Reflections from PAEA 2026
At this year's PAEA conference, I found myself returning to a question that surfaced across several sessions: How do we ensure students are developing the clinical reasoning and judgment they'll need in practice, long before they're expected to demonstrate those skills on an exam or with a patient?
PA education, like much of health professions education, operates in an environment where exam performance matters tremendously. Students need to pass their certification exams, and programs face significant pressure to demonstrate strong outcomes. Those measures serve an important purpose.
But clinical competence is about more than passing an exam. It requires the ability to gather information, recognize patterns, consider alternatives, communicate with patients, and make sound clinical judgments.
And developing those skills takes practice.
One of the more thought-provoking sessions I attended, Testing the Waters: Evaluating the Clinical Impact of PISCEs Participation, examined an educational approach at Boston University that brought pre-clinical PA and medical students together through team-based and case-based learning.
The presenters described an approach that introduced clinical cases early and used classroom time for active learning, discussion, and application. Rather than waiting until students had mastered every piece of foundational knowledge, they created opportunities to begin applying that knowledge as they learned it.
Starting early doesn't mean expecting novice learners to reason like experienced clinicians. It means providing appropriately structured opportunities to begin developing those skills alongside their foundational knowledge.
Their findings suggested that students participating in this approach demonstrated stronger performance earlier in their clinical education, including improvements in end-of-rotation assessments and clinical reasoning observed by preceptors. Yet those earlier gains did not necessarily translate into differences in eventual certification exam outcomes.
That prompted an interesting question: If students ultimately achieve similar certification results, what is the benefit of stronger performance earlier?
I think the answer gets to the heart of what we're trying to accomplish in health professions education.
If students enter clinical rotations with stronger reasoning skills, greater confidence, and more experience applying their knowledge, they may be better positioned to take advantage of those experiences from the beginning. Rather than spending their first rotations developing foundational approaches to patient encounters and differential diagnoses, they can continue building on skills they've already practiced.
And those benefits may extend beyond the individual rotation. Earlier preparation can create more opportunities for meaningful participation in patient care, richer learning experiences with preceptors, and continued development of clinical judgment.
The value isn't necessarily in reaching a different finish line. It's in being better prepared for the experiences along the way.
And perhaps that's an outcome worth paying more attention to.
Another session explored an early warning framework for identifying students at risk of failing the PANCE using end-of-rotation exam performance.
The presenter described the "holy grail" as identifying learners who need remediation before they reach the certification exam.
The research explored how performance across multiple end-of-rotation exams could help programs identify students at risk. The more assessment data available, the more information educators have to recognize patterns in performance.
But as I listened, I kept thinking about the timing.
An end-of-rotation exam tells us something about a student's performance after they've completed that clinical experience. And when we're looking at performance across multiple rotations, we're accumulating data over an even longer period.
By the time we've identified a student who is struggling, how many opportunities to practice and improve have already passed?
Remediation is important, and identifying learners who need additional support is essential. But what if we focused more intentionally on developing clinical reasoning skills before students begin to struggle?
That means thinking beyond the clinical years.
We don't have to wait until students enter rotations to begin developing their clinical reasoning, patient communication, and decision-making skills. Intentionally designed learning experiences during the didactic year can give students opportunities to apply knowledge, make decisions, receive feedback, and build confidence before entering clinical settings.
And when students have opportunities to practice earlier, educators also have opportunities to observe how their reasoning is developing, identify areas where additional support may be needed, and intervene before challenges become more significant.
With this approach, the goal becomes earlier development rather than earlier remediation, with the feedback and guidance students need to continue progressing.
This theme surfaced again in a session from Arcadia University titled Training Thinkers in an MCQ World: Redesigning Clinical Reasoning.
During a live audience poll, case-based learning emerged as the most frequently selected approach for developing clinical reasoning. At the same time, faculty time and capacity were identified as significant barriers.
That tension resonated with me.
Educators recognize the importance of helping students apply knowledge, but creating meaningful opportunities to do so takes time, resources, and intentional planning.
And those opportunities matter because exposure to clinical practice isn't always the same as participating in it.
During rotations, students may observe a clinician taking a history, discuss potential diagnoses, or present a patient summary. Those are valuable experiences, but they don't always provide opportunities to independently practice every skill involved in a patient encounter.
How often does a student get to:
Lead a difficult patient conversation?
Practice breaking bad news?
Work through an uncertain diagnosis, make a decision, receive feedback, and try again?
The opportunities vary considerably depending on the rotation, clinical setting, and preceptor.
Yet we expect students to demonstrate many of these skills during OSCEs and, ultimately, in patient care.
