On Student Loans and Being Professional

I will freely admit I’m something of a conspiracy theorist.  I think conspiracies often occur, and I think we’re foolish if we rule certain ideas in or out based solely on a notion of “conspiracy”.  Don’t get me wrong, my preference is to follow the evidence.  Sometimes, though, the evidence is curiously missing which forces us to read between the lines.  And it’s always fair to question the evidence, particularly when the outcome has a significant dollar sign attached to it in some way (in other words, we need to follow the money as well).

I don’t know how many of you are following the student loan/graduate loan situation.  In a nutshell, the federal government is looking for ways to save money on student loans.  There are more and less rational ways of going about this task and, as per usual, the government has chosen what is in my opinion the least rational way of cutting costs.

As you might imagine, degrees, especially graduate degrees, that result in state licensure are among the costliest in terms of education.  These degrees are typically referred to as “professional” degrees.  People with these degrees are medical doctors, doctors of osteopathy, lawyers, professional engineers, nurse practitioners, physical therapists, dieticians, nutritionists, doctors of Chinese medicine, doctors of chiropractic medicine, and so on.

Recently, the federal government has done a few things.  One of the first things they did was start evaluating schools in terms of graduate income in their first few years after graduation relative to student loan debt incurred by the program.  There are a lot of schools who fail this test; mainly schools of Chinese medicine, but not only schools of Chinese medicine.  The feds are curtailing loans to these institutions which is leading to school closure across the US.

In and of itself the test of income versus student loan debt is not a particular failing of the government.  This issue rests largely on the schools and the professional organizations.  Professional organizations have increased educational requirements resulting in increased costs for students in the face of flat or falling incomes for those students after they graduate.  At the same time, at least in the Chinese medicine space, schools have largely done nothing to improve the situation for graduates. Few schools of Chinese medicine have established partnerships with other medical institutions. There are virtually no jobs waiting for freshly licensed graduates. For the most part, we have to be entrepreneurs and not everyone is cut out for that role on top of practicing Chinese medicine.

My lived experience of this is specific to Chinese medicine, so I understand the forces in play best in that space.  Other professional graduate degrees are affected including physical therapy.  Other degree and certification programs are also affected like massage therapy.  I cannot comment directly on the issues PTs and PT schools are having or massage therapists and massage schools are having because I’m not a PT or massage therapist, and I’m not as familiar with their specific problems.

Part of the problem is insurance reimbursement.  Massage therapists, physical therapists, and practitioners of Chinese medicine sit very close to the bottom rung in terms of how much insurance pays for services rendered (or even if they’ll pay for services rendered).  This has become a big enough issue that many PT and Chinese medicine practitioners have stopped taking insurance all together.

The community of providers affected should probably be taking a minute to reflect and figure out if the schooling they’re currently requiring for practice licenses is necessary.  Specific to Chinese medicine the reason we settled on master’s degrees in the US as the minimum for a practice license is….

Yeah, someone somewhere simply decided master’s degree is the ticket.  Many other counties use bachelor’s degrees as the minimum practice requirement, and they don’t seem to be experiencing any negative outcomes from this decision.  A bachelor’s degree would be somewhere around half the cost which would bring loan to income back into alignment with federal guidelines. 

There exists a panoply of other issues in attempting to go down this path, not the least of which is the fact that in the US the body that accredits schools of Chinese medicine only accredits graduate programs and our national board organization only deals with accredited programs.  We’ve pigeonholed ourselves in such a way that we cannot honestly evaluate what should be required in terms of education.

Obviously, there is a lot we could be talking about with respect to loan to income for graduate degrees and how schools and various professional organizations ought to be responding to these changes.  There is another aspect we need to discuss, though.

The department of education is also changing the definition of what they consider a “professional” degree.  The degrees that make the department’s cut won’t be as affected in terms of having federal student loans curtailed.  The degrees that made it over the department’s bar is an interesting list. 

From the perspective of healthcare medical doctors (MD), doctors of osteopathy (DO), Chiropractors (DC), pharmacists (Pharm D), dentists (DDS, DMD), optometrists (OD), podiatrists (DPM), clinical psychologists (Psy D), and veterinarians (DVM) all made the list.

Nurse practitioners (DNP), physical therapists (DPT), dieticians (RD), nutritionists (RDN), and Chinese medicine (DAc, DACHM, DAOM) did NOT make it.

Interestingly, outside of healthcare theology (M Div) made the cut along with law (LLB, JD).  Law makes sense to me.  Theology, though?

And here’s where we circle back to conspiracy.  Why did chiropractors make the cut when DNP, DPT, and practitioners of Chinese medicine did not?  The evidence base for the practice of nursing and the practice of Chinese medicine is light years beyond the evidence base for chiropractic.  Solely from the perspective of evidence, DNP and Chinese medicine should easily have been included.  Physical therapists have long been recognized as part and parcel of the standard medical system, so why are they left out?

