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Center for the Future of the Health Professions Nov. 2022 digest

This month, The Center for the Future of the Health Professions will post another monthly op-ed column for 2022. Our columns represent strong, informed, and focused opinions on issues affecting the health professions’ future. As mentioned previously, 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 features a discussion of the future of athletic training education and is authored by Dr. Tamara Valovich McLeod. Dr. McLeod is chair, director, and professor for the Athletic Training department, professor in the School of Osteopathic Medicine in Arizona, and John P. Wood, DO, endowed chair for sports medicine at A.T. Still University in Mesa, Arizona. Dr. McLeod completed her PhD at the University of Virginia and is the founding director of the Athletic Training Practice-Based Research Network. Her research has focused on the pediatric athlete with respect to sport-related concussions. Dr. McLeod serves on numerous editorial boards, publishes frequently in the athletic training and sports medicine journals, and is a NATA Fellow.

We look forward to your comments.

Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA

Professor & Director

The Center for the Future of the Health Professions

A.T. Still University

Dr. Tamara Valovich McLeod

Athletic training education

In the last decade there have been some considerable shifts in athletic training education, including a professional degree transition, the development of residency and fellowship programs, and the emergence of doctoral level programs of study. Historically, the athletic training degree was offered at the baccalaureate level and students would be eligible to sit for the Board of Certification examination following the completion of that degree. In 2014, a recommendation was made to transition the professional preparation of athletic trainers to the master’s degree level. The rationale for the recommendation was due to several key factors, including the evolution in the professional competency requirements, better alignment with peer healthcare professions, facilitation of interprofessional education, and retention of students committed to the athletic training profession. Current data from the Commission for the Accreditation of Athletic Training Education (CAATE) reports 273 professional master’s programs and 45 professional programs still offering bachelor’s degrees.

In addition to professional programs, athletic training has numerous post-professional educational options. Prior to the degree transition, post-professional master’s degree programs, like the one offered at A.T. Still University from 1995-2022, were one path that credentialed athletic trainers could follow for advanced coursework. However, the transition of the professional degree to the master’s level limited the need for post-professional master’s degree programs and paved the way for the emergence of programs offering a doctor of athletic training (DAT) degree. The DAT is an advanced practice doctoral degree designed to prepare future leaders in athletic training who are capable of making substantial contributions to improvements in the delivery of athletic healthcare to improve the health of their communities. There are currently eight DAT programs across the United States.

In addition to advanced practice doctorates, athletic training education has recently added residencies and fellowships to the post-professional educational pathway. Residency programs allow athletic trainers to engage in a structured curriculum with didactic components and mentored clinical components to develop expertise in a specialty area. The CAATE has identified eight focused areas of clinical practice for accredited residencies including: prevention and wellness, urgent and emergent care, primary care, orthopedics, rehabilitation, behavioral health, pediatrics, and performance enhancement. Future opportunities may exist within athletic training fellowships that would provide the opportunity for athletic trainers to subspecialize in a very focused area of practice.

Athletic training programs at ATSU

The athletic training (AT) programs at ATSU launched in 1995 as one of the original programs within the Arizona School of Health Sciences. Since that time, the program has expanded offerings to an online doctor of athletic training (DAT) degree, online master of science in athletic training (MS-AT) degree, five certificate programs, continuing education programming, and has just begun a digital badging initiative.

Initially called Sports Health Care, the residential master’s degree in athletic training was a post-professional degree for athletic trainers looking to advance their knowledge and skills beyond the professional degree. Students are board certified and licensed as athletic trainers in Arizona. Most hold graduate assistantships at local colleges and high schools where they provide athletic training services. This residential program was closed in August 2022 as we transitioned to an online format for our MS-AT degree.

Anticipating the professional degree transition, the AT programs launched DAT in January of 2015. This post-professional program targets working athletic trainers who are interested in advancing their career and the athletic training profession by becoming clinical and academic leaders. Students in the DAT program are employed in a wide variety of settings, including secondary school, college, professional sports, occupational health, dance medicine, academia, and the military.

The DAT program is online and asynchronous, with the exception of a one-week winter institute. Students develop a customized academic degree plan that includes three foundational areas (clinical decision-making, winter institute, applied research) and 24 elective credits from the orthopaedic, rehabilitation, leadership and education, and sport neurology and concussion concentration areas. The culmination of the DAT degree program is the completion of an applied research project, with options for original research, case studies, quality improvement initiatives, and special projects.

