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Founding director of the Doctor of Medical Science program at The College of St. Scholastica, Kenneth Botelho, discusses his article, “In the absence of physician mentorship, who will train the next generation of primary care clinicians?” Kenneth highlights the accelerating crisis caused by the erosion of physician mentorship, particularly impacting physician associates (PAs) in primary care who historically relied on close, hands-on guidance. He explains that with an aging physician workforce and doctors leaving primary care, this traditional apprenticeship model is breaking down, leaving many new PAs with minimal supervision and high-pressure roles, increasing risks of burnout and clinical error. Kenneth argues that while the old system cannot be revived, innovative solutions like postgraduate PA fellowships and residencies, supported by Doctor of Medical Science (DMSc) programs, offer a path forward. He details how these programs can create a new pipeline of PA leaders equipped with advanced clinical competence, leadership skills, and an understanding of value-based care and health care economics, enabling them to fill mentorship gaps and improve a strained health care system. Kenneth stresses that this is a system issue requiring bold, collaborative action to support learners and ensure patient safety.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Kenneth Botelho. He’s the founding director of the Doctor of Medical Science Program at the College of Saint Scholastica. Today’s KevinMD article is “In the absence of physician mentorship, who will train the next generation of primary care clinicians?”

Kevin Pho: Ken, welcome to the show.

Kenneth Botelho: Thank you so much for having me, Kevin. I’m delighted to be here today and chat with you and see if my answers resonate with your audience.

Kevin Pho: All right. So just briefly share your story and then talk about what led you to write this KevinMD article.

Kenneth Botelho: I appreciate it. So, I’m a PA in primary care. I’ve been in primary care for well over a decade, and like a lot of clinicians, probably more particularly PAs and nurse practitioners, come to a point in our careers where we start to realize that there’s really not a lot of structured pathways for continued growth.

You reach a level of competence in your practice and confidence with your patients, and unless you have any additional pathways within the organization that you work in, you’re kind of left without much room for that professional growth that some of us crave.

So that frustration I was feeling had brought me to create something called Paving Practices, which is an initiative I formed that focuses on structured postgraduate training for PAs and, at some point in the future, for nurse practitioners. But it is mainly focusing on PAs right now. And what that does is it addresses that mentorship gap that I had written about in the article. I wasn’t really trying to create anything in particular; I was really trying to create something that was missing for somebody like myself, but also for a lot of other colleagues of mine that have that similar feeling of being kind of stifled in certain levels of practice.

And then that journey also brought me over here to the College of St. Scholastica, up in Duluth, Minnesota, where I’m, like you had said, the founding director. And we’re trying to align education with real-world workforce needs, which is something that I think a lot of us need to try to use our imaginations and innovate in a world that really needs a lot more innovation.

And your second portion of your question was, what came to create that article? So I see it all the time. Clinicians are in practice, they just get out into practice, and they’re stepping in a place where mentorship has historically been present. But more recently, it has not because as physicians are leaving the workforce, particularly in primary care. Now, of course, not all physicians are leaving the workforce. This is just a generalization, but that’s a problem for folks that are getting out of school in a profession that’s traditionally had a mentorship model or an apprenticeship model.

Personally, that was how I trained. And so the erosion of this mentorship is really a crisis. It goes beyond just the physician delivering care. It’s also the physician delivering mentorship to PAs and nurse practitioners. And so if we don’t address that in some way or speak up, I think that we’re complicit in the system still having ongoing issues with this.

Kevin Pho: So just to clarify the situation, you’re talking about when physician assistants and nurse practitioners finish their training and they get their first job, let’s say in the emergency department, for instance, there’s just not a lot of mentorship to help them with the transition as they’re doing clinical care after training for the first time. Am I reading that right?

Kenneth Botelho: You are 100 percent correct. There is some nuance to it, to some degree, but for the most part. I’m starting to notice that when I was in school and then I got out of school, fellowships and residencies for PAs and nurse practitioners were not as prominent. Because of exactly what we just discussed, even on a personal basis, I was trained pretty directly by a physician who owned his own practice, and I became quite clinically competent and confident in that setting.

But I see that because physicians are owning fewer practices and maybe they are more overburdened, that time for that mentorship so that we can gain some additional confidence or gain the competence that we really need to be more independent over time is starting to become more of a problem.

