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

[SummitRN]

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).

[Dodongo, APRN, NP]

In his/her defense, Drexel does has a truly part-time option for their PA program.

[SummitRN, BSN, RN]

What if someone reads this and thinks oh this person must be an expert and knows what they are talking about 100%.....when you don't.

Then that someone would be just as guilty as you of not reading the opening of my post where I said:

Let's examine that idea with the caveat that I am no expert in PA/MD education

[twinsmom788]

Thank you to the OP for starting this discussion. I'd like to point out that MDs do not have to work in healthcare before starting med school. I think that is the better analogy to NPs and PAs.

Oh My Goodness...med school students, in most situations, go straight from college to med school. They do have certain work/volunteer experience in health care. Not certain what you mean by an analogy to NPs or PAs. Please explain.

[BostonFNP, APRN]

I also told all my preceptors that I will be following their entire weekly schedule, because, again, NP students need WAY more hours than required in their programs. They all enthusiastically agreed.

Out of curiosity, does your program know about this? This has been a big issue in the past with students because of the manner in which the school's malpractice insurance covers students.

[BostonFNP, APRN]

Why on earth would anyone agree to precept a student who freely admits she "knows nothing"??

I feel like most first semester students don't know very much about clinical practice, but I absolutely won't take a student that hasn't been taught how to do a basic H&P (as some schools now try to send preceptors).

[SummitRN, BSN, RN]

Out of curiosity, does your program know about this? This has been a big issue in the past with students because of the manner in which the school's malpractice insurance covers students.

I explicitly asked schools if they would allow excess clinical hours before accepting as I intend to do much more than the requirement.

[Dodongo, APRN, NP]

Out of curiosity, does your program know about this? This has been a big issue in the past with students because of the manner in which the school's malpractice insurance covers students.

I asked before I applied. I was told the minimum requirement is just that - a minimum. Students are able to do more should they desire to do so.

[BostonFNP, APRN]

I asked before I applied. I was told the minimum requirement is just that - a minimum. Students are able to do more should they desire to do so.

If you are full covered for that, cool, enjoy!

[KatieMI, BSN, MSN, RN]

1). Neither MD, nor PA programs generally designed for students who continue to work while studying. NP programs must follow the reality, in which most students continue to work.

2). For the same reason, NP programs cannot count on students moving across the country for attending schools (please do not make CRNA schools as contrargument. CRNA students have to spend significant time working in ICU, and frequently schools have their "privileged" units from which they draw most applicants. So, many prospective students probably have to move closer to large teaching hospitals where they can get required experience and connections).

3). MD, as well as PA, programs provide very inconsistent exposure in terms of subspecialties while allowing minimally restricting privileges in these specialties after graduation. A PA may have as little as 6 weeks rotation in mental health over 2 years and be hired as a new grad in inpatient psych unit. Rural ERs, which have difficulties attracting physicians Board-certified in Emergency Medicine, are commonly staffed with Family Medicine doctors who might never deliver a baby by themselves (there are ways to avoid this experience during residency training if one really wants to do so) and never have an ophthalmology rotation at all; yet, they are considered competent to treat such patients in ER. Good thing that most of them know their limits and promptly arrange transfers. Yet, there is no evidence that such providers deliver inferior care overall.

4). There is NO EVIDENCE of NPs, as a composite body, delivering lower quality care, or experiencing more liability risks, or achieving worse outcomes vs. MDs or PAs within comparable specialties. There is no such evidence over the last 10+ years, despite of mushrooming of NP schools of all kinds. That can be explained by only two ways: either NPs are taught well enough in schools or right after graduation but before they hit the full scope of practice, or the business of medicine is really not that of a rocket science and can be safely practiced by someone prepared as well as a NP school grad. Or both of them.

5). There is no evidence that online education delivers inferior knowledge. Outside of the USA, the concept of online education is much more evolved and so far was only seen as a tool of improvement of quality of education, nod diminishing it. Imagine a scholar of European medieval linguistic working in University of Perth, Australia or female chemical engeneering class in King Abdala University, Ryad.

Besides this, online format is an effective remedy for professionals like nurses who had the concept of "teamwork" pushed hard down their throats. One of the most difficult things for new NP students, as I saw, was absense of "teammates" available nearby at all times. As an NP, you're not a teammate, you're a collaborator and provider, and that's entirely different thing.

6). Regarding for-profits... are any medical, PA or NP school in the USA works entirely for charitable purposes? Where are humongous student debths of doctors are coming from then?

All schools are for profits, only one difference is that some of then consider $$$$ as the only one prerequisite, and the others require some actual studying to be done. Neither of them guarantees 100% of new grads being well-prepared, and the tool which can easily and successfully sieve bad grads out should be Board exams.

I did a well-reputable FNP program because I wanted easily marketable degree which would allow me more flexibility. I also went into online school because I happen to live 2.5 hours from the nearest large academic center in a place where driving might be life-threatening expereince from November to April. I found my own preceptors who wanted to work with me, were not intimidated by my quirks (including foreign accent) and happily accepted my willingness to follow them like a tail 30%+ required clinical time. First time in my life I felt free from being followed by a monster with a stetoscope sufferirng from acute attack of power abuse.