Each of the concentration areas and the clinical decision-making foundation are also offered as 12-credit graduate certificate programs for students interested in a specific content area. In addition, an online MS-AT degree was launched in July 2021. This 30-credit fully online program will allow students who completed professional programs at the baccalaureate level to complete a master’s degree while beginning their career.

Through our Athletic Training Practice-Based Research Network, the AT faculty and post-doctoral fellows have authored 14 continuing educational courses available to athletic trainers free of charge. Since 2015, there have been more than 110,000 course completions covering contemporary content such as clinical outcomes assessment, quality improvement, health information technology, injury prevention, and concussion.

Remote learning and the COVID-19 pandemic

The faculty within the AT programs have developed, instructed, and managed online courses since the inception of the DAT in 2015. While each faculty member may use different assignments and instructional tools that best fit their course content, all are comfortable and proficient in online instruction. When the pandemic closed the Mesa campus and required our residential courses to move to online instruction, our faculty were able to transition seamlessly for the most part. As with other programs, lab activities needed to be modified, but the experiences in developing clinical and lab-based content for our DAT were helpful through the transition. The faculty did use synchronous class meetings to continue to have a face-to-face presence with our students and added Friday afternoon “coffee talks” to discuss current topics and increase engagement. This addition was especially helpful early on in the pandemic as most graduate assistantship positions were not in person either, with secondary schools and colleges going remote. Many of these discussions focused on telehealth and how our students could continue to serve their patients in a remote capacity. Additionally, we mentored students on navigating employment interviews remotely.

While the transition to remote learning had less of an impact on our DAT and graduate certificate programs, we recognized that students in those programs were dealing with the uncertainty of their own employment and navigating management of their own patients, all while continuing in courses towards their doctoral degree. The faculty increased their virtual office hours and communication with our DAT students to ensure that the program was meeting their needs during this difficulty time and the program director started monthly drop-in hours to improve accessibility for students.

Future initiatives

The athletic training programs have two primary initiatives. The first is a digital badge initiative, in which digital badges are awarded to students and alumni for completion of courses, tracks, and the degree. Digital badges allow students to showcase their accomplishments and professional development with current or future employers, or among peers in a manner that can be easily displayed and verified online.

The athletic training programs are also exploring the development of a hybrid professional master’s degree program. This program would target students interested in becoming an athletic trainer and would use our expertise in online learning with clinical experiences at sites across the country. The program would be taught using a competency-based model that may include the digital badge framework to teach and verify skills. Unlike traditional residential programs, the hybrid model would allow students to learn from where they feel most comfortable and even seek immersive clinical experiences near their home location or in specific settings of interest.

Ultimately our goal is to meet students where they are and provide educational offerings across the entire spectrum of athletic training education including professional, post-professional, and continuing education opportunities.

This month, The Center for the Future of the Health Professions will post another monthly op-ed column for 2022. Our columns represent strong, informed, and focused opinions on issues affecting the health professions’ future. As mentioned previously, 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 features a discussion of Future of Diversity in the Health Professions and is authored by Clinton J. Normore, MBA, the vice president for Diversity & Inclusion at A.T. Still University. Normore leads a universitywide diversity effort, encompassing ATSU’s seven graduate health professions schools in Kirksville, Missouri, St. Louis, Missouri, Mesa, Arizona, and Santa Maria, California, and an online school of graduate health studies. This work also touches community health centers nationwide. He works with faculty, staff, students, deans, and leadership at the University’s highest levels in support of ATSU’s mission of providing healthcare to the underserved and serving on many University committees.

Normore was a National Institution on Minority Health Disparities Scholar in 2015. He is a trained civil rights investigator and is a certified campus security authority. Since joining the ATSU community, Normore has been instrumental in developing a framework for diversity and a diversity strategic plan. Under his leadership, the University was the first health professions university to receive the coveted Higher Education Excellence in Diversity (HEED) Award in 2017. The University subsequently won the HEED Award for five consecutive years. The University was awarded the 2022 National Association of Diversity Officers in Higher Education (NADOHE) Excellence in Diversity award for a professional school. Normore has led the creation of the University’s award-winning Dreamline Pathways program in 2016. Since August 2014, he has been a faculty member of ATSU’s Missouri School of Dentistry & Oral Health and has been a faculty member of ATSU’s Arizona School of Dentistry & Oral Health since 2021. Normore has also served as an instructor in the business department of Phoenix College and is a lead consultant for Ben Harrison & Associates on its community policing initiative, providing workshops for police departments in Arizona. He chairs the ATSU Advisory Council on Diversity and serves on many University-level committees and task forces.

