Center for the Future of the Health Professions April 2024 digest
This month, The Center for the Future of the Health Professions will publish another monthly op-ed column for 2024. Our columns offer strong, well-informed, and focused opinions on issues impacting the future of health professions. The center was established to provide policymakers at the state, local, and national levels, as well as stakeholders in the health system, with accurate, reliable, and comprehensive data and research on the healthcare workforce. This is crucial for effective planning for a sustainable future and optimal utilization of available resources.
This month’s column will focus on artificial intelligence (AI), which is rapidly transforming healthcare delivery and medical education. The integration of AI technologies in healthcare has led to significant advancements in diagnostics, personalized treatment approaches, and patient care coordination in recent years. Furthermore, AI presents cutting-edge opportunities in health professional education, offering tailored tutoring platforms and immersive simulations to enhance and personalize learning experiences.
This article’s author, Ted Wendel, PhD, currently serves as the senior vice president for university planning at A.T. Still University (ATSU). Dr. Wendel has a rich academic background, with experience spanning various institutions and leadership roles in education and research. His contributions to neuropharmacology and hypertension research, as well as his innovative approaches to educating health professionals, have been significant.
In addition to his academic pursuits, Dr. Wendel has been actively involved in humanitarian efforts as a longtime volunteer, serving as a photojournalist for Project HOPE, an international healthcare organization. His dedication to capturing the stories of humanitarian aid initiatives reflects his commitment to making a difference in global health.
We hope you find this article informative and engaging, and we welcome your feedback and comments.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Ted Wendel, PhD
Artificial intelligence in the education of healthcare professionals
Artificial intelligence (AI) is rapidly changing the landscape of healthcare delivery and medical education. In just the last few years, integrating AI technologies into healthcare has propelled advancements in diagnostics, personalized treatment plans, and patient care management. AI offers innovative solutions to adapt and optimize learning experiences within health professions education, from customized tutoring systems to immersive simulations.
This paper explores AI in healthcare and its implications for medical education. Today’s graduates will face future medical practice that will take advantage of AI and be challenged by its flaws. By examining the current state of AI in healthcare and educational settings, this paper aims to elucidate the opportunities, challenges, and ethical considerations surrounding its implementation. This paper seeks to provide a simple understanding of the AI landscape and explain key trends, successes, and areas for further exploration.
To appreciate AI’s future, it is essential to have some understanding of the technology and recent achievements that unlocked potential changes that stagger the imagination. In its simplest form AI strives to create machines that mimic the thinking of humans. The constant evolution of microchip technology over the last 20 years has made it possible for computers to ingest and analyze data at astounding rates. Computer scientists have taken advantage of a computer’s ability to ingest data and establish relationships between and among huge amounts of data organized into datasets.
AI tools such as ChatGPT are based on supercomputers scanning the content of billions of documents posted on the worldwide web and establishing statistical algorithms that define the relationships of the text in the documents. This process, known as training, is used to create a large language model (LLM). These LLMs permit individuals to have seemingly natural conversations with computers that understand the input and respond based on the relationships discovered as part of the training. Computers can be and have been trained on almost any type of data. Data can be derived from words in a document to the arrangement of pixels in and image or the reported speed of a car in rush hour traffic.
Medical research has always been based on collecting and comparing datasets, such as a treated dataset versus a similar dataset of untreated individuals. This comparison type is supervised since a researcher has labeled each patient outcome as either treated or untreated. However, imagine a scenario like an LLM where the data is not labeled and computers discover the statistical relationships existing in a large dataset of patient medical records or millions of images of breast scans. With enough data, and over time, the statistical algorithms become increasingly accurate at defining what patterns may be associated with what pathologies or clinical outcomes in much the same way a healthcare provider becomes an experienced professional.
The rapid evolution of AI in healthcare presents a dynamic and transformative landscape, with innovations emerging regularly. Health professionals should be aware of key trends as illustrated in the following applications of AI that reflect the current and future potential of AI in healthcare. Understanding these trends will help professionals harness AI’s capabilities effectively and ethically. Health professional educators must understand AI to prepare graduates for practice in a world dramatically different from today.
Chatbots
The evolution of LLMs used as chatbots like ChatGPT (as well as other LLMs like Gemini, Perplexity, and others) and the ability to interact using a natural language interface is the most dramatic technological advance in decades. These tools present a transformative potential. By automating administrative tasks such as clinical paperwork, billing, and recordkeeping, LLMs can significantly reduce the burden on healthcare professionals, allowing them to focus more on patient care rather than administrative tasks.
Moreover, the ability of these models to serve as an additional layer of analysis and insight can aid in diagnosis and treatment, acting as a support system for medical professionals. This can lead to more accurate and timely interventions, potentially improving patient outcomes.
The potential for these models to monitor patient compliance and predict clinical interventions is fascinating. By analyzing patient data, AI can identify patterns and may be capable of predicting health events before they occur, enabling proactive rather than reactive healthcare. This could lead to personalized and timely interventions, reducing hospital readmissions and improving overall patient health.
The latest version of Chat GPT released in April 2023 shows significant improvement over the previous version. The advancements in ChatGPT 4.0 encompass significant enhancements in linguistic understanding, context retention, information integration, reasoning, multilingual support, bias mitigation, customizability, interdisciplinary application, and ethical considerations. These improvements underscore the model’s evolution toward more nuanced semantic understanding, comprehensive knowledge representation, and sophisticated problem-solving abilities. Also, these improvements highlight the focus on language equity, adaptability for specific population needs, and the importance of addressing ethical concerns and biases in AI deployment. Chatbots’ sophistication represent technological progress and opens new avenues for academic exploration across computational linguistics, AI ethics, continual learning, and cross-disciplinary applications, emphasizing the broader impact of advanced AI systems in healthcare and society.
Diagnostic imaging
AI has made significant strides in diagnostic imaging, revolutionizing how images are acquired, interpreted, and used for patient care. Automated image analysis of scans such as CT, MRI, X-rays, and ultrasound have improved both the accuracy and speed of diagnosis in several areas such as breast cancer screening1, bone fracture analysis2, and lung disease detection.3
Beyond diagnosis, AI in imaging can predict patient outcomes by analyzing image patterns that correlate with prognosis, helping clinicians make informed decisions about treatment strategies. AI tools can streamline radiology workflows by prioritizing urgent cases, automating routine tasks, and facilitating image triage, ensuring patients requiring immediate attention are identified and treated promptly.
An outstanding example of AI’s impact on diagnostic imaging is EyeArt by Eyenuk, the first FDA-cleared AI technology for autonomous detection of diabetic retinopathy, a condition causing vision loss and blindness that affects millions of Americans annually. EyeArt enables in-clinic, real-time diabetic retinopathy screening for primary care practices, diabetes centers, and optometric offices. This tool provides an inexpensive, rapid, and accurate diagnosis allowing healthcare practitioners to identify referable diabetic retinopathy patients quickly and accurately during a diabetic patient’s regular exam. This AI tool has proven its value in early diagnosis of possible vision loss at a remarkably reduced cost.
Tools like EyeArt illustrate the breadth of AI’s impact on diagnostic imaging, enhancing accuracy, efficiency, and patient care. The field continues to evolve, with ongoing research and development aimed at expanding the capabilities and applications of AI in medical imaging.
Knowledge acquisition
For decades, knowledge has been widely available through the internet using browsers to search for information. Internet searches deliver a list of links to various websites. There is little curation of the search links, and the searcher must scour them to glean the desired information.
SciSpace is an academic search engine that facilitates access to scientific literature. While it primarily serves researchers and academics across various fields, healthcare professionals can significantly benefit from its features and capabilities.
SciSpace is an innovative platform aiming to streamline the process of accessing academic papers, journals, and scholarly articles. It leverages advanced search algorithms to help users find relevant literature quickly and efficiently. The platform offers a user-friendly interface that simplifies the search for high-quality, peer-reviewed scientific information.
AI tools like SciSpace offer healthcare educators access to various scientific articles, including those from medical and healthcare journals. The time saved by using this AI tool cannot be overstated. Anyone who has spent hours searching the literature on a specific topic will be astounded by the time saved using an application that provides immediate access to peer-reviewed, credible literature.
SciSpace and a growing number of similar applications serve as a vital tool for healthcare professionals, enhancing their ability to access scientific literature, stay informed about the latest research, and apply this knowledge to improve patient care, drive research, and contribute to advancing the medical field.
Use with caution
AI tools like those described in this paper must be used and applied with great caution. As with any new and rapidly developing technology, AI tools cannot be relied on for their accuracy. LLMs have been known to hallucinate and provide false or misleading information and then promote and justify these errors. All systems make errors and using tools like ChatGPT demands policies and procedures that check and confirm results. Chatbots are not now, nor will they be in the immediate future, a primary or exclusive source of medical knowledge or care.