So, where are they getting the opportunity to practice?
The Arcadia presenters discussed approaches ranging from collaborative, choose-your-own-adventure clinical cases to individual activities requiring students to interpret heart and lung sounds and make decisions.
These examples reinforced something important: Active learning isn't simply about presenting students with a case. It's about what we're asking them to do with it.
Reading a clinical scenario can support learning. But requiring students to gather information, consider alternatives, make decisions, and explain their reasoning creates a different level of engagement.
Simulated patient encounters can take that practice further, giving students opportunities to navigate conversations, ask questions, respond to patient concerns, and receive feedback in a safe environment.
These experiences don't replace clinical rotations. They can help students arrive better prepared to participate in them.
Throughout the conference, I also had conversations with educators interested in creating their own clinical cases, sometimes using AI to accelerate the process.
I understand the appeal. Faculty have tremendous clinical expertise and often recognize specific learning needs within their programs. They can and do create effective learning experiences with clear objectives, curricular alignment, and meaningful feedback.
But creating an individual case is different from providing consistent, repeated opportunities for clinical reasoning development across an entire curriculum.
A single case may address a specific learning need. Developing clinical reasoning requires students to encounter different clinical presentations, apply their knowledge in new situations, practice decision-making, and receive feedback over time.
That raises questions about scale and consistency.
How do programs provide those opportunities across dozens of cases and hundreds of learners, particularly when faculty time and resources are already stretched?
How do they ensure students are working toward shared learning objectives across different instructors and clinical settings?
How do they provide authentic, interactive patient encounters with consistent educational quality and meaningful feedback while reflecting the variability of real clinical practice?
And how do they understand what students are learning so they can identify opportunities for additional support and refine the learning experience?
These considerations go beyond the time required to write an individual case. They involve instructional design, curriculum alignment, content development and maintenance, technology, delivery, and assessment.
It's an approach that informs how we think about clinical learning at Aquifer. Our educator-developed cases and virtual patient experiences are intentionally designed around learning objectives, clinical authenticity, and opportunities for students to engage in decision-making and receive feedback. They provide faculty with learning activities that can be integrated throughout the curriculum, helping programs create more consistent opportunities for students to develop and apply clinical reasoning without having to build and maintain every experience themselves.
As AI makes it easier to generate clinical content and simulations, I think these considerations become even more important. Faster content creation doesn't automatically produce better learning experiences, and the ability to generate an interactive patient scenario doesn't necessarily ensure consistent instructional quality or meaningful feedback.
We also need to be thoughtful about when and how AI enters the learning process. Students should learn to evaluate AI-generated recommendations, but not become so reliant on them that they miss opportunities to develop their own reasoning and judgment.
The concern isn't only de-skilling experienced clinicians. It's the possibility of never-skilling students who haven't yet developed the expertise to recognize when an AI-generated answer is incomplete or incorrect.
One of the ideas from the PISCEs presentation that stayed with me: learning to ride a bicycle.
We don't expect children to understand every mechanical component of a bicycle before they begin riding. They learn through experience, adjustment, feedback, and repetition.
Clinical reasoning is far more complex, but the underlying principle is relevant.
In health professions education, we often describe the didactic and clinical years as two distinct stages: one is where students acquire knowledge and another is where they apply that knowledge.
But learning doesn't really work that way.
We acquire knowledge, apply it, gain experience, refine our understanding, and apply it again. Each experience helps reinforce what we've learned while revealing what we still need to understand.
That's how expertise develops.
When students work through clinical problems during their didactic education, they're doing more than practicing a future skill. They're also reinforcing and connecting the foundational knowledge they're learning, making it more meaningful and easier to retrieve when they need it.
The PISCEs presenters emphasized that their approach wasn't a one-time intervention. Active, case-based learning was integrated throughout the educational experience. That integration, rather than any single learning activity, is an important reminder for educators as a whole.
Clinical reasoning development shouldn't begin when knowledge acquisition ends. The two should reinforce each other throughout the learning journey.
My conversations at PAEA reinforced how much educators value clinical reasoning and understand its importance in preparing future clinicians. They also highlighted the practical challenge of creating consistent, meaningful opportunities for students to develop those skills.
Passing the PANCE matters. So does performing well on end-of-rotation exams. But preparing students for clinical practice extends beyond these important milestones. We want to develop clinicians who can think critically, exercise sound judgment, communicate effectively, and continue developing their expertise throughout their careers.
If we want students to be ready for those responsibilities, we need to be intentional about the opportunities we give them to practice, make mistakes, receive feedback, and grow.
Perhaps the question isn't how early we should begin developing clinical reasoning, but why we would wait.