Normore speaks broadly (e.g., workshops, presentations, keynote speaker) for campus constituents, professional organizations, corporations, and educational institutions. He is a proud member of Omega Psi Phi Fraternity and has a rich history of community service. He chairs the Phi Iota Chapter of Omega Psi Phi Fraternity’s Community Oriented Policing Initiative Task Force. He is also a member of many professional organizations. He earned a master of business administration from Oklahoma City University and a bachelor of science degree from the University of Central Oklahoma. Now, he is pursuing a doctoral degree in graduate health education.

Normore was a member of the 1988 University of Kansas national championship basketball team. He also has served as a police officer, owned several businesses, and taught and coached at every school level, culminating as an assistant women’s basketball coach for Oklahoma City University’s 2012 national championship team.

We look forward to your comments.

Randy Danielsen, PhD, DHL(h), PA-C emeritus, DFAAPA

Professor & Director

Clinton J. Normore, MBA

Future of diversity in the health professions

Unless there are stark systemwide changes in health professions education, increased workforce diversity is not likely to occur. The primary barriers to improving workforce diversity are student access to graduate Health Professions Programs, (particularly medicine), institutional accountability, and the culture of these schools.1 Without a more diverse student body, there cannot be a more diverse workforce. African Americans and Hispanics represent only 11.8% of physician assistant (PA) matriculants compared to 32% of the U.S. population.2 A specific group among Black Indigenous People of Color (BIPOC) students in PA programs is a point of emphasis in this article. These historically underrepresented groups (HUGs) consist of Black/African American, American Indian or Alaska Native, Hispanic, Native Hawaiian, and Other Pacific Islanders.

There is some trepidation toward emphasizing access programs, particularly among predominantly White schools (PWIs), because of the lack of clarity around affirmative action.  Affirmative action in the labor sector has been inappropriately associated with the education sector because of race-conscious admissions practices.3 Executive Order 11246 was signed by President Lyndon B. Johnson and derived from the Civil Rights Act of 1964. This piece of legislation required federal contractors, who do more than $10,000 of business, to take affirmative action steps to ensure employment and fair treatment of applicants and employees regardless of race, creed, color, ethnicity, sex, religion, or national origin.

Policies must be designed to create student groups that are more reflective of society.4 Diversifying the student body improves outcomes and provides a richer academic experience for all students. Health outcomes are improved, and health disparities are decreased with more workforce diversity.5 Nevertheless, affirmative action legislation progress has been challenged since the Supreme Court upheld the University of California v. Baake case (1978). Students For Fair Admissions (SFFA) v. Harvard University (2014) is among the more recent cases challenging race-conscious admissions. The Supreme Court has recently decided to hear this case. The longer these assaults on race-conscious admissions continue to glean credibility, the more likely student matriculation among HUG students will not meet the growing need for more workforce diversity.

Though affirmative action assaults persist, there are more tailwinds now toward improving workforce diversity through targeted recruitment efforts, and more importantly, open communication about the need for this kind of representation. PA programs attempt to address diversity in structure, curriculum, and marketing. However, institutions are still tethered to traditional access issues, education methods, and accreditation, which exemplifies culture superseding policy. PA programs still rely on standardized tests, GPAs, shadowing hours, and community service hours for student access measures.6 Though HUGs demographics are growing (particularly among Hispanics), medicine continues to track towards White and Asian providers. White and Asian students matriculate into PA programs at rates of 80.4% and 11.4% respectively.7 The perception of bias is embedded throughout the admissions process.8 The ARC-PA’s most recent accreditation standard requires that programs demonstrate a commitment to diversity.9 Demonstrating a commitment to diversity, equity, and inclusion (DEI) can simply mean increasing HUG recruitment, creating a DEI position, or a diversity strategic plan. Accrediting bodies must hold institutions and programs accountable for outcomes that do not increase HUG representation.