AI tools are subject to a training bias. The results provided by these tools are dependent on the populations used for their training. Should the training population be skewed by factors such as age, gender, or race, they will propagate knowledge biased by the distortion of the training population. This echoes the process of drug discovery and testing during the 20th century. Most drugs were tested and evaluated on a population of middle-aged white males, essentially ignoring the critical gender and race differences in drug actions and adverse effects. So, training of AI tools may reflect skewed populations resulting in responses that lack diversity
Moving forward
As healthcare educators move forward it is imperative to establish clear guidelines for using AI tools in the education of healthcare professionals. A July 2023 report from Cornell University’s Center for Teaching and Learning encourages faculty to explicitly set expectations for when and how students can employ generative AI in their work with proper attribution. Future policies and guidelines must be tempered with the dichotomy that recognizes the value of AI tools in practice while still promoting student learning. Ohio University’s Center for Teaching and Learning offers example AI policies and assignments from faculty members at the University to provide a reference point.
In the forthcoming decade, the trajectory of AI tools is anticipated to undergo rapid evolution, a progression aptly represented by the S-Curve model – a graphical illustration traditionally employed to depict the dose-response relationship of pharmaceuticals. Analogous to medications, AI technologies must be subjected to rigorous regulatory frameworks akin to those applied to the discovery and monitoring of new drugs. Such regulation must ascertain the safety and efficacy of AI tools, safeguarding the public from adverse consequences and misuse. Furthermore, regulatory measures must be instituted to ensure the economic implications of AI technologies do not preclude access for socio-economically disadvantaged populations globally.
AI applications are poised to fundamentally transform the domain of healthcare and therefore the education of health professionals. These advancements promise to enhance access to medical services, diminish costs, and alleviate the administrative burdens associated with scheduling, recordkeeping, and billing, among other tasks. As these tools evolve, they are expected to achieve greater accuracy and user-friendliness. Presently, AI technologies serve as an invaluable complement to healthcare practice – a potent assistant capable of swiftly navigating and structuring vast repositories of knowledge.
Author’s note: The author created the original outline and drafts of this paper and used two AI tools. The OpenAI Chatbot V 4.0 was used to clarify some content and improve the readability of several paragraphs. The SciSpace tool noted in the paper was used to identify published resources noted in the publication. These tools were used in support of this paper between November 2023 and March 2024. The author takes full responsibility for the thoughts and ideas expressed in the publication.
References
1 Nisha, Sharma., Jonathan, James., et al. (2023). Comparing Prognostic Factors of Cancers Identified by Artificial Intelligence (AI) and Human Readers in Breast Cancer Screening. Cancers, 2023;15(12):3069-3069. doi: 10.3390/cancers15123069
2 Jonas, Oppenheimer., Sophia, Lüken., Bernd, Hamm., Stefan, M., Niehues. A Prospective Approach to Integration of AI Fracture Detection Software in Radiographs into Clinical Workflow. Reproductive and developmental Biology, 2022; 13(1):223-223. doi: 10.3390/life13010223
3 Yumi, Kuroda., Tomohiro, Kaneko., et al. Artificial intelligence-based point-of-care lung ultrasound for screening COVID-19 pneumoniae: Comparison with CT scans. 2023 PLOS ONE, 18(3):e0281127-e0281127. doi: 10.1371/journal.pone.0281127
Welcome to the March 2024 op-ed column of the Center for the Future of the Health Professions Digest! Our goal is to provide reliable information and research on the healthcare workforce, helping policymakers and health system stakeholders plan for a sustainable future. This month, we will delve into the physician assistant/associate (PA) profession, which has become an essential component of the American healthcare system in the last 50 years. Currently, there are more than 168,000 PAs across the United States practicing in various specialties and settings. PAs engage in over 500 million patient interactions yearly, showcasing their significant impact. The PA profession consistently ranks among the top healthcare jobs in the U.S. News & World Report. Various studies highlight how PAs enhance healthcare quality and cost efficiency. Given the ever-evolving healthcare landscape, it is valuable to explore the future trajectory of the PA profession.
This article is a compilation of information written by me and two consummate PA educators. The first is Albert F. “Bert” Simon, DHSc, PA-C Emeritus. Dr. Simon is the associate director of the Doctor of Medical Science (DMSc) program at A.T. Still University-Arizona School of Health Sciences (ATSU-ASHS). In 2005, Dr. Simon joined A.T. Still University’s PA program as chair and program director. He later served as the associate dean for Evaluation and Quality Innovation at A.T. Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA) from 2006 to 2008 and then as vice dean from 2008 to 2012. In 2012, Dr. Simon returned to ATSU-ASHS as chair and director of the Department of Physician Studies and director of the PA program. In 2019, he took on the role of associate director of the DMSc program, which he designed as a professional doctorate option for PAs. He has authored and co-authored numerous articles and chapters for various journals and publications and served as a co-editor for Appleton and Lange’s Q&A for the Physician Assistant.
Next is Melinda Rawcliffe, DMSc, PA-C. Dr. Rawcliffe is an experienced and highly respected medical professional with more than 16 years of dedicated service as a PA. Throughout her career she has worked tirelessly to improve healthcare access for marginalized populations. Her leadership roles, including her past presidency of the Arizona State Association of Physician Assistants (ASAPA), advisory positions to the ASAPA Board, and chief delegate to the American Academy of Physician Associates (AAPA) House of Delegates, demonstrate her commitment to this cause. Currently, she plays a crucial role on the AAPA Government Relations and Practice Advancement Commission, influencing the PA profession’s future. Additionally, Dr. Rawcliffe serves as an assistant professor and interim director of for Franklin Pierce University’s Hybrid PA program, as well as an adjunct professor for A.T. Still University’s DMSc program. Beyond her academic endeavors, she actively contributes to disaster relief efforts, deploying with the Federal National Disaster Management Services’ AZ-1 DMAT team. Furthermore, she leads the Phoenix chapter of the Flying Samaritans, providing healthcare in remote areas of Baja California Sur, Mexico.
We invite you to share your thoughts on this month’s digest.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Albert F. “Bert” Simon, DHSc, PA-C EmeritusMelinda Rawcliffe, DMSc, PA-C
Independence v. interdependence: The PA conundrum
After more than 50 years, the physician associate/assistant (PA) profession has solidified its crucial role in the American healthcare system. There are over 168,000 PAs in the United States working in various specialties and practice locations with PAs providing more than 500 million patient interactions per year. There are 306 PA programs nationwide with new applications for additional programs made each year. In addition, the PA profession continues to be listed in the top best healthcare jobs list by the U.S. News & World Report.1 Research consistently shows PAs continue to improve the quality and cost-effectiveness of healthcare.2 PAs are working to meet the challenges of increased demand for healthcare services fueled by an aging population and the implementation of healthcare reform.
Recent data from the Association of American Medical Colleges (AAMC) highlights a projected shortage of 139,000 physicians in the United States by 2033.3 To bridge this gap, PAs are vital in providing high-quality and cost-effective care. The employment outlook for PAs is promising, with a projected 31% increase by 2029.4 Professional association leaders, regulators, and state legislators continue to recognize the need to reform PA state regulations to align with workforce needs and the changing healthcare landscape. PAs are increasingly taking on responsibilities for medically complex patients with chronic conditions. The legislation governing PA practice needs to mature to match these changes with updates of professional practice.
The controversy surrounding the expanded role of PAs, particularly their dependent relationships with physicians, remains a persistent issue. In May 2017, the American Academy of Physician Associates (AAPA) House of Delegates passed an Optimal Team Practice (OTP) policy. This policy encourages state chapters to advocate for changes in state laws eliminating the legal requirement for PAs to maintain a specific collaborating physician relationship to practice. A number of states have already achieved success in implementing these changes.5 For example, Utah implemented a law in 2021 granting PAs the authority to deliver medical services within their expertise and competency. The bill outlined collaboration requirements for PAs with less than 10,000 hours of practice experience to address concerns raised by various stakeholder groups.6 Additionally, the legislation mandated that PAs collaborate with the appropriate healthcare team member based on the patient’s condition, the PA’s education, experience, competencies, and the applicable standard of care.
In a significant move in 2020, Minnesota transitioned from the term “supervision” to “collaboration” to define a PAs practice. This groundbreaking legislation eliminated the need for PAs with over 2,080 practice hours to have formal agreements with physicians. It also removed any references to delegation, the responsibility for care, and delegated prescriptive authority. Instead, PAs are now authorized to prescribe medications based on their qualifications.7 Recently, Arizona passed a law allowing licensed PAs with at least 8,000 clinical hours and certification from the regulatory board to work without supervision. This legislation also changes the requirements for supervision agreements between PAs and their supervising physicians or employers. Previously, PAs were only allowed to perform delegated healthcare tasks from their supervising physician. However, under the new legislation, PAs can provide any legal or medical service they have been educated, trained, and experienced in and are competent to perform. This includes tasks previously outlined in the statute. The law no longer requires specific delegation from a supervising physician for healthcare tasks. However, a supervision agreement that outlines the PA’s scope of practice and prescribing authority is still necessary.8
Physician groups continue to advocate for the formal supervision of PAs, opposing the independent or autonomous practice of PAs. Some physicians view the increasing number of PAs as potentially threatening their profession. The American Medical Association (AMA) strongly opposes legislation allowing PAs to practice medicine independently. They argue physicians must retain the ultimate responsibility for coordinating and managing patient care while incorporating the input of PAs to ensure healthcare quality. The AMA also opposes legislative efforts to establish separate regulatory boards for licensing, regulating, and disciplining physician assistants outside the authority of existing state medical licensing and regulatory bodies.9 The American Osteopathic Association (AOA) also argues PAs must maintain a formal regulated relationship with a specific physician.10
The physician/PA relationship has long been described as a relationship of dependence or interdependence. This means clinicians rely on each other for support and collaboration. State laws often dictate the specifics of this relationship, emphasizing its importance. Since physicians established the PA profession, it is not surprising this relationship has been valued and maintained for so many years. Many PAs believe this relationship should continue and oppose any changes in state legislation. However, in the past few decades, the requirement for a designated supervising physician has become a significant obstacle for PAs. This has resulted in limited job opportunities and a shrinking job market despite the increasing demand for PAs. As a result, potential employers have found hiring nurse practitioners more accessible due to fewer bureaucratic hurdles. Subsequently, to the authors of this article, the problem is not the interdependence relationship but somewhat archaic state rules and regulations.
