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My son Hal is in love with the movies of Wes Anderson. Hal’s a visual kid who, at the age of six, drew a vivid picture that still hangs in my office: monsters entering his bedroom from all directions including a fire-breathing dragon descending from the ceiling, a pitchfork stabbing up through his mattress, and – worst for a boy whose palate was limited to pasta and grilled cheese – ascending through a hole in the floor, a man-sized broccoli wearing a T-shirt that reads “I ♥ Broccoli.” So I get Hal’s affinity for Anderson’s visually stunning films. Every scene and shot is meticulous. Over the holidays we watched The Royal Tenenbaums, which Hal adored, most of all the confrontation between characters played by Luke and Owen Wilson in front of a disturbing painting of menacing, primitive-mask-wearing, shirtless men on mopeds.
Hal’s favorite Wes Anderson film remains The Grand Budapest Hotel with its vision of a European ancient regime – palette, perfumes, confections, symmetry, and order – that never existed, but nonetheless died in war and totalitarianism. Hal says seeing the art of Grand Budapest for the first time was a life-changing experience. But for me, the grandest part isn’t what’s on screen, but Anderson’s dialogue. And the Gap Letter highlight is when hotel concierge par excellence Monsieur Gustave interviews aspiring lobby boy Zero.
M. Gustave: You’re now going to be officially interviewed.
M. Gustave strides through the front doors into the lobby. Zero is quickly at his heels, terrified. M. Gustave withdraws a small notebook from his pocket as they walk. Zero is uncertain.
Zero: Should I go and light the candle first?
M. Gustave: What? No. (starting the interview) Experience?
Zero: Hotel Kinski, Kitchen Boy, six months. Hotel Berlitz, Mop and Broom Boy, three months. Before that I was a Skillet Scrubber in the banquet hall at…
M. Gustave (noting this): Experience: zero.
Gustave’s extravagant experience expectations for lobby boys didn’t prevent him from hiring Zero, making Grand Budapest a glorious career-launch story compared to what’s going on with nurse practitioners, the subject of a depressing Bloomberg Businessweek article that came out just in time for the holidays. Here’s the first paragraph:
Across the U.S., nurse practitioner students face the same problem. Like medical doctors, they need to complete clinical rotations to graduate. Unlike doctors, they don’t have access to federal funding to support that training, and their schools often leave them to find their own clinical instructors, known in the industry as preceptors.
In order to become a nurse practitioner (NP) – a nurse licensed to diagnose, treat, and prescribe – a registered nurse with a bachelor’s degree in nursing (BSN) must obtain either a two-year Master’s degree (MSN) or a four-year doctoral degree (Doctor of Nursing Practice or DNP). Each typically requires 100+ hours of clinical practice per semester. But the accreditor for nursing programs, the Commission on Collegiate Nursing Education (CCNE), doesn’t require NP programs to arrange clinical rotations. So students have no choice but to “beg on Facebook for placements” and “drop off cookies for potential preceptors.” Which is why, like a Wes Anderson film, the Bloomberg story veers surreally to profile Dino Soriano, a former NP who pleaded guilty to Medicare fraud in 2020, lost his license, then focused on growing his side business: Clinical Match Me, a platform that matches NP students from over 280 programs with clinical rotations. Clinical Match Me charges students $1,995 per rotation “with easy payment plans available.” In the Wes Anderson movie, devil-may-care Dino Soriano would be played by Owen Wilson.
Although NP signifies “no problem,” that’s not the case here as concerns mount about the clinical experience of NP students – a life-or-death matter for millions of Americans. (With the shortage of primary care physicians, NPs are increasingly filling the gap.) As NP students struggle to find willing medical practices, and as there’s little oversight of the clinical experience students are receiving, in a remarkable breach of solidarity, CCNE’s former director of accreditation confided to Bloomberg that it’s “difficult to know whether the [NP] professional who is providing your care is qualified to do so… Graduation from an accredited program is not sufficient assurance.” Bloomberg quotes one NP student as saying that she was told by her university “not to worry about the quality of my clinical training… [because] I would learn everything I need to know after graduation.”
