Yale PA didactic year impressions

Back in 2013, I was making a decision familiar to every prospective PA student: which PA programs to apply to.

Hours of research into each program’s qualities added up to a loosely ranked wishlist; the price of applying being roughly $200 for the first program and $100 for each additional program, nobody wants to apply to programs they can’t get into, or programs they wouldn’t want to attend.

The Yale PA program emerged as an early front-runner in my selection, thanks to a combination of Yale’s well-known socially progressive leanings (which would align well with my own), its affiliation with the Yale MD program (suggesting high quality of education), and its dual PA/MPH degree offering.

As I later went on to interview at several programs, Yale continued to impress me. The program director at the time (Jim Van Rhee) spoke of the ongoing transformation of the program from a lecture-centered pedagogy to problem-based learning. Problem-based learning had worked well for me in my previous undergraduate and graduate days, and I was excited about continuing with that approach as I transitioned into healthcare education.

The program also advertised its preference for independent learners — and as someone who’s spent countless hours researching esoteric topics in science and engineering to satisfy my curiosity, this appealed to me.

And so I applied, and was wait-listed, and reapplied, and was accepted into the joint PA/MPH program at Yale. I started public health didactics in the fall of 2015, and PA didactics in fall of 2016.

Shortly after starting with PA didactics, I learned that the program I interviewed at no longer existed.

In 2016, Jim Van Rhee left his post as the director of the Yale PA program, and transitioned to his new role as the director of the nascent Yale PA Online program.

The online program was to be run as a completely separate entity from the existing on-campus program, and as Jim Van Rhee departed the on-campus program, so did his pedagogical inclinations. Problem-based learning initiatives evaporated, and the on-campus program rapidly returned to its predominantly lecture-based didactic format.

I was not particularly enthusiastic about a lecture-based curriculum, but I figured at least — being at Yale — I’d be getting an excellent lecture-based curriculum.

Revolving door of lecturers

The didactic content during the first year of the Yale PA on-campus program is delivered almost entirely by Yale School of Medicine (YSM) faculty; the portion of the didactic curriculum delivered by the core PA faculty is both small (in terms of hours delivered) and narrow (in terms of subject areas covered).

At the same time, most of the YSM lecturers make only a brief appearance during the didactic year. During the first semester, ~240 total lecture hours (not counting exams or labs) are delivered by ~120 different lecturers. Of those, over 80 lecturers deliver only a single lecture.

From what I’ve been able to piece together, this structure is driven by pressures external to the PA program. YSM’s abundance of research faculty seems to lead not only to a general glut of lecturers, but also to lecturers for whom teaching is neither a priority nor a forte.

The end result, then, are lectures that lack coherency at many levels. It was common for our lecturers to ask the students mid-lecture whether a specific point had been covered by other lecturers, or to begin their lecture by asking the students how long the lecture was supposed to be.

This incoherence lead to a variety of failures, some more egregious than others. On more than one occasion, a lecturer — upon learning that information they needed us to already know had not been previously covered — decided to launch into a mini side-lecture before they could return to the main topic of their lecture.

Perhaps the most glaring error of this type came from a lecturer who informed us they would assume a particular topic had been previously covered by someone else… for a topic they were supposed to cover.

Mediocrity of lectures

Some lecturers at the PA program (including some YSM lecturers) are exceptionally good teachers; some are even able to bring memorable entertainment to material that is inherently dry.

At least as commonly, they are exceptionally bad. Every hallmark of inexpert lecturing was exhibited by some lecturer: spending the entire lecture looking at the projector screen; declaring upfront that the solution to having a lot of material to cover is to talk fast; muttering inaudible tangents into one’s own lapel; erratically flipping back and forth between slides multiple times per second; and so on.

Most lectures were mundane and uninspiring; the kind you sit through and then get on with your life. Many lectures were neither as informative nor as well-presented as the half-dozen videos on the same topic readily available online.

Lecture slides, too, were mediocre at best. From font sizes illegible from the back row of the lecture hall, to line graphs displayed on a photo background, to typos in nearly every lecture, to acronyms not explained before use — these were not documents created with attention to detail, or even elementary familiarity with principles of good design and clear scientific communication.

I assume that none of these individual lecturers aspire to be mediocre-at-best. More likely, I suspect, is a lack of institutional incentives and support. This shortfall in institutional support was particularly evident with lecturers who apologized for the quality of their lectures — suggesting that, even though they knew there was much room for improvement, they lacked resources or incentives to pursue it.

YSM has a Teaching and Learning Center, whose mission is to “foster excellence in education”. However, from the viewpoint of my PA didactic year, this mission was aspirational at best. Excellence was manifested in only a small portion of the curriculum, delivered by a handful of educators.