I do feel, too, that NP education should be purged from excessive amount of nursing theory, "role development", paper writing and other fluff and get a hefty additional amount of clinical knowledge. Biochem, genetics, clinical pharma, normal physiology and regional anatomy should be given in accordance with course work of medical schools, and number of clinical hours should be increased. It probably will lead to removing of "accelerated" programs, as all that cannot be stuffed into one's head in less than 2.5 years full time. But that concept of NP schools being convenient and affordable is to stay. Furthermore, considering that so many undergrad nursing instructors and bedside nurses are fiery anti-intellectual and openly abuse students whom they perseive as "too smart" or "bookish", the flight of smart and daring, but unexperienced nurses directly from undergrad to NP schools will continue (and therefore will be used by NP schools promoting direct admits). Nothing can be done with it except making work conditions more tolerable for new grads and abusing them as acceptable as "n" word.

[SummitRN, BSN, RN]

6). Regarding for-profits...

....

All schools are for profits, only one difference is that some of then consider $$$$ as the only one prerequisite, and the others require some actual studying to be done. Neither of them guarantees 100% of new grads being well-prepared

Thank you for your excellent post. It is spot on except regarding for-profits. I think you fundamentally misunderstand the guiding principles of a for-profit vs non-profit/public schools.

Public schools are not solely reliant on tuition. Their primary responsibility is to the population of a state, region, or city because they are chartered, regulated, and partially funded by the taxpayers. Thus the ultimate mission is to meet the educational needs of that group of people. They ultimately answer to a board of regents (or equivalent) who are publicly elected or appointed by public officials.

Non-profit schools are also not solely reliant on tuition as they have self-sustaining endowments and large donations from successful graduates and companies (public universities also receive donations). Being non-profit, they must reinvest their profits in the form of campus capital improvement, faculty training, scholarships, etc. Their ultimate mission statement is about the education of their students and they ultimately answer to their board.

For-profits rely solely on tuition supplied by cash/loans from their students. Ultimately they answer to shareholders and their number one motive is to turn a maximum profit. This offers very perverse incentives when the main goal should be quality education. I can expound but it should be obvious, but letting in subpar students and having low academic standards are the easiest way to make more profit. The board exams are an imperfect sieve, thus it should not be the only filter in the NP pipeline.

Non-profit/public schools are subject to much weaker perverse incentives mostly relating to fiefdom creation/building within departments and cost controls (eg it is cheaper to offer some more theory classes instead of labs and doing so might open up some great tenure spots).

I also went into online school because I happen to live 2.5 hours from the nearest large academic center in a place where driving might be life-threatening expereince from November to April. I found my own preceptors who wanted to work with me

Very similar situation for me

I do feel, too, that NP education should be purged from excessive amount of nursing theory, "role development", paper writing and other fluff and get a hefty additional amount of clinical knowledge. Biochem, genetics, clinical pharma, normal physiology and regional anatomy should be given in accordance with course work of medical schools, and number of clinical hours should be increased. It probably will lead to removing of "accelerated" programs, as all that cannot be stuffed into one's head in less than 2.5 years full time. But that concept of NP schools being convenient and affordable is to stay. Furthermore, considering that so many undergrad nursing instructors and bedside nurses are fiery anti-intellectual and openly abuse students whom they perseive as "too smart" or "bookish", the flight of smart and daring, but unexperienced nurses directly from undergrad to NP schools will continue (and therefore will be used by NP schools promoting direct admits). Nothing can be done with it except making work conditions more tolerable for new grads and abusing them as acceptable as "n" word.

Spot on! I need more than two hands to count the number of times comments equating to, "you should have gone to medical school" were tossed my way by fellow nurses or professors, and frequently not in a complimentary manner. Anti-intellectualism is sadly a strong undercurrent in the cultural problems of nursing.

[Bob Loblaw]

There are also Associate Degree PA programs and online ADN to FNP programs. Is there actually a baseline educational limit? Or is a race to the shortest?

What I know about practitioners, no matter what they dangle behind their name: word of mouth reputation, but I'm in the profession- I know who I would want to work on me and mine and who I wouldn't. If you were a regular Joe Bloe on the street sounds like a crapshoot.

"I do feel, too, that NP education should be purged from excessive amount of nursing theory, "role development", paper writing and other fluff and get a hefty additional amount of clinical knowledge." I feel this way about RN school also. 60 page care plans are a thing of the past. Nursing diagnosis-what? Call a diabetic a diabetic- even though that is a medical diagnosis.

[BostonFNP, APRN]

4). There is NO EVIDENCE of NPs, as a composite body, delivering lower quality care, or experiencing more liability risks, or achieving worse outcomes vs. MDs or PAs within comparable specialties. There is no such evidence over the last 10+ years, despite of mushrooming of NP schools of all kinds. That can be explained by only two ways: either NPs are taught well enough in schools or right after graduation but before they hit the full scope of practice, or the business of medicine is really not that of a rocket science and can be safely practiced by someone prepared as well as a NP school grad. Or both of them.

I do feel, too, that NP education should be purged from excessive amount of nursing theory, "role development", paper writing and other fluff and get a hefty additional amount of clinical knowledge. Biochem, genetics, clinical pharma, normal physiology and regional anatomy should be given in accordance with course work of medical schools, and number of clinical hours should be increased.

I am playing a bit of devil's advocate here for the purpose of the discussion, but why (having made a statement that NPs are taught well enough in school) do you think there needs to be an excessive "purge" on NP education?