Misconceptions in NP/PA/MD education: experiential requirements, online, and for-profits

  1. Does PA or medical education have some of the same hot-button issues we see in NP education?

    There has been a great deal of teeth gnashing about NP education. The complains generally relate to a few of the following in combination:

    1. Online programs
    2. Part time programs
    3. No experience required
    4. For-profits


    Usually the gaze is then cast on PA and MD education where supposedly none of these problems exist. Let's examine that idea with the caveat that I am no expert in PA/MD education, but I often see a lot of posts from folks who have discernibly less awareness.

    1. Online programs

    PA programs such as UND, Red Rock, Yale, Lock Haven, MCPHS and others offer programs that are either distance learning or a hybrid curriculum where some courses are online while campus visits are required similar to Vanderbilt's NP program.

    2. Part Time

    While I don't know of any part time allopathic/osteopathic programs (although some will allow 5 years to lighten the intensity), there are some part time PA programs such as Drexel, Rutgers, University of Detroit,

    3. No Experience Required
    There is much teeth gnashing about direct entry MSN programs despite evidence supporting the practitioners they educate. How about on the PA/MD/DO side?

    MD/DO
    To point out that MD/DO applicants need not have experience is just asinine because of residency. However it possible for MD/DOs to practice without a residence in many states. They might practice independently as a general practitioner or they not be independent, functioning more like a PA.

    PA
    16% of programs require 1000-2000 hours of healthcare experience (less than 1 year full time)
    40% require no experience
    44% of programs require somewhere between 8 and 500 hours

    The experience requirements, where they exist, vary from shadowing to volunteering to paid professional experience.

    4. For-Profit

    There have long been plenty of for-profit medical schools outside of the US that accept applicants who couldn't get into US schools. They are US accredited, so their graduates do practice in the US. The first for-profit medical school in the US opened 10 years ago and more have followed.

    I am not aware of a for-profit PA program... yet...

    Summary: When I look at these for categories of concern, it turns out most of them are in PA and MD/DO education. However, they seem to less prevalent and the online learning shift is coming from the elite-end of education while in NP education, these changes started at the lowest common denominator (which, not coincidentally, are the for-profits).
    Last edit by SummitRN on Aug 29
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  2. 81 Comments

  3. by   Zyprexa
    The lack of clinical hours for many NP programs (often around 550 hours) is concerning, especially combined with the lack of oversight and students being required to find their own clinical instructors. This is not an issue for either PA or MD/DO programs.
  4. by   SummitRN
    I split my original post into two as my commentary made it beyond tldr;

    Here is my commentary:

    1. Online:

    Commentary: There is an implicit bias against online learning, but is it warranted? I love lecture and wish my program had more of it, but many do not learn well this way. So can we demonstrate a didactic instruction methodology as superior? Why is it that recorded lecture isn't more prevalent in online learning? There is no dispute that all schools are adding online and distance classes in all programs.

    2. Part Time:

    Commentary: There is an implicit bias against "part-time" that is unsupported by any evidence I am aware of, but the confusing part here is that many regard 2-3 year NP programs as "part time" solely because some students are able to work while in school. This definition includes highly reputable programs. It is thus implied that any curriculum that leaves any student with time to do anything but learn is insufficient. Never-mind the value a student-NP may gain while continuing their RN practice with NP-school knowledge to frame their experience!

    3. No Experience Required

    Commentary: Much like NP, PA started out with the very experienced healthcare practitioner in mind (the first PAs were Vietnam medics). But like NP, such requirements are no longer universal. However, the question as I see it is not "is there only one ideal applicant with respect to experience?" I think the right question is, "what type of applicant is a particular program designed to take, and what are the outcomes?"

    4. For Profit

    The problems of for-profit RN and NP schools are legion. Conflicts of interest abound because the ultimate mission statement is not server a city, state, or student, but to make a profit. For-profits make money by having more students. The easiest way to compete for more students in the education market is to offer convenience and have a wider pool of applicants.

    Online and/or part time offers convenience and a wider pool of applicants without necessarily diluting quality. Lowering standards for applicants, teachers, and the curriculum offers convenience and a wider pool of applicants by directly diluting quality. The market response was for non-profits to compete by also offering online and a wider pool of applicants... some would say they also lowered the standards.

    SUMMARY

    There is a lot of bias in the naysayers who operate off from logical fallacies of "the way I did it is the only way" or "only those who want it bad enough to suffer should be allowed into my club." It is useful to examine the follow through of such critical ideas. There are those who think that a lecture hall at a big B&M is the only proper way to NP, thus a rural RN should have to uproot their family and move to the big city while incurring debt and "learning hard enough" to not be able to work.

    Presumably, we want to see schools adopting new paradigms without compromising standards. The real discussion is where these standards originate and how they are enforced. The market will eventually exert pressure if supply goes to high while quality goes too low. The thing about relying on market forces to correct professional education is that the corrections lag far behind the need for them and they are very painful to all involved: patients, providers, schools.

