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What is it with Millennials and destination weddings? I mean, it’s an honor to be invited to any wedding. But should a celebration of love have to involve a journey across the globe? I attended one Millennial destination wedding – a 12-hour trip – where guests had no choice but to stay at the island resort. In return, the happy, fiscally prudent couple received a discounted reception and free honeymoon.
Weddings are joyous, fun, and worth some travel. It’s not crazy to ask guests to drive a few hours. I’ve attended and enjoyed destination weddings in Vermont and Long Island, forcing my (now) wife to stay in dusty, kitschy B&Bs, which she can’t stand. But for a ceremony and party, Europe is an ocean too far. Several of my Millennial colleagues have made this ask, including one who had good reason: she was marrying a wonderful Italian young man. So they decided the event would take place at Lake Como. She invited our entire firm and everyone undertook the journey. Everyone, that is, except me.
I happened to have an excuse: a friend’s son’s Bar Mitzvah that same weekend. So I sent my regrets, which freed up space for the bride to invite a friend +1. This friend had been dating a man for some time, but they’d never traveled together; the Lake Como wedding would have been their first trip. She asked him to join her, but he kept making excuses, to the point that the woman – a young lawyer – got suspicious. So she did what any suspicious girlfriend would do: a background check. And she found that her boyfriend was married. My colleagues report that the woman did travel to Northern Italy for the wedding. But she traveled alone and spent much of the weekend – a celebration of love in one of the world’s loveliest locations – crying.
None of this would have happened without my brave stand against destination weddings. I may have saved her months of dating bigamy, or worse, and undoubtedly ruined her weekend. But by doing nothing, I did something!
You know who else is doing nothing? Healthcare programs that require clinical experience for a degree but leave students to find it themselves. Perhaps universities selling degrees with a hole in the middle can take credit for doing something by doing nothing e.g., making students more industrious. But like that happy, fiscally-prudent couple, they’re just passing the buck.
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In a world of uncertain returns on postsecondary education, healthcare programs are increasingly seen as a relatively safe bet. The Wall Street Journal calls nursing “the surefire new path to American prosperity,” noting the median income for RNs is $94K and $132K for advanced practice nurses. As there are no signs healthcare spending is slowing down, students are flocking to degree programs in these recession-proof fields; for the past decade, BSN programs have routinely rejected over 50K qualified applicants each year and thousands more are turned away from graduate healthcare programs.
One reason healthcare is a safe bet is the same reason capacity is limited. As these programs are applied and because healthcare degrees should signify an ability to safely perform in a clinical environment with real patients, state licensing boards mandate a minimum number of supervised clinical hours – between 500 and 2,000 hours, depending on the program. After all, simulations and dummies only go so far, and the best way to learn to use an electronic health record platform like Epic isn’t in a classroom, it’s by using it. And for the same reason that we have a shortfall of millions of apprenticeship and internship opportunities, there aren’t enough employers – in this case, hospitals, clinics, and practices – willing and able to do the heavy lifting of onboarding, training, and supervising unlicensed practitioners. In a clinical setting, supervising a student is often a measurable drain on productivity e.g., clinician who normally sees four patients an hour can only manage three while supervising a student.
This problem has given rise to a unique role in health professions: clinical preceptor. A preceptor is a healthcare professional who wears a second hat: on-the-job supervisor and instructor. In some clinical settings, supervision and teaching are considered part of the job. So all the doctors and nurses on The Pitt do this work without (much) complaining (but plenty of drama). But outside of academic medical centers – in outpatient settings – preceptors must be recruited. Some are persuaded by the prospect of a new talent pipeline. Others are lured by the sheen of being affiliated with a university program, by adjunct faculty titles, or even library and parking privileges. But most expect to be paid for the extra work.
Not surprisingly, there’s a market for preceptors with programs competing for placements, clinicians charging for supervision, and intermediaries trying to make it all work. Preceptor time and matching have become increasingly costly given understaffed health systems, burned out clinicians, growing documentation burdens, and universities seeking to grow tuition revenue in one of their few safe bets. So the market has heated up and one of the biggest issues in healthcare education is who should bear these growing costs: school or student?
Unfortunately, it’s not a debate or discussion. It’s a decision made by institutions and accepted by students, or not. But since there’s a line out the door for these programs, the answer is rarely not. And although the deans of these programs would love to arrange clinicals for every student, they can’t because they don’t have marketing and sales functions to recruit preceptors or budgets to compensate them. Which raises the role of accreditors. Healthcare programs are separately accredited by the likes of the Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE), the Council on Social Work Education (CSWE), and an alphabet soup of other accreditors – a lid for every healthcare pot. Where are accreditors on allowing schools to pass the buck?
It’s a mixed bag. The largest nursing accreditor, ACEN, which primarily accredits associate degrees at community colleges, requires programs to have written agreements with all preceptors. And while ACEN prefers that schools directly arrange clinical placements, institutions are only held accountable for “assisting students to arrange clinical/practicum experiences that are consistent with… licensure.” Recognizing this loophole, the second largest nursing accreditor, CCNE, which covers university-based programs, recently updated its standards to clarify that although students may be expected to take specific steps to secure placements, programs must provide evidence showing that they are ultimately responsible for obtaining clinical placements. But, as one nurse commented, it doesn’t mean “it’ll be placements you prefer, placements that are not 2 hours away, etc.” (A spokesman for CCNE acknowledged as much, but stated that programs are required to inform students if there’s a risk of being placed in a distant clinical.)