Allowing PAs to deliver patient care and loosening strict laws and regulations while still prioritizing patient safety is crucial for meeting the demands of patients and the U.S. healthcare system. A study conducted by DePalma and colleagues analyzed data from 2010 to 2019 to evaluate whether states with more flexible PA scope of practice laws had higher rates of medical malpractice payment reports, which are indicators of patient harm. The findings of this study indicate that easing restrictive laws and regulations on PA practice does not raise the overall risks to patients or lead to higher malpractice rates in the U.S. healthcare system.11
Healthcare in this country has undergone significant changes in the past 50 years. Regardless, PAs will continue to work together, seek advice from, and refer patients to other healthcare providers, particularly their physician colleagues, when their condition exceeds their education, training, and experience. Some argue it is time for the profession to take ownership of their role and strive for autonomy. Is that too much to ask? Autonomy implies independence and self-governance, but it is essential to acknowledge that in today’s healthcare landscape, “independent practice” does not exist within team care. With the support of their professional associations, PAs are determined to modernize their state legislation nationwide. According this article’s authors, the PA profession should have acted on the valuable contributions a collaborative effort between physicians and PAs could bring to the table to resolve this issue. The expression “the train has left the station” is frequently used when this matter comes up. However, the main focus of this discussion is indeed patient access to healthcare, quality of healthcare, and practitioner competence. In that case, there may still be an opportunity for a unified solution.
According to the book “(P)luck: Lessons We Learned for Improving Healthcare and the World” by Alfred and Blair Sadler, significant progress can only be achieved when individuals and organizations join forces and pool their resources and abilities toward a shared objective. Successful partnerships involve mutual support, combining complementary skills, leveraging unique resources, and embracing diverse perspectives. Unfortunately, collective efforts are frequently hindered by ego clashes, territorial behavior, or conflicting ideologies. Does that sound familiar? The Sadlers contend that a highly efficient and interdependent medical team is an excellent example of collaboration. Is it too much to expect this level of collaboration?12
In light of projected shortages, the time has come for healthcare professionals, association leaders, and stakeholders to convene and collectively determine the most optimal healthcare model for the citizens of this country. A healthcare system allowing all providers to work at the top of their license is a true team environment.
References
Information Graphic, January 2024, published by the American Academy of Physician Associates (AAPA) accessed at https://www.aapa.org/download/80021/
Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009;66:36S-89S.
Kidd, Vasco Deon DHSc, MPH, MS, PA-C; Cawley, James F. MPH, PA-C, DHL (hon); Cloutier, Dagan MS, PA-C; Tankersley, Dennis DMSc, PA-C. Optimal Team Practice: The Way Forward. JBJS Journal of Orthopaedics for Physician Assistants 7(2):p e0010, April-June 2019. | DOI: 10.2106/JBJS.JOPA.19.00010
DePalma SM, DePalma M, Kolhoff S, Smith NE. Medical Malpractice Payment Reports of Physician Assistants/Associates Related to State Practice Laws and Regulations. J Med Regul. 2023;109(4):27-37. doi:10.30770/2572-1852-109.4.27.
Sadler S, Sadler B. (P)luck: Lessons We Learned for Improving Healthcare and the World. Silicon Valley Press; 2023.
Welcome to the February 2024 op-ed column of the Center for the Future of the Health Professions Digest! We are committed to delivering trustworthy information and research on the healthcare workforce, assisting policymakers and health system stakeholders to plan for a sustainable future. This month, we will review certified registered nurse anesthetists (CRNAs). CRNAs provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity and have done so for more than 150 years. They provide much-needed healthcare services in this country.
We are pleased to introduce Michael J. Kremer, PhD, CRNA, CHSE, FNAP, FAAN, a professor and interim chair of the Adult Health and Gerontological Nursing Department in the Rush University College of Nursing. He practiced clinically as a CRNA for 35 years in tertiary medical centers in Seattle and Chicago, community hospitals, surgery centers, and office-based practices.
Dr. Kremer completed undergraduate degrees in psychology, nursing, and nurse anesthesia; a master of science degree in nursing leadership; a PhD in nursing science; and postdoctoral studies in psychoneuroimmunology. He has served as a didactic and clinical nurse anesthesia educator and a nurse anesthesia program director at Rush and Rosalind Franklin University. In addition, he was the Rush Center for Clinical Skills and Simulation co-director for 17 years.
Dr. Kremer has held elected and appointed local, state, and national positions. He has served as an on-site reviewer and board member for the Council on Accreditation of Nurse Anesthesia Educational Programs. Dr. Kremer is a peer evaluator for the Higher Learning Commission. He has provided poster and platform presentations at local, regional, national, and international conferences and has authored multiple journal articles and textbook chapters. Dr. Kremer is a fellow in the American Academy of Nursing, the National Academies of Practice, and the Institute of Medicine – Chicago. He is also a Certified Healthcare Simulation Educator (CHSE).
We invite you to share your thoughts on this month’s digest.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Michael J. Kremer, PhD, CRNA, CHSE, FNAP, FAAN
Certified registered nurse anesthetists: Past, present, and future
Certified registered nurse anesthetists (CRNAs) provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity.
Nurse anesthetists in the United States have provided anesthesia care for over 150 years. Catherine Lawrence was a nurse who administered anesthesia in combat zones during the American Civil War. Agatha Hodgins, founder of the American Association of Nurse Anesthetists (AANA), pioneered techniques in trauma anesthesia care during World War I. Nurse anesthetists were the primary providers of anesthesia care to wounded soldiers on the front lines of these wars and subsequent armed conflicts.1,2 By historical and legal precedents, anesthesia is the practice of nursing provided by CRNAs and is the practice of medicine when provided by physicians.3
The first national certification examination for nurse anesthetists was administered in 1945. By 1952, AANA implemented an accreditation process for nurse anesthesia programs in the U.S. The CRNA credential was developed in 1956. Nurse anesthesia was the first nursing specialty to require continuing education in 1978.4 CRNAs have had direct reimbursement rights under Medicare Part B since 1986.2 In 2001, the Centers for Medicare and Medicaid Services (CMS) altered the federal physician supervision rule for nurse anesthetists, permitting state governors to opt out of this facility reimbursement requirement. Analysis of Medicare data found no evidence that opting out of the physician oversight requirement increased anesthesia morbidity or mortality.4 To date, 24 states and Guam have exercised this opt-out.5
The National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA) reports there are more than 59,000 CRNAs in the U.S.6 AANA member survey data shows that 50,259 CRNAs are members of this organization.7 The gender mix of CRNAs is 47% male and 53% female. Most CRNAs are hospital employees (41%), work for anesthesia groups (25%), or are independent contractors(18%).
Alternatively, a few serve in the military or Veterans Administration (3%). CRNAs have full practice authority in every branch of the military. They are the primary anesthesia providers for deployed U.S. military personnel in all settings, including navy ships and aircraft evacuation teams worldwide. CRNAs are entrepreneurs who own or partner in anesthesia groups and provide anesthesia independently in office-based surgical settings.7
Most CRNAs (87%) are clinical practitioners. CRNAs also serve as clinical administrators (3.6%), business owners/partners (3.3%), nurse anesthesia program administrators (2.1%), and teaching faculty (2.3%).7 In 2023, 8,369 students were enrolled in 133 accredited nurse anesthesia programs, with an additional 15 programs in development.8
There are four CRNA/physician anesthesiologist anesthesia delivery models commonly used in the U.S.: CRNA-only, physician anesthesiologist supervision of CRNAs, physician anesthesiologist direction of CRNAs, and physician anesthesiologist-only. Despite the variety of anesthesia delivery models, CRNAs are not required by deferral or state laws, except in New Jersey, to be supervised, directed by, or even work with a physician anesthesiologist.5
Healthcare systems and facilities have addressed rising costs and flat or declining reimbursement for surgical and diagnostic services, resulting in increased demand for CRNAs, who are paid significantly less than anesthesiologists for many of the same services. In 2023, the mean compensation for CRNAs was $235,000, while the average anesthesiologist salary was $427,800. Since outcomes data are positive for CRNAs, this enhances their participation in emerging quality/value-based reimbursement mechanisms.10
The cost-effectiveness and quality of care provided by CRNAs bode well for the profession’s future. CRNAs provide anesthesia services in hospital operating rooms, labor and delivery suites, and numerous ancillary areas, including cardiac catheterization laboratories, endoscopy suites, and interventional radiology settings. CRNAs may be the sole anesthesia providers in rural and medically underserved areas and downrange military settings. Anesthesia in ambulatory surgery centers and office-based practices may be provided by a CRNA working collaboratively with a surgeon, dentist, or podiatrist.11
The U.S. Bureau of Labor Statistics projects 194,500 average annual openings for registered nurses between 2020 and 2030, with employment expected to grow by 9%. In 2020, the median age of RNs was 52 years, with more than 20% stating their intent to retire from nursing over the next five years.12This nursing workforce shortage could decrease the supply of eligible applicants for nurse anesthesia programs.