Although this wobbly training regimen somehow maintains the staunch support of the industry association, the American Association of Nurse Practitioners, this hasn’t been how we’ve trained the MDs for whom NPs are filling in. Doctors have two years of clinical rotations built into MD programs, and – upon graduation – transition directly to residencies (effectively apprenticeships) that last 3-7 years depending on the field of practice. But no other healthcare profession – not even doctor-like nurse practitioners – has anything like this level of work experience.
Why doesn’t the U.S. Department of Education, from whence CCNE’s authority arises, take action? Some ED spokesman told Bloomberg that “federal law bars the department from setting standards for accreditors, and that its oversight of them is limited to determining whether they meet the standards they set for themselves.” This spokesman would have done well to heed my late grandmother’s timeless advice: if you don’t have anything good to say, don’t say anything at all.
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Why do we allow universities receiving federal student aid and plenty of other government funding to shrug off work experience requirements? I suspect it’s the same reason we don’t see colleges and universities setting up and running apprenticeship programs (or at least not yet). And why the number of universities with comprehensive co-op programs can be counted on two hands. Accredited academic institutions simply aren’t very good at arranging in-field work experience, let alone paid work, and will go to great lengths to avoid it. Reaching out to employers and selling student labor requires an employer-focused sales-and-marketing arm that fits nowhere on a traditional higher education org chart.
It also requires resources. On its site, Clinical Match Me attempts to convince healthcare providers to take on NP students. It lists four reasons to make a match:
The first two reasons are motherhood and apple pie: heart-warming but unconvincing. The third is highly hypothetical and wishful thinking in a world where there are hundreds of applicants for nearly every good entry-level position. But the fourth – payment – is a telltale sign that, for most, taking on an untrained worker is no benefit at all, but rather a cost. It’s costly to have an unproductive worker in the workplace. It’s costly to provide supervision and complete the (admittedly thin) preceptor paperwork. And when employers tally the various costs of hiring (or engaging an unpaid worker), orientation, and supervision, while amortizing these expenses over full-time hours might make sense, it almost never pencils out for a part- or limited-time student worker. Clinical rotations and residencies for doctors work because of money: taking on MD students increases access to federal grants, funding, and residencies. Taking on pretty much any other student? Not so much.
And so despite obvious risks, universities offering MSN and DNP programs won’t build out costly employer-facing infrastructure and/or commence costly payments unless they’re forced to. And right now, no one is forcing them to.
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The market is about to have its say. And not only for nurse practitioners, but for new professionals across most sectors of the economy.
Although from a very different time and place, Monsieur Gustave has much in common with today’s hiring managers. What used to be viewed as relevant experience increasingly counts as zero. While healthcare jobs have become more complex with exponentially more care protocols, most other good entry-level jobs now involve workflows built into complex industry- or function-specific software platforms. And prior sales, marketing, finance, project or product experience may count zero unless it’s occurred in the specific industry or function, and – critically – on the specific software platform.
This bad situation is about to get worse. (If this were a Wes Anderson movie, cue Velvet Underground.) Any entry-level vestiges and remnants are about to disappear in an artificially intelligent puff of smoke. With entry-level routine work supplanted by AI and new hires expected to provide higher value from day one, new graduates stand little chance of landing a good first job without prior relevant work experience.
Unlike nurse practitioners, the vast majority of new grads about to experience career launch challenges will have completed degree programs without experience requirements. But if colleges and universities are sloughing off work experience for programs like NP, what hope is there for the rest of us? Very little unless accreditors and policy makers recognize the magnitude of the problem and make two paradigm shifts:
With these two changes, millions of young Americans who’d otherwise struggle to launch careers will get life-changing experiences. But it won’t happen without a major change in funding postsecondary education. The good news is that federal and state governments are already investing hundreds of billions of dollars each year in college classrooms. And outside of college faculty and administrators, it’s hard to think of who’d militate against redirecting a fraction of that money not only outside of classrooms, but to in-field off-campus work experience.
Let’s hope for quick action in Washington and the states. Because students deserve better than Dino Soriano / Owen Wilson. And because if you’re ever attacked by menacing, primitive-mask-wearing, shirtless men on mopeds, being seen by a new nurse practitioner could be the wrong kind of life-changing experience.