The Clinical Placement Crisis: Is Reality Becoming Virtual?

One of the most talked-about issues in physician assistant (PA) education focuses on the shortage of student clinical training opportunities. We all have had to deal with this problem — yet it doesn’t appear to be improving. And PA education is not unique. These shortages affect a number of health professions and were described in detail in “Recruiting and Maintaining U.S. Clinical Training Sites,” a joint report of the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the Association of American Medical Colleges, and PAEA. You’ve heard the proposed solutions to the problem:

  • Paying preceptors and sites
  • Expanding the radius of search for sites
  • Increasing the use of simulation and/or supplemental didactic or computer-based curricula for students.1

The growing number of PA programs and the trend toward increased enrollment will certainly have an impact on the already overwhelming need for clinical sites. Technology now enables us to offer equivalent quality didactic distance education to larger numbers of PA students per class cohort. And it goes without saying that these same online students will progress to the clinical training stage. This only adds to the urgency of finding a way to tackle the clinical site challenge, calling for some serious and innovative thinking.

Exploring Other Options

If we were to collectively brainstorm options to help us address the growing shortage of supervised clinical practice experiences, what might those options be? How about a hybrid combination of competency-based simulated (but live) patient assessment coupled with the rapidly emerging technology of interactive 3-dimensional clinical simulation? Many health professions programs use clinical simulation technology, ranging from the most basic (Resusci-Anne®) to highly sophisticated high-fidelity equipment (Anatomage®, SimMan®3G, and others). While these tools can provide quality supplemental education in a number of subject and skill areas, a significant financial investment is required, including large and expensive pieces of equipment, secured space for storage, personnel for maintenance, and shared program access requirements, to name a few — making acquisition an insurmountable obstacle for many.

Given the crisis of clinical site shortages, what else can programs do if paying for sites is out of the question; if simulation equipment, labs, and centers are unachievable; and if expanding the radius for clinical sites results in nothing more than irritating neighboring programs?

Thinking Outside the Screen

Three new and emerging products have the potential to be game-changers for clinical education simulation as the levels of interactivity increase. In no particular order, they are:

For a taste of what HoloLens® can do, check out this brief video.


HoloLens® has been described as “the next PC” by hologram developers, and there are rumored to be a number of third-party medical application developers working on software that will bring the clinical setting to virtual reality in three dimensions with this application. Oculus Rift® and Project Morpheus® are virtual reality gaming sets that are already in use, but with limited current applicability to clinical simulation.

If medical application software developers expanded the uses for these technologies, teaching and confirming competence in a range of required skills could be achieved. Effective 3-D medical education platforms already exist, but the next step in making the transition to superior clinical simulation is the burgeoning element of virtual interactivity (4-D with animation).2 Surgical and other clinical procedures could be taught in a 4-D virtual reality that could replace some of the time currently devoted to supervised clinical practice experiences.

Companies such as Sony© and Siemens© have reached new levels of quality and realism with a number of new and emerging clinical applications. Imagine teaching a student how to perform a physical examination or a surgical procedure, but not by the traditional over-the-shoulder methods we use now. Imagine both the instructor and student wearing 4-D glasses and ultra-thin digitalized tactile gloves where both the instructor and student can see, feel, and hear exactly the same things at the same time — from different buildings, states, or countries. The instructor can then guide the student through a detailed examination or procedure, making corrective suggestions and movements along the way by verbal and tactile override. Now multiply this by 10 or 100 students doing the same things at the same time in differing locations, with one master teacher leading the instructional delivery. All of this is now within the realm of possibility.

Academic purists may scoff at these notions as science fiction or pretend training, but given the fact that clinical training sites will continue to be a growing challenge, we can no longer be content with the status quo. We must do something different in order to properly prepare our students to enter the health care workforce.

Of the current solutions proposed to address this problem, the increasing use of simulation and/or supplemental didactic or computer-based curricula may provide the stimulus needed to change the way we educate our students. The current generation of students is ready for this technology. The question is: are we?

 1 Association of American Medical Colleges. May 2014. “Recruiting and Maintaining US Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey.”
2 Battulga, Bayanmunkh, Takeshi Konishi, Yoko Tamura, and Hiroki Moriguchi. “The effectiveness of an interactive 3-dimensional computer graphics model for medical education.” Interact J Med Res 2012 Jul-Dec; 1(2):e2. doi:10.2196/ijmr.2172.