A shortage of anesthesia providers is impacting hospitals, healthcare systems, and patients. An increasing disparity between the number of anesthesia providers and available practice opportunities contributes to this shortage. Other factors related to the attrition of current anesthesia providers include anticipated retirements and burnout. Currently, 31% of CRNAs and 56% of the 42,264 physician anesthesiologists in the U.S. are 55 or older. Almost 30% of currently practicing physician anesthesiologists plan to leave practice by 2033, resulting in a shortage of 12,500 physicians. The demand for qualified anesthesia providers will increase when CRNAs and physician anesthesiologists retire. Burnout is another factor that may contribute to retirements, with 47% of physician anesthesiologists and 56% of CRNAs reporting burnout. CRNA attrition has significant implications for rural counties, where CRNAs represent over 80% of anesthesia providers.13
CRNA employment is forecasted to grow by 11.8% between 2021 and 2031. Since surgical services comprise about 60% of a facility’s revenue, maintaining staffing for surgeons, anesthesia providers, and OR staff is critical. Some healthcare organizations utilize interim directors and locum tenens to fill key roles and supplement existing staff. AI-based technology has been deployed to improve OR utilization, reduce costs, and expand efficiencies. Providing a supportive and flexible work environment can be an effective retention strategy for anesthesia providers. Measures including flexible scheduling, professional development opportunities, and mentorship programs can help organizations surmount the anesthesia provider shortage.13
Based on current and projected demand, CRNAs will continue to be valued and highly recruited healthcare team members. In addition to the salary and autonomy associated with the CRNA role, job satisfaction is high: 95% of CRNAs report that they are satisfied or very satisfied with their career choice.7
Bankert M. 1989. Watchful care – A history of America’s nurse anesthetists. New York, NY: Continuum.
Blumenreich G. 1990. Is the administration of anesthesia the practice of medicine? AANA J, 85(4): 261-269.
Dulisse B,, Cromwell J. 2010. No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8); 1469-1475.
American Association of Nurse Anesthesiology. 2023. Fact sheet concerning state opt-outs and November 13, 2001 CMS rule. Rosemont, IL: AANA.
National Board for Certification and Recertification of Nurse Anesthetists. 2023. Promoting patient safety by enhancing provider quality: About the NBCRNA. Available at: About Us | NBCRNA, accessed 1/21/2024.
American Association of Nurse Anesthesiology. 2023 Member Survey Data. Rosemont, IL: AANA.
Gerbasi F. 2023. Program Directors’ Update. Issue 94: 1.
Liao C, Quraishi J, Jordan L. Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations. Nursing Economics. 105;33(5): 263-270.
Welcome to the January 2024 op-ed column of the Center for the Future of the Health Professions Digest! We are committed to delivering trustworthy information and research on the healthcare workforce, assisting policymakers and health system stakeholders to plan for a sustainable future. This month, our focus is on the crucial role of mentoring in shaping the next generation of clinician scholars. Effective mentoring is key to the success of medical, dental, and health science students, whether they pursue careers as clinicians, basic scientists, or clinical researchers.
We are thrilled to feature Len Goldstein, DDS, PhD, as our guest writer once again. Dr. Goldstein serves as the Assistant Vice President for Clinical Education Development in the Office of Academic Affairs, primarily based on the Mesa, Arizona, campus. His responsibilities include ensuring that all ATSU clinically based programs offer a sufficient number of high-quality clinical rotations and experiences in core and elective fields, aligning with program accreditation standards and the respective number of students. He collaborates with deans, directors, and ATSU clinical partners, including community health centers (CHCs), to create additional quality clinical opportunities for ATSU students.
Dr. Goldstein’s accomplishments include being awarded fellowship in the International College of Dentists, the Pierre Fauchard Academy, and the American College of Acupuncture. He is a diplomate of the American College of Forensic Dentistry and the American Academy of Pain Management. With more than 60 published scientific articles in peer-reviewed publications, Dr. Goldstein has demonstrated expertise in mentoring students and colleagues engaged in scholarly activity.
We invite you to share your thoughts on this month’s digest with us.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Dr. Leonard Goldstein
Mentoring tomorrow’s clinical medicine scholars
My starting point in osteopathic medical education began in early 2003 as director of clinical education at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). From the beginning, I saw a need to mentor students and assist them with clinical education, especially in publication. Although there was no requirement for medical students to publish, I saw the value in a student being published. By assisting students with writing and publishing, they took a “deeper dive” into the subject matter. This helped them with their residency applications and interviews. While not a requirement, it was better to be published than not published. I made myself available to any and all NYITCOM students, writing and publishing articles with them. The student was always the “first author”.
When I came to A.T. Still University, I continued writing and publishing with students at A.T Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA), Arizona School of Dentistry and Oral Health (ATSU-ASDOH), and Arizona School of Health Sciences (ATSU-ASHS).
Before entering medical education, I published numerous articles and participated in clinical research. I had been part of the executive editorial board of Practical Pain Management, a peer-reviewed journal for practitioners who required information regarding pain management. I have published more than 130 manuscripts with students and have currently submitted 21 for publication. Since I am not a physician, an ATSU-SOMA faculty member co-authors any manuscript.
I have found that students see the value in increasing subject knowledge and have a desire to research and publish more. I now have developed a reputation with students in which they seek out opportunities to write with the “team.” Over the years that I have been at ATSU, I have seen many students “match” into outstanding residencies, and I hope my mentorship and their research/publication(s) have assisted in this endeavor. Hopefully many more faculty members in all of our programs will, if they are not already doing so, utilize their own time to mentor our students.
In this era of explosive medical scientific growth, it is important to mentor tomorrow’s medicine scholars with availability, dedication, and creativity. In this same era, substantial impediments prevent gifted medical and other healthcare students (dental, PA, PT, OT, etc.) from developing into independent patient-oriented investigators.1,2
Superior mentoring is a vital ingredient to the success of all medical and healthcare students, including those who become clinicians, basic scientists, and clinical researchers.3
With Step 1 of the United States Medical Licensing Exam(USMLE) and/or the Step 1 Comprehensive Osteopathic Medical Licensing Exam(COMLEX) recently changing to a Pass/Fail format, medical students now, more than ever, are looking for true mentorship to excel in their future in medicine, and equally important, to be competitive with their residency application.
Relationships between medical students and faculty are an effective means of navigating a student’s professional development path,3,4 increasing the success of their future careers,5 and potentially preventing burnout.6,7
Despite the potential benefits, there has been a lack of mentoring relationships between medical students and physicians/faculty.8 An engaged mentor who takes interest in a trainee’s development is critically important to a successful career. Mentoring will typically encompass a number of functions and relationships, including counseling, career guidance, discipline, and teaching. A commonly used definition of mentoring in medicine is from the Standing Committee on Post-Graduate Medical and Dental Education (SCOPME 1988). According to SCOPME, mentors should support the trainee/student to acquire or hone skills and foster career goals.9
Finally, specific to health professions students, is the goal of integrating research skills with clinical knowledge and education; the three pillars of an academic health professional.10
The United States Accreditation Council for Graduate Medical Education (ACGME) has developed a list of core competencies11 that provide a useful guideline for mentors to impart practical skills and a sense of social and ethical responsibility, including:
Patient care
Medical knowledge
Interpersonal and communication skills
Professionalism
Practice-based learning
System-based practice
All of us in health sciences professions should consider becoming a mentor to tomorrow’s clinical medical scholars.
I want to acknowledge James Keane, DO, MEd, ATSU-SOMA associate professor, OMT/OM, a very important mentor who works with me on student publications.
References
Wyngaarden JB: “The Clinical Investigator as an Endangered Species”; NEJM; 1979; 301: 1254-1259
Heinig SJ, Quon AS, Meyer RE, Korn D: “The Changing Landscape for Clinical Research”; Academ Med; 1999; 74: 726-745
Schrier RW: “Ensuring the Survival of the Clinician—Scientist”; AcademMed; 1997; 72: 589-594
Kalen S, Ponzer S, Seeberger A, et.al.: “Longitudinal Mentorship to Support the Development of Medical Student’s Future Professional Role: A Qualitative Study”; BMC Med ED; 2015; 15: 97
Morrison IJ, Lorens E, Bandiera G, et.al.: “Impact of a Formal Mentoring Program on Academic Promotion of Department of Medicine Faculty: A Comparative Study”; Med Teach; 2014; 36(7): 608-614
Fallatah HI, Park YS, Farsi J, et.al. : “Mentoring Clinical Year Medical students: Factors Contributing to Effective Mentoring”; J Med Educ Curric Dev; 2018; 5: 2382120518757717
Vogan CL, McKimm J, Silva ALD, et.al. : “Twelve Tips for Providing Effective Student Support in Undergraduate Medical Education” Med Teach; 2014; 36(6): 480-485
Buddeberg-Fischer B, Herta KD: “Formal Mentoring Programs For Medical Students and Doctors—A Review of Medline Literature”; Med Teach; 2006; 28(3): 248-257
Bower DJ, et.al. : “Support-Challenge-Vision: A Model for Faculty Mentoring”; Med Teach; 20(6): 595-597
Manabe YC, et.al. : “Resurrecting the Triple Threat: Academic Social Responsibility in the Context of Global Health Research”; Clinic Infec Diseas; 2009; 48(10: 1420-1422
We are excited to introduce the December 2023 op-ed column for the Center for the Future of the Health Professions Digest! Our goal is to provide accurate and reliable information and research on the healthcare workforce to help policymakers and health system stakeholders effectively plan for a sustainable future. This month’s column covers the evolution and future of postgraduate physician associate/assistant (PA) training programs. These programs have become a vital component in PA postprofessional education and training. We explore where we currently stand and where we might be heading.