Access to PA programs for HUG students remains a challenge. Access issues are predicated on the costs of education.10 The average undergraduate student loan debt for the class of 2020 was calculated to be $36,635.11 Black student loan debt averages $52,000.12 The vast majority of BIPOC students leave college with more loan debt compared to their White peers.13 The net worth of Black college students is almost $9,000 less than that of their White peers. The private loans of Black and Latino students are substantially higher than their White peers.14 The projected PA debt load is approximately $112,500.15

Access is also constrained by the traditional admissions practices in graduate health programs. Approximately 8.1% of HUG applicants matriculated into a PA program during the 2017-2018 cycle, compared to 91.8% of White and Asian applicants.16 If workforce diversity were a sincere goal, the percentage of HUG matriculants would be significantly greater than that among White and Asian groups.

The future of workforce diversity in the PA profession faces tremendous challenges that also exist in most health professions. Fewer HUG student matriculants, increasing costs, and reflective campus climates are among the more pressing issues in need of addressing. Health professions institutions must reassess their organizational culture to improve outcomes.17 Innovative changes to the selection process must be incorporated. HUG outreach must be increased at the K8 level to introduce the PA profession and nurture any interest beyond that point. Mitigating the bias embedded in student selections must be central to selection processes. Accrediting agencies should focus more on outcomes related to HUG applicants and employees.

The PA profession continues to be ripe with growth opportunities. In 2021, the US News & World Report rated the profession first on the best 100 jobs list and second on the best healthcare jobs list.18 In 2018, the PA profession was fifth on the fastest growing jobs in America list. A.T. Still University is recruiting and matriculating HUGs to improve workforce diversity. Approximately 39% of the ATSU-CHC inaugural PA class are HUG students. The ATSU-ASHS PA program matriculated approximately 31% of HUG students in its 2024 Class. ATSU’s Dreamline Pathways program is designed to meet K8 students and their influencers where they are to introduce them to the health professions and nurture their academic growth beyond high school. Intentionality in health professions education is the only way to improve workforce diversity.

References

  1. Cuenca JP, Ganser K, Luck M, Smith NE, McCall T, Diversity in the physician assistant pipeline: Experiences and barriers in admissions and PA School. The Journal of Physician Assistant Education: July 8, 2022 – Volume – Issue – 10.1097/JPA.000000000000442: doi.org/10.1097/JPA.0000000000000442
  2. Cuenca JP, Ganser K, Luck M, Smith NE, McCall T, Diversity in the physician assistant pipeline: Experiences and barriers in admissions and PA School. The Journal of Physician Assistant Education: July 8, 2022 – Volume – Issue – 10.1097/JPA.000000000000442: doi.org/10.1097/JPA.0000000000000442
  3. Miller C. Affirmative Action and its Persistence Effects: A New Perspective. California Management Review. 2019;61(3): 19-33. doi.org/10.1177/0008125619849443
  4. Burke, Constance JD, MS, PA-C. Underrepresentation in Higher Education: Affirmative Action’s Role in Bridging the Gap. The Journal of Physician Assistant Education: March 2021: 32(1), 54-57. doi.org/10.1097/JPA.
  5. Mickey-Pabello D, Graces LM, Addressing Racial Health Inequities: Understanding the Impact of Affirmative Action Bans on Applications and Admissions in Medical Schools. American Journal of Education. 2018:125(1), 79-108. doi.org/10.1086/699813
  6. VanderMeulen SMP-C, Snyder JAP-C, Kohlhepp WDhsMP-C, et al. Pipeline to the Physician Assistant Education (Lippincott Williams & Watkins). 2022;33(1) e1-e10. Doi:10.1097/JPA.0000000000000414
  7. CASPA. (2022). The PA pipeline to practice: Applicant and matriculant data from CASPA™. Retrieved August 6, 2022, from https://paeaonline.org/wp-content/uploads/2020/10/paea-presentation-caspa-20200106.pdf
  8. Cuenca JP, Ganser K, Luck M, Smith NE, McCall T, Diversity in the physician assistant pipeline: Experiences and barriers in admissions and PA School. The Journal of Physician Assistant Education: July 8, 2022 – Volume – Issue – 10.1097/JPA.000000000000442: doi.org/10.1097/JPA.0000000000000442
  9. ARC-PA Accreditation Review Commission on Education for Physician Assistant, Inc. Accreditation Standards. http://www.arc-pa.org/wp-content/uploads/2022/03/Standards-5th-Ed-Mar-2022.pdf
  10. VanderMeulen SMP-C, Snyder JAP-C, Kohlhepp WDhsMP-C, et al. Pipeline to the Physician Assistant Education (Lippincott Williams & Watkins). 2022;33(1) e1-e10. Doi:10.1097/JPA.0000000000000414
  11. Hanson, Melanie. Student Loan Debt by Race. EducationData.org. June 13, 2022, https://educationdata.org/student-loan-debt-by-race
  12. Hanson, Melanie. Student Loan Debt by Race. EducationData.org. June 13, 2022, https://educationdata.org/student-loan-debt-by-race
  13. Ishak, Natasha. How would $10,000 in student loan debt forgiveness impact BIPOC borrowers? May 10, 2022,  https://prismreports.org/2022/05/10/10000-student-debt-forgiveness-bipoc-borrowers/
  14. Hanson, Melanie. Student Loan Debt by Race. EducationData.org. June 13, 2022, https://educationdata.org/average-graduate-student-loan-debt
  15. Pasquini, Stephen, PA-C. How Much Does it Cost to go to Physician Assistant (PA) School? 2022. Retrieved August 6, 2022, from https://www.thepalife.com/how-much-does-it-cost-to-go-to-physician-assistant-pa-school/#:~:text=The%20Average%20Cost%20Across%20all,assistant%20program%20is%20%2488%2C6777
  16. CASPA. (2022). The PA pipeline to practice: Applicant and matriculant data from CASPA™. Retrieved August 6, 2022, from https://paeaonline.org/wp-content/uploads/2020/10/paea-presentation-caspa-20200106.pdf
  17. Tiffany Jana, Mathew Freeman. Overcoming Bias: Building Authentic Relationships Across Differences. Vol First edition. Berrett-Koehler Publishers; 2016. Accessed August 18, 2022. https://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=nlebk&AN=1231888&site=eds-live
  18. U.S. News & World Report. Best Health Care Jobs. 2022. https://money.usnews.com/careers/best-jobs/rankings/best-healthcare-jobs

