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5 The Role of Eclucat;ional Policy in Influencing Supply TF NO STEPS ARE TAKEN to bolster the future supply of personnel in 1 several allied health fields, health care institutions will be hampered in meeting the public's demand for services. These steps will require coor- dinated actions by educators and employers, encouraged by modest but strategic federal, state, and private programs. Many of the recommenda- tions in this and the following chapter are directed toward educators, em- ployers, and the allied health professions themselves. Although the committee believes its recommendations will be beneficial to those parties, it looks to public intervention to stimulate and amplify their implementation. This chapter is divided into three sections. The first deals with policies to influence the decisions of persons choosing careers. The second discusses the role of educational institutions in maintaining or expanding enroll- ments. The third addresses concerns about the preparedness of the future allied health work force. THE ALLIED HEALTH STUDENT APPLICANT POOL For most fields the available trend data on allied health programs and graduations do not signal an imminent crisis requiring dramatic public intervention. Looking to the future, however, the committee is deeply concerned that the weak infrastructure of allied health education may compromise the system's ability to maintain enrollments, let alone increase the supply of personnel in fields in which employment demand is high. A key to the viability of allied health education is its capacity to maintain its 159

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160 ALLIED HEALTH SERVICES share of qualified students from the traditional college-age applicant pool while tapping into less traditional pools of students, particularly minority students. For a number of years, allied health deans and program directors have expressed concern about the declining number of applicants to their pro- grams and the implications of this decline for the academic quality of the student body. Reportedly, spaces in many programs are going unfilled, and this lack of student interest is jeopardizing the survival of academic programs. Comprehensive data collection concerning applicants to allied health programs is not currently being done. However, CAHEA annually surveys program directors in several allied health fields about whether applications to their programs are increasing, decreasing, or remaining 1 1 1 stable. In its 1987 survey, program directors in 13 of 22 fields reported decreases in the number of applicants (CAHEA, 19881. The clinical laboratory fields in particular were experiencing distress. For example, almost two-thirds of the medical technology program direc- tors reported decreases in applicants in 1987. Of the 116 programs that voluntarily withdrew from CAHEA accreditation between 1983 and 1987, 36 attributed their decisions to a declining applicant pool. Unpublished survey data from the American Society of Allied Health Professions suggest that only physical therapy has a large applicant pool to draw upon, with about five applicants per academic space. Other fields such as dietetics, medical technology, radiologic technology, and medical record administration average only slightly more applicants than needed to fill their classes. A recent (1987) survey of the College of Health Deans, an organization composed of allied health administrative units in 20 universities without medical centers from 17 states, revealed that only 3 out of 17 respondents reported that all of their professional classes were filled. Although clinical laboratory programs were those most frequently cited as having excess capacity, many other fields also reported unfilled classes. Although the current level of applications worries academic administra- tors, they are even more concerned about the future because of the pre- dicted decline in the college-age cohort of the population, an issue discussed in Chapter 3. This decrease suggests that in the future there may be even greater competition among schools for technically oriented students than there is today. Information from annual surveys of college freshmen on changing occupational preferences shows a slow but steady decline (from 3.3 percent to 1.1 percent) between 1977 and 1985 in women's interest in careers in laboratory technology and dental hygiene, dietetics and home economy (from 1.1 percent to 0.4 percent), and health technology (from 3.7 percent to 1.8 percent). Women's interest in the category headed "ther- apist" has remained relatively stable over the period; men have exhibited