Kevin Pho: So you alluded to this earlier, what are some of the root causes why that mentorship isn’t there? You talk about the employed model, which is the majority of practices now, where maybe physicians are too overburdened or overwhelmed, or perhaps the institution has too much of a focus on productivity and revenue. From your perspective as a leader of a doctor of medical science program, what’s your perspective in terms of the root causes?

Kenneth Botelho: I think you hit the nail on the head with a lot of them. It’s multifactorial, so one is absolutely physicians having less autonomy in the system. I think that has created more of a problem. And I’ll elaborate on that briefly, too. So I had mentioned that the physician I trained with owned his own practice. Well, at one point, that became unsustainable in the current health care environment, but that wasn’t unsustainable when I had gotten out of school. It was a rapid change in health care that occurred.

And so that has been detrimental to care delivery, but it’s also detrimental to the education and mentorship of early-on or earlier clinicians. So if we have physicians or more senior PAs or nurse practitioners that are very well respected in their field, it’s not as though they have less productivity that they have to meet or fewer demands clinically that they have to meet. They still have to meet those things now.

But the mentorship has not necessarily been something that’s been well discussed. That is something that’s being taken away in a lot of places because of those measures that need to be met and boxes that need to be clicked. And so we’ve kind of become, and I mean this in the best way possible, hamsters in a wheel.

And so in order to help our colleagues and really mentor them so that we can display knowledge or advance our own knowledge to our peers, we need to have the time and space to do that in a way that’s sustainable. And right now, in a lot of places, it’s not.

Kevin Pho: And what happens to physician assistants when they’re just coming out of training, they’re getting perhaps their first job, and they don’t have that mentor to help with that transition? What happens to them? Are you seeing increasing numbers of burnout or them staying at those first jobs for a shorter period of time? What kind of data and numbers are we talking about here?

Kenneth Botelho: Yeah, so as far as data and numbers, I’m to reference data. Don’t quote me on the exact data, but I know burnout is about one-third of the PA population in primary care. So one in every three PAs in primary care is likely to have some semblance of burnout. Now, you had asked the questions related to when they come out of school, what does that look like? And the answer is variable.

And what I mean is, right now I’m out here in Minnesota. Minnesota has some great fellowship programs for PAs that are new to practice so that they get their feet wet or really wet clinically. But they also have a lot of the structured growth where they could offer or ask questions and not feel as though they’re burdening their colleagues by asking them. In other states or other health care landscapes, they may not have that. And they may not even have a transition-to-practice program, which is becoming increasingly common, and it’s becoming increasingly common for the same reasons that we just discussed.

So, I’m going to answer your question with my experience. In primary care, one of two things happens. They come into primary care and they enjoy the patient population that they see. And maybe they are in a good transition-to-practice program or they’re in a good fellowship, or they meet a really good mentor and they stay there. That doesn’t mean that it’s not difficult for them, but they stay.

And more commonly, I see them come out into practice and they say, and this is in primary care specifically, “This is way more than I bargained for.” Because the support is not always there. Again, it’s variable based on the state health care system. And so having that variability can become a little scary for folks as they come out of school.

Kevin Pho: So my next question is going to sound blunt and transactional, but what’s in it for the physician? What benefit do they have to them to mentor physician assistants and nurse practitioners?

Kenneth Botelho: That’s a fantastic question. And the answer isn’t necessarily, if I think of it from a future-aligned perspective, I don’t know if there’s a ton of benefit in it for them, to be frank.

I think as the PA and nurse practitioner professions, we need to ensure that we step up because you are right. If I’m a physician and I’m already overburdened, I don’t have that inherent interest, not in a bad way, in trying to mentor these new folks coming in. It’s not necessarily part of my job description, especially if I’m now part of a large organization.

But that doesn’t mean that the PA and nurse practitioner professions shouldn’t consider this deeply because the way they were set up in the sixties was that they would be complementary to physician practice. And so if now we’re reducing the numbers of physicians in these areas, then as PAs and as nurse practitioners—I’ll speak for PAs specifically because that’s where I tend to be at this point—we need to create that.

And if we don’t, we’re complicit in the failure of care delivery to our patients.