Let’s consider a few things.  For almost 200 years, the American Medical Association (AMA) has been making and executing plans to place physicians (primarily MDs) at the top of the practice hierarchy in the US.  Whether we even need a hierarchy could be debated.  There is no doubt that physicians currently occupy the top slot when it comes to clinicians, and I don’t deny there are some good reasons for the current arrangement. 

For several years, advance practice nurses (NP/DNP) were required to have physician collaborators to practice.  Essentially this was an MD/DO who collected a fee to review and sign off on clinical decisions made by advance practice nurses.  As you might imagine, this was mostly a money pass through for the doctors.  I know NP/DNPs who worked under this system and saw their physician collaborator once in a blue moon.  I’m sure there were other physician collaborators who were more involved.  This is not an evaluation of the character of the doctors who functioned as collaborators.  I’m simply noting money was involved and, in many cases, it was basically money for nothing (or money for very little work).

For several years, PTs/DPTs couldn’t practice independently.  They were required to have a physician referral.  In other words, a patient couldn’t walk into a PT clinic off the street and request some number of PT sessions.  They had to visit an MD/DO, pay a co-pay to that physician, and get a referral for PT.  Another money pass through for the doctors.

In a nutshell, physicians (MD/DO) were gatekeeping access to NP/DNP and PT/DPT services while collecting a fee (either in the form of a co-pay or as a direct arrangement for providing oversight) for acting as a gatekeeper.

Then, slowly, advance practice nurses and physical therapists began separating themselves from this arrangement.  DNPs managed to gain their independence first and now, in most states, they no longer require physician oversight to run their own clinics.  In a hospital setting, DNPs still get “oversight”, but it’s not legally required.  Again, in many states, PTs now do not require physician referral to practice, anyone can walk into their clinic and request an evaluation and treatment.

While I’m sure they’d like to, MDs and DOs never had oversight of chiropractors (DC).  They’ve also never had oversight of those of us who practice Chinese medicine (LAc).  Both DC and LAc have always been independent providers in the US.

From the perspective of the medical system (not talking about individuals here), it would be easier if these independent providers didn’t exist or only existed in small numbers.  Why DCs made the cut is an interesting question and I’d have loved to have been a fly on the wall during that discussion.  It’s clear why the rest of us didn’t make the cut and it boils down to control and money.

We are fools in the extreme if we think the department of education sat down, amongst themselves, and generated the list.  The list we have is the result of heavy lobbying (i.e. money) by the impacted professions.  It’s highly likely that many of the impacted professions didn’t even get a seat at that table – they either didn’t know what was happening or didn’t have enough money on a short enough timeframe to buy their way into the conversation.

Much like the Flexner report of the early 1900s, these moves ultimately impact patients via the removal or curtailing of treatment options.  Unlike the Flexner report where this was done essentially by a waving of hands and labeling multiple modes of treatment as “unscientific” (some of which have come back in recent years as totally “scientific”, so think on that for a while), this time we’re removing choices on the sly by simply not paying for people to get the education. 

Interestingly this change is predominantly affecting providers who either never had much oversight from physicians or used to have oversight and have separated themselves from that arrangement.  Coincidence?  Maybe, but who benefits if there are fewer independent advance practice nurses, physical therapists, nutritionists, dieticians, and practitioners of Chinese medicine?  Keep in mind that under Kennedy the Department of Health and Human Services has requested that medical schools teach more nutrition as part of their programs, and medical schools are largely agreeing to do so.

Do I think we need to re-evaluate what’s required to be a safe and effective practitioner?  Yes.  Do I think we need to address student loans and higher education costs across the board?  Yes.  Do I think this is the way to do it?  No.  What’s being proposed amounts to an easy, short-term fix that is going to have serious long-term repercussions which we are not adequately thinking through.

Rather than thinking about this in terms of hierarchy and who is allowed to concentrate money and power in the pyramid, we need to be thinking about this in terms of patient choice and evidence.  What do patients prefer?  What does the evidence say about the effectiveness of treatment options in a given condition?

It is long past time for systemic change in healthcare.  The system is doing what systems do: attempting to protect its status quo and prevent change.  We need to find a way to push through and get to something more rational that respects patient preferences.  At the same time, it would be nice if we could lower costs across the board.  I think we can do both, but it’s going to require threading a needle to get there.

What we need most is fresh thinking.  Speaking only for the Chinese medicine profession, our national groups have been run by essentially the same people/same type of person for entirely too long.  Their push, so far at least, is to maintain status quo (again, systems are going to system – as a profession Chinese medicine isn’t immune), and that likely isn’t going to work.  At some point we must realize a couple things:

1. Doing the same thing over and over again expecting a different result is tantamount to insanity.

2. Problems are rarely fixed by the same thinking that created them.

In the US, Chinese medicine has repeatedly backed itself into a corner and then pulled out the surprised Pikachu face when things go sideways.  There are a variety of reasons why this keeps happening, but it needs to stop if we expect to still have a functioning profession in the next 20 or 30 years.

We have been terrible stewards of this medicine in the US.  We need to do better.