We are excited to feature Dr. Melissa Ricker. Dr. Ricker holds a bachelor of science in human biology from North Carolina State University, a master’s in PA studies from East Carolina University, and a doctor of medical science from A.T. Sill University. She also completed the WakeMed Health and Hospital Surgical Trauma Critical Care PA Fellowship Program.
Currently, Dr. Ricker practices clinically in pulmonary critical care and serves as the PA fellowship director for the enterprise-wide Atrium Health Advanced Practice Provider (APP) fellowship, overseeing tracks in Charlotte, North Carolina, Winston-Salem, North Carolina, and Macon, Georgia. Since taking on the role of PA fellowship director in 2018, she has collaborated closely with co-director Anne Vail, DNP, to maintain the national reputation of being the largest and most clinically diverse APP fellowship in the country.
To ensure these PA fellows are equipped to provide compassionate care to all, recent program enhancements have included a diversity, equity, and inclusion curriculum, a formal leadership program, local and international service opportunities, and education/research collaborations with other allied health residents at Atrium Health.
We invite you to share your thoughts on this month’s digest with us.
Randy Danielsen, PhD, PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Dr. Melissa Ricker
The evolution and future of postgraduate PA training programs: A vital component in PA education and training
With just over 50 years of the physician assistant (PA) profession in the rearview mirror, it is humbling to think how far the profession has come in such a relatively short period. Certainly innovative for its time, the PA curriculum was designed to run over just two years from its inception, intended to build upon an educational and life experience foundation to fulfill a post-war workforce shortage. Initially a primary care focus recognizing the value of the PA profession, didactic and clinical training were eventually broadened, per accreditation standards, to include a minimum of family medicine, emergency medicine, internal medicine, surgery, pediatrics, women’s health, and behavioral health.1 These professionals are prepared to practice clinically after completing a standardized national certification exam. This is the story we, as PAs, all know and tell.
Unknown to many, in a blind spot on that same rearview mirror lies the fact that PA postgraduate education has co-existed for nearly the same duration. Just six years after the PA profession was founded, Montefiore became the first hospital to include PAs as house officers on inpatient surgical services, and their clinical experience was formalized into [the first] 12-month residency in general surgery and surgical specialties.2 Healthcare professionals and institutions saw value in postgraduate education for these PAs decades ago, enhancing specialty education and training while intensively cultivating other professional skills not traditionally taught within this PA education and continuing to invest in them today. In 2023, more than 160 programs across the United States offer advanced specialty training in nearly every specialty of medicine and surgery.3
This raises the question, do postgraduate PA training programs continue to have a place in the future of PA education and training?
For new graduate PAs entering the workforce, the job market can be challenging. According to the Physician Assistant Education Association’s June 2023 End of Program PA Student Survey, only 35.0% of graduating PA students reported accepting or receiving at least one job offer.4 Landing that job took an impressive number of applications, an average of 9.9. However, even more impressive, those reporting no job or offer reported submitting an average of 13.3 job applications.4 For those for whom clinical work experience or specialty training is an employment barrier, seeking an optional PA fellowship may be a solution to secure long-term employment. A certificate of completion is often awarded following the successful completion of a PA fellowship program and is used to demonstrate increased competence and confidence. In a 2020 national survey of postgraduate physician assistant fellowship and residency programs, 96% of the respondents were employed within two months and 78% reported the demand was “high” for their employment, often presented with “multiple offers”.5 Following the hiring trends of new PA graduates and institutional tendency to hire a PA without experience will be vital to potential increased adoption and growth of the postgraduate training of PA new graduates.
Adding to the marketability of a PA completing a fellowship, PA fellowships seek collaboration with Doctor of Medical Science (DMSc) programs to add to their value, combining the efforts of academic clinical coursework and the structured clinical fellowship experiences. PA fellows enroll in a clinical fellowship and time de-escalated academic doctorate program to apply academic concepts, research methods, and educational and leadership learnings deeply. Graduates receive both a fellowship certificate of completion and a doctorate. While no published work exists on the impact on their employability, one can hypothesize that the increased academic skill only boosts their marketability and value to any hiring institution.
That said, these programs are not solely beneficial for the PA fellow, they are often very beneficial for the sponsoring organization. After all, with the affordability of healthcare becoming more at the forefront of our training and clinical decision-making, hospital operational leaders are choosing to invest in PA fellowship programs because of the financial and nonfinancial return on investment. The opportunity to select highly motivated PA candidates, enroll them into a year-long program at a reduced stipend, invest in their clinical and leadership growth, introduce them to key system leaders, and promote engagement in scholarly work all collectively facilitate this introduction into a multifaceted and fulfilling career as a PA. In the same 2020 postgraduate survey previously mentioned, 83% of participating programs endorsed a local retention strategy to retain trained talent, with 55% intentionally cultivating graduates to serve in local [leadership] roles post-training.5 Additional retrospective added value was the interprofessional collaboration these programs fostered (93%). And, 76% reported they felt their fellowship programs helped improve the overall system autonomy of their APPs.5 As financial value becomes more transparent to the public, this will likely influence further institutional investment into PA fellowship programs.
Lastly, without a doubt the pandemic challenged the medical community, and PAs were not immune to the hardships. Our professional flexibility afforded many PA transitions into new or virtual roles, often with limited mentorship or training. APP fellowship curriculum remains dynamic as healthcare delivery evolves and institutional changes occur. PA fellowship programs can more readily and intentionally provide training for PAs entering these specialties. Mentorship is also a pivotal root of the program (lasting often after fellowship) that can influence future career trajectories, development, and advancement. Examples include training those in behavioral health and specialty medical tracks telehealth, preparing new leaders as their institutions develop their APP leadership structures, and opening/closing fellowship tracks that may align with future institutional growth or consolidation.
When we look in this rearview mirror in another 50 years we envision a future where postgraduate training for PAs is readily visible, highly esteemed within the field, and characterized by rigorous academic and clinical standards. This training will foster intentional collaboration across disciplines and serve as a valuable optional pathway for PAs to enhance their expertise and confidence in both academic and clinical settings.
The Center for the Future of the Health Professions is publishing another monthly op-ed column. These columns provide strong, well-informed opinions on matters that impact the future of the health professions. As mentioned previously, the center was established to offer accurate, reliable, and comprehensive data and research on the healthcare workforce to support effective planning for a sustainable future and optimal use of available resources for state, local, and national policymakers, as well as health system stakeholders.
This month’s column will serve as a follow-up to last year’s article, “Further Confessions of a Recovering Sage-on-the-Stage Performer,” by Norman Gevitz, PhD, professor of history and sociology of health professions and senior vice president-academic affairs at A.T. Still University. This addition, “Sage on the Stage – Part 3 – A Return to the Classroom,” further explores Dr. Gevitz’s humorous presentation on his return to teaching as he shares his experiences in an entertaining manner. We eagerly await your response.
Randy Danielsen, PhD, PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Sage on the Stage – Part 3 – A Return to the Classroom
When I was hired to be the new senior vice president-academic affairs at A.T. Still University in 2013, I believed my time in the classroom was done. The new position was, and is, labor intensive; you’re directly responsible for, and have oversight of, all the schools/colleges and degree and certificate programs at our University, including its programmatic and institutional accreditation. As I hope I have conveyed in my previous two contributions* to this series, I loved teaching, whether as a “sage on the stage” and, subsequently, as someone who created an interactive dynamic where students essentially taught themselves by discussing cases in the classroom, using basic concepts presented to them. So, when I accepted the position as senior vice president-academic affairs, it was with great anticipation of looking forward to the challenge, yet with regret that a significant ongoing joy of mine – teaching – would not be a part of my new responsibilities.
Nevertheless, nine years into my position at ATSU, I was asked by one of our colleges – the School of Osteopathic Medicine in Arizona (SOMA) if I would consider getting “back in the saddle.” The professor who taught medical ethics had just retired, and they could not find someone within their faculty to teach the subject. I consulted with the President, who raised appropriate concerns, which I addressed, and told SOMA I would agree. I would teach four two hour blocks – to two sections of students – 16 classroom hours. Not a heavy load, I thought. I have been teaching medical ethics for more than 25 years. I could do this.