Kevin Pho: So what are some paths forward? You mentioned that you have a program that addresses this. What are some potential paths forward from a policy standpoint, and what are some other initiatives and efforts that are being undertaken to address this?

Kenneth Botelho: Yeah, that’s a great question. I think it’s been under-discussed on a national basis. Now, that’s not to say that it’s not been under-discussed because it’s not widely seen or visible. I think there are so many things going on in health care that need to be fixed that… I mean, we talk about a physician shortage, but this is a part of a physician shortage that maybe not a lot of us fully think about or grasp.

But at first, what we’re doing at the College of St. Scholastica is reaching out to a number of different fellowship programs, more regionally to start, in offering some of the fellowship credit in the sense that if I just graduated from an institution and received my PA degree and I was interested in going into a fellowship, during my fellowship year, I could obtain doctoral credit that could eventually lead to a doctor of medical science degree.

Now, it doesn’t mean it has to be all crammed into one. And this is a model that’s a bit different than those that exist out there. That’s not to say, though, that it’s not necessary. In a lot of ways, we need better-structured postgraduate training in a world now that doesn’t have that mentorship that we had historically.

And so if you are doing a fellowship in your profession—by the way, the PA profession is likely moving towards a doctorate degree as a terminal degree, more commonly as a terminal degree—then having credit in that fellowship area is a natural progression into discussions on scholarly writing or discussions on health care innovation, and then down the road, discussions on leadership and what that means in different institutions in primary care or in hospitals or what have you.

I think it helps promote lifelong learning. It helps promote professional development. And it may also help—and I know fellowships help reduce burnout—but doctor of medical science programs, where they help elevate those that take them, may also do that. And so having a better pathway, because the PA profession historically hasn’t had that structured pathway, may make for a more sustainable career in different areas.

Kevin Pho: So for those who aren’t familiar with the PA pathway, when you talk about a PA fellowship, what exactly are they, how common are they? Just tell us a little bit more about that.

Kenneth Botelho: Absolutely. So what Kevin and I are referring to is essentially after graduation from PA school, a lot of folks will either go into clinical practice right away or they may go into something like a fellowship. And a fellowship is typically about a year or so in length, depending on the institution that offers it. And it’s similar in a way to a residency. It’s not exactly the same. There’s no way around that.

But basically, it allows for that mentorship that we’re discussing in this program to occur in a structured manner, and they may go through different types of shadowing experiences that may not be directly related to their specialty. For instance, you may be in primary care and then you’re doing shadowing in OB-GYN or you’re shadowing in the hospital setting just to ensure that you get a good understanding of exactly what that just prior to discharge of a patient may look like, so that when you receive it on the primary care end, you have a better understanding of that whole process.

Same thing for an OB-GYN and then maybe see the same thing for an emergency room where you see that transition occur so that when you receive it as a clinician, you have a better understanding of exactly where you stand and maybe the perspective of the clinician that may be doing the discharging or taking care of the patient. And so that typically lasts for about 12 months. There’s also typically some leadership involved there. There’s coding involved. A lot of us talk about coding left and right out in the field, but when we’re in school a lot of us don’t get that coding experience. Value-based care is becoming increasingly interesting to have in those discussions as we move closer to 2030 when Medicare wants us all to know about it. So there’s a lot of opportunities for PAs in that area.

Kevin Pho: We’re talking to Ken Botelho. He is the founding director of the Doctor of Medical Science Program at the College of St. Scholastica. Today’s KevinMD article is “In the absence of physician mentorship, who will train the next generation of primary care clinicians?” Ken, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kenneth Botelho: Yeah. You know, there are two things that immediately come to mind. This is one thing I want to share because I saw this the other day, and I think it might resonate with a lot of people, is watching Les Misérables. The main character in there is Jean Valjean.

And this is newer to me, but it struck me. I think a lot of us in clinical practice are like Jean Valjean. And I’ll tell you why: because he wasn’t perfect, but he always carried the weight of a broken system, yet he still acted with courage and compassion. And I think so many of us are doing that right now.

The only thing that I would say in addition to that is that if we don’t speak up, nothing changes.

Kevin Pho: Ken, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Kenneth Botelho: Thank you so much, Kevin.