As there’s usually local capacity for student-nurses and schools are well-versed in taking the lead for pre-licensure nursing programs, this hasn’t been a major issue at the undergraduate level. But donut degrees are a huge problem for graduate programs like MSN (master’s of science in nursing), DNP (doctor of nursing practice), and PA (physician assistant) where universities have scaled online enrollment to meet demand. These programs aim to have students everywhere, but aren’t resourced to find clinical placements everywhere. For example, a Wisconsin-based student in an online DNP program may be told that her placement is in Minneapolis. So while the program is CCNE-compliant, the student has no choice but to pay AMOpportunities up to $5,000 to find a local placement or save some money by using Clinical Match Me, an NP placement service run by Dino Soriano, a former NP who lost his license after pleading guilty to Medicare fraud.
Here’s one nurse’s recent experience:
For three months, I searched for a preceptor. I reached out to clinics, private practices, and community providers. I emailed offices, followed up, and posted in professional forums and Facebook groups. I approached the process with persistence and respect for the clinicians whose time I was requesting. Most of the time, I received no response. When I did, the answer was typically the same: not accepting students, already at capacity, not affiliated with your college, or unable to accommodate. I initially believed that with enough persistence and legwork, I would be able to secure a placement on my own. However, I quickly realized I was not alone; many of my classmates were facing the same challenges and ultimately felt forced to turn to paid placement agencies.
In many programs (something that might come as a surprise), students are expected to find their own clinical placements... After exhausting available options, students are often left with one remaining path: third-party placement agencies. These services promise to match students with preceptors quickly, and they do. Placements that seemed impossible to secure independently suddenly become available within days. But at a cost. Students are routinely asked to pay $4,000-$5,000 for a single semester placement, typically covering around 250 hours of required clinical training.
An aspiring nurse practitioner may require four such placements – an additional $16-20K out-of-pocket.
The problem is also visible outside of nursing and PA: in physical therapy, occupational therapy, respiratory therapy, surgical tech, in behavioral health fields like social work, and even in public health programs. No accreditor goes further than CCNE in putting the onus on schools, and most allow institutions to pass the buck to some extent. I reached out to several programmatic accreditors with questions and only one responded. The Council on Social Work Education (CSWE) directed me to its requirement that “programs have a process for placement.” But when I questioned the depth of responsibility students have in that process, CSWE directed me to its interpretation guide which “clearly states… that students are not solely responsible for locating their own field placement (but can assist), and that programs cannot place undue burden or hardship on a student as part of that placement process.” As one industry observer told me, “master’s in social work programs – particularly online MSWs – frequently expect students to identify agencies, reach out to supervisors, and self-arrange placements with only loose faculty oversight. CSWE does not have CCNE's binding language closing that door.”
Adding insult to student injury, state boards generally prohibit paid work from counting towards clinical hours. For example, the American Nurses Credentialing Center “will not accept work hours or practice experience for certification eligibility.” So nurses can’t count RN work towards NP clinical requirements; hours must be part of an approved educational program, supervised, and distinct from ordinary employment. (Social work is an exception; CSWE allows paid placements in any form.) So our system of healthcare education and licensure is harming the financial health of future practitioners in two distinct ways.
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Students in graduate healthcare programs shouldn’t have to pay extra for clinical placements, especially when they’re not being compensated for their work. As students are paying tuition (and likely taking on debt), institutions should be required to deliver the whole program, of which clinical hours are an integral element. All healthcare accreditors should level up to CCNE’s standards and also require universities to disclose metrics like: (1) % of placements arranged by institution; (2) avg. student out-of-pocket placement costs; and (3) avg. distance to placement.
If universities are reaping the benefits of lucrative online healthcare programs, they have the resources to arrange accessible placements for all students. That could mean establishing a clinical placement office on par with other functions like development and alumni relations. More likely, it means engaging firms like Alchemy, which partners with schools to expand their clinical capacity and provide a concierge approach for supporting students and preceptors.
This conundrum is a byproduct of overfunding classroom-based learning and dramatically underfunding work-based learning. The bizarre puzzle we ask our future caregivers to piece together demonstrates how much we desperately need a new funding model for clinical training. Healthcare is the canary in the coal mine singing about how America hasn’t yet figured out how to systematically fund clinical placements, internships, or apprenticeships. The sooner this changes, the better.
In the meantime, provosts, presidents, and trustees need to stop trying to balance budgets on the backs of future advanced practice nurses, physician assistants, and social workers rather than resourcing these programs appropriately. While academic observers might attempt to justify this by saying healthcare students will be able to afford it (while students in other programs won’t), that’s the kind of blitheringly egalitarian approach that disrespects the individual and gave rise to the backlash that’s been harming America since 2016. It’s also unsustainable. Soon fiscally-prudent prospective NPs and PAs will follow the suspicious wedding guest’s example, do a background check, and recognize that universities are selling donut degrees. And as every nurse knows, donuts aren’t good for you.