This aids graduates toward making sound decisions and to avoid making costly mistakes. NWCC wants to build self-reliance and self-confidence in its students, rather than dependence upon outside consultants. Our students should possess not only the highest level of professional skills, but also a real enthusiasm for chiropractic care. With greater confidence, one builds greater success through ethical patient management, and achieves a better understanding of the personal responsibility to patients, family, community, and the chiropractic profession.

To date, over 30 states have licensure laws that allow for CPAP or similar programs. At NWCC, there is a rapidly growing trend toward out-placement; learning in offices at a distance from the campus. Approximately 60 percent of current CPAP students are placed outside of the Minneapolis-St. Paul metropolitan area and into other states. CPAP is a first step toward the state or region of eventual practice for many. For some, it offers an experience outside of a metropolitan environment and into small towns and rural communities. Through the placement interview and by careful selection, we have an opportunity to link a particular office with the perceived needs of a particular student. Some students are unsure of their skills in chiropractic methods. Others are concerned about their practice management knowledge. Still others believe that small town life is right for them, but have not yet lived it. CPAP can fill the voids and give the chance to find out about the, as yet, unknowns.

At NWCC, the CPAP is governed by the Clinical Outreach Training Advisory Committee and is chaired by the department director. The committee includes college faculty, students and preceptors. The committee sets the preceptor selection standards, program guidelines, and has created the evaluation process for student performance, preceptor performance, and recommends program refinement.

Through the years the program has changed in response to identified needs. We have established clearly defined program objectives that emphasize professional skills development, practice and patient management experience, and the continued building of awareness and appreciation for the unique chiropractic orientation toward health and disease. As CPAP has evolved, a growing emphasis has been placed on extern education and a diminishing emphasis on the practice assistance needed by the preceptor. Student stipends have been eliminated and have been, in part, replaced by support for housing, if needed.

The college has found the CPAP experience to be of greatest value when there is a focus on hands-on patient care. At this state of skills development, it is very important to continue the learning process under the individual attention of the preceptor. Performance of the chiropractic adjustment is an essential component of CPAP. This is clearly not the time for students to revert to the role of observer. At this important state of development, even more emphasis should be placed on the performance of professional skills.

Evaluations are made by the preceptor of student progress at mid-term and at the end of the term. At least one hour each week is set aside for preceptor-extern formative evaluations, and for discussion of questions or concerns. The college department makes contact with each office during the term to evaluate progress. Most contact is made by phone with occasional site visits. Before entering the preceptorship office, students receive an orientation regarding the guidelines for the program and are instructed to report directly to the college if questions arise. Students are required to create a clinic procedure manual as a term assignment. At the end of the term, students complete a survey of 90 questions that assess CPAP, the preceptor, the preceptorship office, the college preparation for the experience, and the perceptions of personal development as a future doctor of chiropractic.

Over the past three years an assessment survey has been conducted involving more than 300 student CPAP experiences. An analysis of the data has revealed striking results. The findings reported here were included as a part of a presentation entitled "Preceptorship -- The NWCC Model" given at the annual meeting of Federation of Chiropractic Licensing Boards (FCLB) in Las Vegas, Nevada on February 16, 1989.

Questions required a response of: strongly agree, agree, not sure, disagree, and strongly disagree. Results are here reported as agreement, not sure, and disagreement.

A number of questions relate to the preceptorship office:

The clinic to which I
was assigned was a
pleasant environment in
which to see patients.

The clinic office
personnel were
courteous and
professional in their
interactions with
patients and with me.

During my T10
experience, I had an
opportunity to become
familiar with the
patient billing
procedures.

The business procedures
of the preceptor clinic
will serve as a model
for me in private practice.

Certain questions relate to the student's perception of preparedness:

Now that I have
completed three terms
of clinic, I feel that
my preparation for
clinic was as adequate
as possible.

In general, I felt
poorly prepared to make
clinical decisions when
I first entered the
preceptor clinic.

The chiropractic
methods courses I had
prior to entering the
preceptor clinic
prepared me to render
care to patients.

I expected the T10
externship to provide
me with a more
structured experience.

Certain questions relate to the assessment of activities during the CPAP experience:

I have been busy seeing
patients or engaged in
other clinical
activities during most
of my T10 externship.

I saw a variety of
clinical problems in
the patients under my
care.

I expected to see
patients with a broader
range of clinical
problems than I
actually saw during my
externship.

The adjusting
techniques used by the
preceptor I worked with
were different from
those I learned prior
to T10.

I was generally
disappointed with the
number and variety of
patients I saw in the
preceptor clinic.

During T10 there were
opportunities to share
in the clinical
experience of others
through case
conferences, etc.

Included is an estimate of the profile of the preceptorship clinic patient population as cared for by the extern.

Please indicate the approximate percentage of patients, by age group, seen by you in the preceptor clinic.

Children under 12:
Teenagers 13-18:
Adults 18-40:
Adults 41-60:
Adults over 60:

Questions assess the perception and the behavior of the preceptor by the extern.

I feel that the
preceptor is an
effective teacher.

The preceptor I came in
contact with had an
enthusiasm for
teaching.

As I understand primary
care, the preceptor in
the clinic I worked in
was a good model.

The preceptor in my
clinic was helpful and
accessible.

I feel that the
preceptor was often
reluctant to answer my
questions or to help me
with patients.

I received regular and
constructive feedback
from the preceptor
regarding my care of
patients.

I wish that I had had
more direct supervision
by the preceptor when I
provided care to
patients.

Questions assess the perception of acquired knowledge, skills and confidence.

I have learned a lot as
a result of my
involvement with the
preceptor.

I feel more competent
now in history-taking
than when I entered the
preceptor clinic.

During my clinic
experience, I have
become more competent
examining patients.

I now feel competent
with my ability to
perform examinations.

I now feel confident in
dealing with patients
having a wide range of
clinical problems.

My clinical decision-
making ability has
improved while in the
preceptor clinic.

I feel that my skills
in spinal adjusting
have improved during my
preceptor clinic
experience.

I am generally
satisfied with my T10
externship experience.

I feel more confident
now in managing
patients than when I
entered the clinic.

Overall, I consider my
T10 externship to be a
positive experience.

Results of the survey conducted each term are reviewed collectively and individually. Each preceptor is identified in the survey, and concerns are addressed on an individual basis. Individual direction, along with an annual training program, has helped to develop a cadre of well-trained and experienced NWCC preceptors.

As the program expands into new states, qualified preceptors are solicited and are assessed over time. Each state has a preceptor coordinator and works accordingly with state and college requirements. Students enjoy CPAP, and preceptors find the experience to be stimulating and professionally challenging. Best of all, patients accept care from externs and enjoy the spirit that an eager new doctor-in-training can bring.

Northwestern College of Chiropractic has made a commitment to CPAP and to the development of experiential education programs. This term, the Chiropractic Office Observation Program (COOP) begins for early term students to provide an observation experience to chiropractic care, while they are immersed in the study of the basic sciences. This experience helps to correlate the value of basic science studies into a better understanding of the human body, and of chiropractic care in health and disease.

Experiential education is a most valued part of the complete clinical experience. Graduates have identified the CPAP as the singular experience to help to "put it all together"; to create a more competent and confident doctor of chiropractic. The success of the program is dependent upon the dedicated efforts of our preceptors and the quality of the clinical experience that they provide.