The biggest surprise for me was the amount of literature I had to review. Ten years is a long time to be away from the printed materials that constitute the corpus of learning in a field – including medical ethics. While the basic concepts of medical ethics were still operative, new applications of these concepts have changed as medicine has been transformed, as well as the related field of medical jurisprudence. This was most apparent in women’s reproductive rights, given the recent Supreme Court decision in Dobbs. Much of what medical ethicists taught and what students were tested on in national board examinations related to reproductive ethics has now been made uncertain and questionable.
Also, though I only wrote a few exam questions, the time I needed to develop board-quality test items was considerable. In my early years of teaching medical ethics, I asked short essay questions, which is a reasonable assessment, but they do not prepare students for the multiple choice vignette-based questions that COMLEX or USMLE ask. In reviewing sample test questions in the written literature and viewing online tutorials, I was struck by how nuanced many of these test questions were, whereby more than one of the choices had merit. It was more a matter of choosing the “most” correct answer based on the precise language in the stem. As a result, I worked on mirroring this approach in many of the questions I constructed.
However, as to the teaching itself, it was a joy. I had truly missed my time in the classroom with health science students – in this case, osteopathic medical students. I followed the classroom interactive style outlined in my first two contributions to this periodical. I wrote the clinical vignettes – approximately eight of them – for each session, had the students discuss the vignettes in small groups five or six at a table, and then asked for volunteers to address the ethical questions posed within the vignette. The discussions that ensued in the larger group were lively, and at the end of these sessions, students appeared to grasp how to work through complex ethical issues in medicine.
The student feedback at the end of these sessions was positive. They enjoyed the interactive nature of these encounters, and frankly, after every session, I felt pumped up. It is truly exhausting to spend four hours in a classroom. However, as any professor who enjoys teaching will likely admit, it feels exhilarating when you believe a teaching experience has gone well. Furthermore, as for me, since SOMA has yet to find a permanent replacement to teach medical ethics, I am happily doing this once again.
We are delighted to present the Center for the Future of the Health Professions Digest’s op-ed column for October 2023. We’re committed to supplying trustworthy and precise data and research on the healthcare labor force, with the aim of assisting policymakers and stakeholders within the health system to efficiently plan for a robust future.
In this edition, we’re excited to spotlight Ellen Gohlke’s article, “The Evolution of the Dental Hygiene Profession.” Ellen holds a bachelor’s degree in dental hygiene from Marquette University in Milwaukee, Wisconsin, and is pursuing her master of health science degree from A.T. Still University’s College of Graduate Health Studies (ATSU-CGHS).
Ellen holds many roles and is a full-time clinical hygiene instructor at the Arizona School of Dentistry and Oral Health’s Center for Advanced Oral Health. Here, she mentors students as well as AEGD residents tasked with treating individuals needing special care or managing medical complexities. Additionally, she dedicates part of her time as an adjunct hygiene instructor at Rio Salado College of Dental Hygiene in Tempe, Arizona.
Ellen’s practical experience in dental hygiene extends beyond her academic surroundings, having practiced in Wisconsin and Lausanne, Switzerland, upon graduating from Marquette. She has gained exposure in various dental specialties, including periodontics, pediatric, and general dentistry. In 2019, Ellen was presented with a fellowship in special care dental hygiene (FSCDH).
Passionate about social care, Ellen commits her time to serve underserved communities, focusing primarily on individuals with intellectual, developmental, and chronic medical conditions.
We welcome your reflections and insights on this month’s digest. Share your thoughts with us!
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Ellen Gohlke
The evolution of the dental hygiene profession
The dental hygiene profession was first established in 1913 by Alfred Fones, a dentist who realized the importance of having clean, healthy teeth.1 He believed it was essential to train female dental assistants to teach patients oral hygiene. He also believed women were less expensive to train and better at cleaning than men. His focus in dentistry was not on treatment, but more on prevention. Dr. Fones’ dedication to improving patients’ oral hygiene through prevention and education led him to establish the first dental hygiene school in Bridgeport, Connecticut, in 1913. Subsequently, he trained the first dental hygienist, Irene Newman, to work in his practice. Most dental hygienists are familiar with Fones since the “Fones toothbrushing technique” is still taught to dental hygiene students. In 1914, Fones initiated a five-year demonstration project in public schools that documented the success of a dental hygienist in providing education for dental disease prevention.2
In the early 1900s, a dental hygiene program began in the United States, requiring a year of training.3 Today, the country has more than 300 dental hygiene programs, most of which are housed in community colleges.4 People entering the dental hygiene profession can pursue a two-year associate degree, a four-year bachelor of science degree, or a master’s degree in dental hygiene. Dental hygienists must take national and regional license exams to enter practice. Degree completion programs allow dental hygienists with a two-year degree to complete their baccalaureate degree and there are no doctoral programs in dental hygiene in the United States. Dental hygienists pursuing leadership positions in universities, hospitals, federal agencies, and healthcare organizations will seek doctoral degrees in other disciplines.5
Dental hygiene is one of the fastest-growing healthcare occupations today. According to the American Dental Education Association, the dental hygiene workforce is estimated to increase by 20% in 2026.6 There are several reasons why the dental hygiene profession continues to grow in this country. The work schedule flexibility, the ability to improve a patient’s oral health, the potential to earn a good income, and the opportunity to get an advanced degree in dental hygiene are common reasons why people choose this healthcare profession. Many dental hygiene programs have a waiting list for acceptance and enrollment.
Since the pandemic, I have noticed a greater demand for dental hygienists. I still receive phone calls, text messages, or emails from dental colleagues asking if I know a dental hygienist interested in a job. However, the profession has faced some challenges, with more hygienists leaving the profession since the COVID-19 outbreak. Many licensed professionals retired during the pandemic for safety reasons, while others stopped working due to high childcare costs and other practice-related concerns.7 Nevertheless, dissatisfaction with salary and feeling unappreciated in the workplace are the main reasons why dental hygienists stop practicing. As a result, in March of 2022 the American Dental Association’s Health Policy Institute reported over 90% of dentists faced difficulties finding hygienists to hire. Despite dental hygienists leaving or retiring, the number of students entering programs continues to increase.
Dental therapy is a new occupation with a different scope of practice than dental hygiene and requires additional education and training. This occupation is distinct from dental hygiene. Dental therapists primarily work in underserved regions and provide essential restorative dentistry services and preventive care. The number of dental therapy programs continues to grow in the United States. Dental therapy first began in New Zealand in the 1920s.8 However, it was not until 2005 that the first dental therapist in the United States treated people in a rural Alaskan community.9 The need to provide dental care to people in underserved areas prompted native tribes to seek help for these impoverished areas. Even though most dental therapists in the United States have a dental hygiene degree, programs exist that train dental health aide therapists to provide dental care to rural tribal communities. Dental therapists practice under the supervision of dentists but may treat patients in settings other than dental offices in 13 states across the country. Licensed dental hygienists interested in dental therapy must complete an additional three-year program followed by a credentialing exam in Arizona.
Dental hygienists play an active role in teledentistry, which is especially helpful in providing patient care to those in rural and other underserved areas.10 Training and regulations for dental hygienists related to teledentistry continue to be developed and differ by state. Patients in remote areas of the country will benefit if teledentistry is allowed under the dental hygiene scope of practice by state dental practice acts. A.T. Still University’s Arizona School of Dentistry & Oral Health includes teledentistry coursework in its curriculum and employs dental hygienists who provide teledentistry services in collaboration with dental faculty to reach several communities of vulnerable patient populations. This model can help people across the country with little or no access to oral healthcare resources.
Dental hygienists may be employed in various settings, including skilled nursing facilities, community health clinics, and hospitals. There are also dental hygienist models who are employed within medical practices, most notably in pediatric medical offices.2 There is a growing recognition among medical professionals about the importance of good oral health as it relates to overall health. The link between poor oral health, particularly poor oral hygiene and periodontal disease, and systemic diseases such as diabetes, heart disease, and respiratory disease is well known. Good oral health is medically necessary for many patients who are critically ill, such as those undergoing cancer treatment or organ transplantation, to ensure successful health outcomes.
Graduating from a dental hygiene program years ago usually meant working in a private dental practice setting. Historically, very few dental hygienists taught in educational institutions and public health facilities. Whole-body healthcare was not the focus when I graduated in the 1980s. As a dental hygiene educator, I recognize that the dental hygiene profession advances by training and preparing future oral healthcare providers to treat the entire body, not just the mouth. The dental students and dental hygiene students I mentor who rotate through our Special Care Clinic at ASDOH realize the importance of treating the whole person. Most patients we treat have physical disabilities, intellectual disabilities, and medical comorbidities. Students and dental residents are taught new skill sets and tools to treat these complex populations.
ATSU focuses on pursuing knowledge, the whole body, and patient-centered care. My journey in dental hygiene has changed me into a healthcare provider who treats the entire individual as I educate lifelong learners on the importance of comprehensive healthcare while serving people from disadvantaged, diverse backgrounds. In the Advanced Care Clinic at ASDOH, I am fortunate to work with students, residents, and faculty as we meet the educational, healthcare, and societal needs of these communities in our state. As our population ages and grows, integrating dental and medical healthcare services for patients is essential. According to an article in the Journal of Dental Education, dental hygienists practicing in solo offices will decline by 2040 as the number of hygienists transition to organizations where medical and dental care are combined.11 In the future, dental hygienists will work with other healthcare disciplines while treating patients’ dental care needs.