On July 1, 2020, the St. Louis City Senior Fund awarded A.T. Still University of Health Sciences (ATSU) a three-year grant for more than $875,000 in support of the University’s project, “Improving Quality of Life: Oral Care for St. Louis Older Adults (OCOA).”

The project is designed to improve the oral health of St. Louis City residents who are 60 and older and live at or below 200% of the federal poverty line. Patients who qualify for the program receive dental care from ATSU’s Missouri School of Dentistry & Oral Health (ATSU-MOSDOH) students at the St. Louis Dental Center. Program participants also learn about proper oral hygiene.

As OCOA enters its third year, ATSU faculty member Patricia Inks, RDH, MS, one of the project’s two directors, is pleased to share the project has exceeded its goal of treating at least 300 people upon the program’s completion. Inks is the assistant professor and director of dentistry in the community and integrated community service partnerships.

As of July 6, 2022, the program had 350 class participants and 337 of those participants have become patients. Approximately 300 patients are in active treatment with a waiting list of 53 people.

For Inks, the project not only enriches the patients’ lives, but it is also extremely beneficial for ATSU dental students. Every third- and fourth-year dental student has seen and treated at least one patient from this project.

“The project fulfills the educational needs of the students and helps them serve the community that we live in,” she said. “It provides students great experiences with special needs patients (older adults who might have comorbidities) and allows them to have a steady group of patients.”

Before the project’s inception, Inks was very involved in the St. Louis community and extremely focused on community outreach. She often traveled to different independent living facilities to educate the community and provide dental screenings. So many of the people she saw were unable to afford treatment, even at a discounted rate.

So far, Inks and her team have planned $322,000 worth of treatment. According to Inks, at least 60% of patients need one or more of their teeth extracted. In addition, the patients may receive a variety of treatments and appliances, including root canals, fillings, and partials/dentures. Most, if not all, of these treatments would not be covered under Medicaid.

In this final year Inks wants to complete all treatment plans and fulfill the commitments to all patients in the program. She also wants to continue collecting survey data from patients to show how providing functional oral health improves overall health.

“We’re really hoping to get additional funding,” she said. “This program has been so beneficial.”

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