(Lack of) interaction in learning

With the didactic curriculum built around slide presentations, the program lands squarely in the comfort zone of higher education — a comfort zone that, unfortunately, results in uncoordinated mediocrity, and falls far short of what I hoped to get from a world-class institution aspiring to excellence in education.

Today, slide presentations compete with free (or cheap, in comparison to Yale tuition) online content. The “talking head” and the “hand at blackboard” styles of content delivery have been used by numerous online medical education outfits, often with excellent results.

Consequently, a competitive classroom-based slide presentation has to be at least as well-rehearsed, entertaining, and informative as a good YouTube video; ideally, it would reach — or exceed — the quality level of a TED talk.

Alternately, classroom education can compete with online materials by relying on the strengths of classroom presence — strengths such as conversation, debate, and collaboration.

Unfortunately, most of our content did neither; lecturers largely stuck to the tried-and-true slide presentation format (thus giving up most of the benefits of a live audience), while simultaneously delivering lectures that weren’t as good as cheap online materials.

As a result, our didactic days frequently progressed from sitting in lectures all day to talking about which YouTube videos to watch to make sense of the lectures. Day after day, my drive for independent learning was squandered.

Case discussions were among the most interactive of our classroom content, and consisted roughly of one or two hours in small groups, out of every 30-40 hours of lectures. Unfortunately, even case discussions were often delivered by teachers who weren’t sure what material we had covered, thus replicating many of the problems from our lectures.

Interprofessional learning

It’s 2017. Having aspiring nurses, PAs, and MDs learn together and work together is still considered to be at the forefront of medical education.

And by that standard, Yale is at the forefront.

Yale’s interprofessional education initiative — the Interprofessional Longitudinal Clinical Experience, ILCE — encompasses first-year APRN, PA, and MD students at Yale. It was piloted to a subset of students in each program in the past years, and rolled out to all first-years in 2016-2017.

Setting aside teething problems inherent in scaling up a new program to several hundred students, ILCE generally succeeded at capitalizing on the strengths of on-campus presence.

The lecture and simulation portions of ILCE were run by a small and well-organized group of faculty, all of whom appeared to be on the same page regarding the curriculum and the objectives of the program. And while the clinical portion was delegated to a larger group of clinical preceptors, each preceptor spent roughly 20-80 hours with their assigned preceptees — thus creating a learning experience that had consistency and continuity.

Unfortunately, innovative efforts like ILCE are hamstrung by the disorganized structure of the didactic year of the on-campus PA program.

A faculty consisting of hundreds of lecturers, most of whom invest roughly an hour each year into PA education, is essentially impossible to steer. Any time new didactic content is added that cuts across many topics, it cannot be added to each topic, as that would require coordinating changes across dozens or hundreds of lecturers; instead, it is added as a separate topic.

For example, transgender health was not mentioned by the lecturers covering breast cancer, or testicular cancer, or ovarian cancer, or reproductive health, or adolescent health, or any other lectures in which it was plainly pertinent. Instead, it was covered in a separate pair of lectures — thus recreating marginalization of trans people in healthcare.

Similarly bolted on are other essential topics in PA education. For every 20-40 hours of lectures, there was a separate hour or two dedicated to preventative health. When lecturer after lecturer after lecturer presented their topic without mentioning prevention, then — despite how much I enjoyed the preventative health content — what I learned was that prevention continues to be an afterthought throughout healthcare.

All in all, the structure of the didactic year is such that it is relatively easy for the program to make changes to individual topics, but nearly impossible for the program to change attitudes or pedagogy.

However, attitudes and pedagogy are where I see leadership and innovation taking place in medical education today; and, consequently, the ability of Yale’s on-campus PA program to be a leader in medical education is dramatically limited by its didactic structure.

Yale is about to have two PA programs. They will inevitably be compared to each other; prospective applicants I’ve spoken to are already asking “Why would I pick one over the other?”. What I would like to see are two programs that play to their respective strengths, thus giving Yale access to a broader pool of applicants.

What worries me is that one of the ostensible strengths of the on-campus program — “access to world-class faculty” — is one of its greatest weaknesses during the didactic year.

Our world-class faculty may be excellent researchers, but most are not excellent educators. They are experts in their respective niches, but — jointly — they deliver an uncoordinated curriculum. Networking with them would be valuable, but I’ve spent much more time compensating for the low quality of lectures than I did networking with the lecturers. And lecturing by hundreds of experts profoundly hampers educational leadership and innovation that I was hoping to find at Yale.

In the end, I suspect that — short of a major restructuring — the on-campus program will continue weighing down its forward-thinking and innovative initiatives, such as ILCE, with the ineptly delivered lectures and regurgitation-heavy exams.

I have no idea whether such a restructuring is feasible, or even desired; I hope it takes place, and soon. Our program staff and core PA faculty have been driven and innovative, and have treated me with kindness and compassion; I think they deserve to be at an excellent program, rather than a program whose structure all but precludes excellence.