References
The History of Dental Hygiene and a Look Toward the Future. Access. 2014;28(2):27-29. Accessed August 26, 2023.
Bowen DM. History of dental hygiene research. J Dent Hyg. 2013 Jan; Supple 1:5-22.
Watson, R. (2023), President’s Message. International Journal of Dental Hygiene. Accepted Author Manuscript. https://doi.org/10.1111/idh.12396
Dental Hygiene by the Numbers. American Dental Education Association. 2023
Gurenlian JR, Rogo EJ, Spolarich AE. The Doctoral Degree in Dental Hygiene: Creating New Oral Healthcare Paradigms. J Evid Based Dent Pract. 2016;16 Suppl:144-149. doi:10.1016/j.jebdp.2016.01.011
American Dental Education Association. Why Be a Dental Hygienist? 2015-2023.
Atchison KA, Fellows JL, Inge RE, Valachovic RW. The Changing Face of Dentistry: Perspectives on Trends in Practice Structure and Organization. JDR Clinical & Translational Research. 2022;7(1_suppl):25S-30S. doi:10.1177/23800844221116836
Fried, J.L., Maxey, H.L., Battani, K., Gurenlian, J.R., Byrd, T.O. and Brunick, A. (2017), Preparing the Future Dental Hygiene Workforce: Knowledge, Skills, and Reform. Journal of Dental Education, 81: eS45-eS52. https://doi.org/10.21815/JDE.017.032
The Center for the Future of the Health Professions introduces its September 2023 op-ed column! Our mission is to provide accurate and reliable data and research on the healthcare workforce to assist policymakers and health system stakeholders in effectively planning for a sustainable future.
We are thrilled to have Sarah Chagnon, a dental therapist and president of the American Dental Therapy Association, as our guest author. Sarah has served her community at the Swinomish Dental Clinic in Washington state for 4.5 years. She is dedicated to promoting dental therapy and ensuring everyone has access to dental care. Sarah believes in empowering patients by providing them with the knowledge and resources they need to make informed decisions about their oral health, as she understands oral health is integral to overall well-being.
We encourage you to share your thoughts on this month’s digest with us.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor & Director
The Center for the Future of the Health Professions
A.T. Still University
Sarah Chagnon
The dental therapy profession is gaining traction in the U.S.
The dental therapy profession started in New Zealand more than a century ago and has expanded worldwide. In fact, dental therapists (DTs) practice in more than 70 countries.1 Dental therapy has gained traction in the United States over the last 20 years, with six states currently licensing DTs and eight states that have passed legislation to codify the profession.
Now, you might be wondering what a dental therapist is. DTs are highly trained mid-level oral health practitioners and are often described as being comparable to PAs. Their scope of practice can vary slightly from state to state. Typically, they provide the most common straightforward and simple dental procedures and are frequently described as restorative experts. DTs also heavily concentrate and participate in health promotion and disease prevention programs.
DTs can benefit the oral health team in the United States because we live in a time where our society faces a continuing shortage of dentists. The U.S. Health Resource and Service Administration estimated the shortfall will grow to 15,600 fewer dentists than needed by 2025 and nearly 60 million people will forgo regular care as a result.1 Dental problems can lead to serious health risks if left untreated. DTs can provide an alternative for those who may not have access to a dentist or who cannot afford it. Their scope of practice consists of preventive procedures such as cleanings, sealants, and fluoride varnish applications, and oral evaluative procedures such as diagnosing and treatment planning. Routine restorative procedures include fillings and stainless-steel crowns on baby teeth, pulp capping, and simple extractions. This helps relieve some of the burden from the dentist’s schedule and ultimately helps the clinic run efficiently and effectively.
Dentists who utilize DTs can rest assured their patients are receiving the most up-to-date preventive and restorative care. They can then focus on complex treatments, such as root canals, crowns, implants, dentures/partials, specialties, etc. DTs help fill the gap in access to care and are cost-effective. Adding this team member can offer more flexible patient scheduling, eliminate patient wait times, increase revenue, ensure clinics operate at their total capacity, allow every provider to work at their full scope of practice, contribute and improve the overall clinical workflow, and provide new workforce opportunities.
The Commission on Dental Accreditation (CODA) serves the public and dental professions by developing and implementing accreditation standards that promote and monitor the continuous quality and improvement of dental education programs. This means the training meets the same standards as a dentist’s. Depending on the educational route, DT students complete three academic years of full-time instruction, including a clinical preceptorship experience.2
There are only five dental therapy educational programs in the United States: Iḷisaġvik College (CODA-accredited) in Alaska, Skagit Valley College (CODA-accredited) in Washington, the University of Minnesota (CODA-accredited), Minnesota State University, and Metro State University, also in Minnesota.
Dental therapy has faced many barriers since its introduction to the United States. Recognition and awareness have been a slow process, as only a few states have approved practice rights. In fact, DTs were initially only allowed to offer their services to tribal clinics, which led to the next barrier: workforce mobility. Because few states employ DTs and their scope varies by state, DTs cannot move anywhere and be ensured employment. Many states are interested in implementing this profession, but the legislation process is a long journey. In some states, lobbyists and dentists have resisted (though it’s important to note not all dentists feel this way). Adding a new role can be overwhelming and daunting since a dental clinic’s workflow has been the same for decades. The resistance could also stem from the fact that dentists simply don’t understand a DT’s scope of practice and/or how to implement a DT into their clinics.
Dentists have also expressed concern about the amount of training DTs receive. While DTs do receive a shorter education, they learn approximately 100 out of the 500+ procedures dentists learn in their four years of training. In addition, there is a high demand for DTs, but not enough DTs to fill these positions because there are not enough educational programs offering this degree.
Despite the hardships, thousands of case studies indicate this profession’s success in the short time its been around. According to the 2018 Journal of Public Health Dentistry, in Alaska, children and adults had lower rates of tooth extractions and more preventive care in communities served routinely by DTs than in communities with no care by midlevel providers.3 According to the report “Provider and Patient Satisfaction With the Dental Therapy Workforce at Apple Tree Dental,” respondents acknowledged having a dental therapist on staff allowed patients to have more needs met in one visit and improved patients’ sense of having a regular dental provider.4A study conducted in rural Minnesota towns found having a dental therapist as part of their oral health team improved dentists’ ability to spend more time performing procedures requiring their expertise, resulting in increased revenue. Satisfaction ratings for the therapist’s chairside manner and technical skills were similar to those given to clinic dentists and dental hygienists.5
References
Potter, W. (2021). The Rise of the Dental Therapy Movement in Tribal Nations and the US [Review of The Rise of the Dental Therapy Movement in Tribal Nations and the US]. Lessons from the W.K. Kellogg Foundation.
Licari, F. W., & Evans, C. A. (2014). Recommended standards for dental therapy education programs in the United States: a summary of critical issues. Journal of Public Health Dentistry, 74(3), 257–260. https://doi.org/10.1111/jphd.12057
ATSU campuses are abuzz with new and returning students ready to complete another exciting academic season. Unusually hot weather in Missouri and Arizona made the first several weeks challenging for all. Thanks for hanging in there!
Summer commencements honored a record number of graduates with 911 students receiving diplomas across six ceremonies. Thank you to everyone who supported our graduates, faculty, staff, and commencement activities. We are also looking forward to September graduations for physician assistant programs in California and Arizona.
Thank you, Board of Trustees members, Danielle Barnett-Trapp, DO, ’11; Bertha Thomas; Jonathan Cleaver, DO, FAOCD, FAAD, FASMS, ’08; and Kim Perry, DO, MBA, MHCM, FACEP, FACOEP, ’91, for participating in commencement and white coat ceremonies.
California dreaming
On Friday, Sept. 8, 2023, ATSU will celebrate College for Healthy Communities’ physician assistant program’s inaugural commencement.
Thank you, Drs. Ted Wendel, Eric Sauers, and Dan McDermott, and faculty and staff, for all of your hard work and perseverance. Also, thank you to the pioneering inaugural class for battling through COVID, curriculum updates, and new campus snafus.
California’s Central Coast community continues to play a vital role in the success of our students and campus. We are thankful for their support.
Incorporating ATSU’s core professional attributes (CPAs) and osteopathic philosophy into students’ education and experiences
ATSU students and graduates possess a unique set of knowledge, capabilities, and skills to succeed in today’s and tomorrow’s challenging world. ATSU’s CPAs cover five domains critical to graduates entering healthcare.
Knowledge regarding the philosophy of osteopathic medicine also provides graduates an advantage in providing, guiding, and leading healthcare delivery. Today, more than ever, understanding the interconnectedness of our bodies’ systems is essential in delivering whole person healthcare.
Exploring artificial/augmented intelligence’s emerging role in healthcare and education
Three ATSU AI projects are underway to improve student, faculty, and staff experiences. Funds have also been allocated to provide pilot research grants for interested faculty and staff.
Ivy.AI chatbots to assist students, faculty, and staff.
Google Bard to assist with generating text, language translation, and answering questions.
Anthology CRM for crafting messages and promoting engagement.
Student recruitment and retention
Colleges and universities are facing future headwinds with fewer high school graduates, the public’s questioning of higher education’s value proposition, and rising costs.
Focusing on student retention is paramount to a successful health science university. College deans and Student Affairs are working closely together to assure ATSU students receive the support necessary for success.