    Right now the ultimate barrier to entry seems to be the board exam and the ability of students to find their own preceptors since some for-profit NP schools will take any RN with a 2.5 GPA, a pulse and the ability to sign the student loan form.
  5. by   elkpark
    Quote from SummitRN
    MD/DO
    To point out that MD/DO applicants need not have experience is just asinine because of residency. However it possible for MD/DOs to practice without a residence in many states. They might practice independently as a general practitioner or they not be independent, functioning more like a PA.
    While it's true that there are states that will allow MDs/DOs to practice without a residency, they can put out a shingle and open an office, but very few hospitals will grant practice privileges to individuals without a residency and BE/BC, so how practical and useful is that?
  6. by   juan de la cruz
    Quote from SummitRN
    4. For-Profit

    There have long been plenty of for-profit medical schools outside of the US that accept applicants who couldn't get into US schools. They are US accredited, so their graduates do practice in the US.
    I didn't care to check but my understanding is offshore medical schools are not accredited by the LCME, the agency that accredits all US and Canadian MD programs. Graduates of offshore medical schools are considered Foreign Medical Graduates (FMG) and are required to be cleared by ECFMG prior to obtaining a residency slot in the US. The latter requires that FMG's graduate from programs that meet criteria for LCME accreditation or listed under a database of worldwide medical schools that uphold standards similar to LCME.
  7. by   SummitRN
    Quote from elkpark
    While it's true that there are states that will allow MDs/DOs to practice without a residency, they can put out a shingle and open an office, but very few hospitals will grant practice privileges to individuals without a residency and BE/BC, so how practical and useful is that?
    GP without admitting is limiting as many insurance companies won't take a doc without admitting privileges. But these folks would function as primary care and could find a market for themselves.
  8. by   juan de la cruz
    Quote from SummitRN
    GP without admitting is limiting as many insurance companies won't take a doc without admitting privileges. But these folks would function as primary care and could find a market for themselves.
    Some do find a market in unregulated and cash only practices such as medical aesthetics and "cosmetic" surgery.
  9. by   elkpark
    Quote from SummitRN
    GP without admitting is limiting as many insurance companies won't take a doc without admitting privileges. But these folks would function as primary care and could find a market for themselves.
    Yes, a v. limited market and a mostly dead-end career.
  10. by   juan de la cruz
    To me it boils down to the absence of a true accreditation agency strictly for NP education. CCNE and ACEN are simply not fulfilling the task of upholding any standards. CRNA education, with their own accrediting body for all CRNA programs, is not known for being infiltrated, if you will, by predatory for profit educational schemes, insufficient preceptor pools and inadequate clinical placements. CNM programs have their own accrediting body as well but they have allowed some degree of distance education (i.e., Frontier) but not let for profit schools open up programs.
  11. by   Dodongo
    Quote from juan de la cruz
    I didn't care to check but my understanding is offshore medical schools are not accredited by the LCME, the agency that accredits all US and Canadian MD programs. Graduates of offshore medical schools are considered Foreign Medical Graduates (FMG) and are required to be cleared by ECFMG prior to obtaining a residency slot in the US. The latter requires that FMG's graduate from programs that meet criteria for LCME accreditation or listed under a database of worldwide medical schools that uphold standards similar to LCME.
    This is correct. Caribbean schools are considered foreign and are not accredited, however, their graduates, if they desire to practice in the US must pass the USMLE step exams and complete a residency.... so there are still barriers to entry.

    Also, the PA programs listed as "online or hybrid" are not "online or hybrid" in the same sense as NP programs. They all require significant time spent on campus - not a couple weeks over the course of the program. Lock Haven is all on campus - they have lectures on the main campus that students on the other campus watches via live feeds. So online but not really. And Yale requires multiple site visits including the entire first semester being on site. MCPHS offers an online doctorate for practicing PAs who already hold a master's degree as a PA. UND is a little more similar to NP education, however it still requires 17 weeks on campus.

    My main complaints are a lack of a graduate gross anatomy class, no surgical training and far too few clinical hours.

    Anecdotally, I just met an FNP student last week who is starting clinical next term who said when she met with the preceptor she told him that she knows nothing. I asked her what she meant when she said nothing and she, again, said she knows nothing. She said she hasn't learned anything clinically yet. The school assumes she will learn it on her clinical rotation. The school requires 675 hours and has just 1.5 weeks on campus. Just mind boggling. I can not imagine starting rotations and not understanding how to develop a differential, what labs/exams to order, how to interpret and formulate a diagnosis. In general, all PA and MD students at least start clinical and graduate with a standard, basic knowledge base.

    Nurses like to throw around phrases like, "the data show..." or "studies show that..." but the studies they are using are poorly designed and the data is biased heavily towards the null in all of them. Because of that, the best we have to go off of is to use common sense and compare ourselves to the other provider level professions. And, when we do so, we fall short.
  12. by   juan de la cruz
    ...and NP programs are still popping up everywhere. I was shocked to see that USC (yeah, that SoCal institution with the Trojans mascot) is now jumping on the bandwagon with an online FNP program. It sounded for-proft-esque until I saw in their FAQ that students are not to secure their own clinical rotation because USC will make every effort to place students (in true University of Strong Connections fashion). They are still waiting for CCNE accreditation but I'm sure it will be handed to them easily.
  13. by   Dodongo
    Quote from juan de la cruz
    To me it boils down to the absence of a true accreditation agency strictly for NP education. CCNE and ACEN are simply not fulfilling the task of upholding any standards. CRNA education, with their own accrediting body for all CRNA programs, is not known for being infiltrated, if you will, by predatory for profit educational schemes, insufficient preceptor pools and inadequate clinical placements. CNM programs have their own accrediting body as well but they have allowed some degree of distance education (i.e., Frontier) but not let for profit schools open up programs.

    Absolutely agree!
  14. by   BostonFNP
    Oh great the local program that was just put on warning by the state BON for their RN program after deficiencies were found in 5/5 categories now has an online PA program.

    EDIT: On further review, it appears that the online doctorate for PA is only for practicing PAs.

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