Cultural proficiency
Essential to becoming the best healthcare professional, student, faculty, or staff member requires understanding and practicing cultural proficiency. Appreciating the unique perspectives we all bring to healthcare and education makes ATSU a great place to learn and work.
Understanding recent conversations around the U.S. Supreme Court’s decision regarding admissions and race is helpful. Please visit this link to learn more.
Reaccreditation news
The A.T. Still University-College of Graduate Health Studies’ (ATSU-CGHS) Master of Public Health – Dental program successfully met all metrics required for reaccreditation. After an April 3, 2023, site visit on the Mesa, Arizona, campus, the program was notified it met all standards and complied with all commission policies. Congratulations to Jeff Chaffin, DDS, MPH, MBA, MHA, assistant professor and program director; Mary-Katherine McNatt, DrPH, MPH, MCHES, CPH, COI, professor and chair; and team on this accomplishment.
ATSU commencement ceremonies
Arizona School of Dentistry & Oral Health (ATSU-ASDOH)
Friday, May 12 Mesa, Arizona 76 graduates Commencement speaker: Wayne Cottam, DMD, MS, vice dean, associate professor, ATSU-ASDOH
Missouri School of Dentistry & Oral Health (ATSU-MOSDOH)
Friday, May 19 Kirksville, Missouri 57 graduates Commencement speaker: Dennis A. Mitchell, DDS, MPH, vice provost for faculty advancement, Columbia University
Kirksville College of Osteopathic Medicine (ATSU-KCOM)
Saturday, May 20 Kirksville, Missouri 166 graduates Commencement speaker: Robert A. Cain, DO, FACOI, FAODME, president and CEO, American Association of Colleges of Osteopathic Medicine
College of Graduate Health Studies (ATSU-CGHS)
Friday, May 26 Mesa, Arizona 217 graduates Commencement speaker: Daryl Nelson, MS, ATC, director of team growth and development, Las Vegas Raiders
School of Osteopathic Medicine in Arizona (ATSU-SOMA)
Friday, May 26 Mesa, Arizona 138 graduates Commencement speaker: Faith L. Polkey, MD, MPH, CPE, CEO, Beaufort-Jasper-Hampton Comprehensive Health Services Inc.
Arizona School of Health Sciences (ATSU-ASHS)
Friday, June 2 Mesa, Arizona 257 graduates Commencement speaker: Victoria Garcia Wilburn, DHSc, OTR, FAOTA, assistant professor of occupational therapy, Indiana University-Purdue University Indianapolis
Upcoming ATSU commencement ceremonies
College for Healthy Communities (ATSU-CHC) Friday, Sept. 8 Santa Maria, California
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In closing
Thank you for taking a few minutes to catch up on ATSU activities. For daily updates, please visit ATSU News.
May your 2023-2024 academic year be one of professional and personal successes.
Yours in service,
Craig M. Phelps, DO, ’84 President
A.T. Still University of Health Sciences 800 W. Jefferson St., Kirksville, MO 63501 | 660.626.2121 5850 E. Still Circle, Mesa, AZ 85206 | 480.219.6000 1075 E. Betteravia Rd., Ste. 201, Santa Maria, CA | 805.621.7648 Office of the President | president@atsu.edu ATSU Communication & Marketing | communications@atsu.edu
A.T. Still University of Health Sciences serves as a learning-centered university dedicated to preparing highly competent professionals through innovative academic programs with a commitment to continue its osteopathic heritage and focus on whole person healthcare, scholarship, community health, interprofessional education, diversity, and underserved populations.
The Center for the Future of the Health Professions will post its fifth monthly op-ed column for 2023. Our columns represent strong, informed, focused opinions on issues affecting the health professions’ future. As mentioned, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce to effectively plan for a sustainable future and make the best use of available resources.
This month we feature a discussion on using standardized patients in health professions education. Standardized patients (SPs) are used in healthcare professions education to simulate a realistic patient experience. SPs can help students learn how to effectively interact with patients, practice communication skills, and gain clinical experience. SPs also help to ensure that all students have the same learning experience and that their assessments are fair. Additionally, SPs provide a safe and controlled environment where students can practice their skills and develop confidence. Finally, students are better equipped to handle real-life patient interactions by interacting with SPs.
This month’s column will turn to our own Mandy Weaver as she interviews her husband, George Cohen, an SP for over two years, in a Q&A entitled “Confessions of a retired standardized patient.” George was a community leader and a senior partner with CPA firms. The majority of his clients were physicians and other health care professionals.
We look forward to your comments on this month’s digest.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor & Director
The Center for the Future of the Health Professions
A.T. Still University
George Cohen
Confessions of a retired standardized patient
Howard Barrows, MD, was the first to use standardized patients (SPs) in 1963. He initially referred to those SPs as “programmed patients.” They have been called by several names since, and the more generic term is “simulated individuals,” especially in nonmedical fields, such as education, spiritual care, law, police training, and many others. Since Dr. Barrows trained those first SPs, human simulation has become an integral part of medical education worldwide.1
A.T. Still University’s Kirksville College of Osteopathic Medicine (ATSU-KCOM) in Kirksville, Missouri, has documentation of SP cases as early as 1995, according to Lisa Archer, director of simulation and performance assessment. Lorree Ratto, PhD, associate professor at A.T. Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA) began the SP program officially for SOMA’s inaugural class of 2011.
ATSU’s Arizona-based Interprofessional and Culturally Proficient Standardized Patient Experience Center opened in 2019. Lisa McNeil is the center’s manager. The facility is open to ATSU’s medical, dental, physician assistant, physical therapy, and occupational therapy students. One technological tool utilized by the center is the GERonTologic suit, which simulates the effects of aging, teaching students empathy for older adult patients.2
This article features an interview between ATSU’s Center for the Future of the Health Professions program administrator Mandy Weaver and her husband, George Cohen, CPA, who was an SP for over two years. He also participated in the SP programs at Arizona College of Osteopathic Medicine – Midwestern University and Southwest College of Naturopathic Medicine. Cohen is a recognized community leader and ambassador for the osteopathic medical profession in Arizona.
What drew you to the SP program?
Cohen: I was a budding actor after retiring from a successful professional accounting career. Soon after my retirement, I talked to someone who was an SP who told me about the ATSU program. I thought, “What better way is there to hone my skills for acting?” Working with students was also appealing.
Were there other actors in the program?
Cohen: There were many actors and other people looking to make a few extra bucks. So, it was a cross-section of individuals. Kudos to the program faculty and staff for getting a diverse population with whom the students can learn.
Were you familiar with medical education?
Cohen: I really wasn’t familiar despite having a career surrounded by physicians and having a spouse who was deeply involved in the medical profession as the executive director of the Arizona Osteopathic Medical Association. So, I wasn’t aware of the educational rigors a budding physician would be going through, particularly in year one.
Were there any surprises about medical education?
Cohen: I was pleased and pleasantly surprised to see how much attention and effort is given to teaching the students empathy. When I grew up, most physicians were very stiff and clinical. Having a physician who has a more caring attitude and takes an interest is much more reassuring to their patient.
Were there any surprises with the students?
Cohen: I was surprised by the diversity of the students. There were older students who had some type of medical background, such as PAs and EMTs. There were also “legacy” students whose parents or other family members were physicians. In addition, there were international students from other cultures with more poverty and different healthcare systems than U.S. students have experienced.
What was the interaction between the students and faculty and staff?
Cohen: The interaction was incredible and a confidence-building relationship. The faculty and staff were genuinely interested in the students. A special thanks to the ATSU team Lisa McNeil and Dr. Lorree Ratto.
Did you have a script?
Cohen: Everything was scripted, and you had to stick to the script – no improvising. The scripts indicate the age and symptoms of the patient and social determinants, such as a homeless single mother. The students took the history and examined the SPs. My favorite symptom was kidney stones because the SPs were told that if the student touches the kidney, it is ok to scream and reach for the roof. Pretending to pass out was also a valuable acting experience.
Did they ask their patients about their current environment?
Cohen: Yes, such as:
Are you depressed?
Do you interact with other people?
Can you walk to a pharmacy to get meds? Do you know the meds you are using?
Are you eating every day?
I understand that the SPs also evaluate the students from a patient’s perspective.
Cohen: There was a checklist that included:
Washing their hands when they entered the exam room.
Knocking on the exam room door before entering.
Helping the patient get on and off the exam table.
Being kind and courteous.
Facing the patient and making eye contact when talking to them.
Taking a thorough history.
Asking for social determinants information.
Note: An instructor can watch the exchange between the SP and the student from a nearby video monitor room. Later, the student and the instructor can view the video and discuss ways to improve exam skills.
What is the benefit of the SP program to the students?
Interacting with a human being is much better than a simulated encounter. You are eye to eye. That is a good life lesson when they learn how to communicate and listen.
What impact did you have on the students and what impact did they have on you?
The impact they had on me was to elevate my medical education and be aware of things going on in my body. I learned that medicine, in general, requires educated guesswork. My expectation that healthcare professionals can just solve things is unrealistic. I must take responsibility for myself in terms of being aware of issues and being able to communicate those issues. I need to take better care of myself.
The ATSU SP program is incredibly well run; I am sure it is a role model for other schools. I really hope that I made a difference in the student’s education. It was a wonderful experience.