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 161 gradually increasing interest over the years (Cooperative Institutional Re- search Program, 1987~. Academic administrators are also concerned that, with fewer applicants from which to select, the quality of students will decline. Thus far, except for the areas of clinical laboratory sciences and radiography, no decrease in student quality seems to be evident to program directors, as measured by the CAHEA survey. More objective evidence for assessing quality changes, such as grade point averages or test scores during students' first year of professional course work, is not routinely collected. The American College Testing (ACT) Program test scores of high school juniors who intend to mayor In allied health fields do not bear out a shift in quality (Table 5-1), although the downward trend in dental hygiene may deserve some atten- tion. Not every allied health field has experienced an applicant deficit, as evidenced by what has occurred in the physical therapy field. Despite a rapid increase in the establishment of physical therapy programs, most directors report that they still have more than an adequate supply of ap- plicants and can limit enrollment to those with high grade point averages. It is not unusual to find physical therapy programs with application-to- acceptance ratios of 10 to 1. In addition to physical therapy a few of the ~ . _ . 1 ~ ' newer professions sucn as perfusion and diagnostic medical sonography are also in great demand, with about 60 percent of program directors experiencing application increases (CAHEA, 19881. Because they are fewer in number and smaller in size, it is difficult to equate the success of programs like perfusion, for example, with programs in physical therapy. Nonetheless, characteristics of perfusion programs are worth noting. Some of the students are often drawn from other disciplines TABLE 5-1 ACT Test Score Means for Students Specifying Academic Majors ACT Composite Test Scores Academic Major Percentage of Change, 1980-1981 1983-1984 1985-1986 1986-1987 1980-1987 Dental assisting 13.3 13.2 13.5 13.3 0 Dental hygiene 16.1 15.5 15.4 15.0 - 1.1 Medical technology 18.2 18.2 18.6 18.2 0 Occupational therapy 16.7 16.6 17.5 17.5 -0.8 Physical therapy 17.8 18.0 18.8 18.5 1.0 Radiological technology 14.4 15.4 15.9 15.8 1.4 Nursing (RN) 16.2 15.9 16.3 15.9 -0.3 Pharmacy 20.0 19.8 20.4 20.1 0.1 Overall college-bound population 18.5 18.2 18.3 18.7 1.1 SOURCE: Unpublished data from the American College Testing Program.

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162 ALLIED HEALTH SERVICES (respiratory therapy and critical care nursing, for example) and therefore have had some exposure to the new field. Employment opportunities abound, and not all graduating students enter the clinical field because other at- tractive opportunities are often available. For example, manufacturers and biomedical engineering laboratories hire some perfusionists; some enter medical school and others choose teaching. Although perfusion is a high- stress profession, it is also a relatively well-paid one. The average salary for a graduating student is $35,000, but highly qualified and experienced perfusionists may earn close to $100,000. Although they are not known to the general public, perfusionists are respected in the allied health world for their success in garnering earnings and their relative independence (Brown, 19871. Why do some programs fare better than others in attracting students? Some reasons come readily to mind. Undoubtedly, the positive economic outlook for physical therapy rising salaries, growing autonomy, and high levels of demand for graduates has affected student thinking. Also, in comparison with such fields as clinical laboratory technology, physical ther- apy has greater public visibility and more patient contact. There may be lessons to be learned from schools of social work, which have succeeded in increasing their applicant pool from 2 applicants per opening in 1983 to 3.5 applicants per opening today. Social work is con- sidered to be closely related to (if not directly under the umbrella of) allied health. Deans of schools of social work attribute the revitalization of interest in social work careers to a wide variety of social and economic factors, including the following: optimism about the status of social welfare programs in the post- Reagan era; a surge (although not as dramatic as during the 1960s) in the sense of social commitment among students; occupational outlook projections of higher-than-average growth in de- mand; growth of independent practices and third-party payment; adoption by some schools of "business-like" approaches to marketing and recruiting students; and salaries that, while not high initially, averaged about $27,800 in 1986- 1987 (Health Professions Report, 19881. Visibility and comparatively high pay are elements that contribute to the attractiveness of a field, and these in turn contribute to the success of schools in obtaining high application rates. Some fields that are viewed by the allied health community as being attractive and offering well-paying careers none- theless do poorly in attracting students because they lack visibility. For example, occupational therapy shares many of the attributes of physical

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 163 therapy, but its role in health care is not well known. Medical record administrators can earn over $50,000 per year and advance to hospital executive positions, but that field, too, is little known to the public. Some allied health occupations (e.g., medical technology and radiogra- phy) do not offer particularly good economic rewards but seek to attract scientifically oriented students to work in potentially hazardous environ- ments in which they may be exposed to contaminated body fluids or ra- diation. Moreover, although laboratory and radiography employment prospects may be rebounding after PPS cutbacks, the atmosphere of job insecurity may still be influencing students' perceptions about those fields. Student Recruitment Many of the social factors that influence career choice are beyond the control of health care institutions or academics. The economic attractiveness of careers and their work environments are largely in the hands of em- ployers (a topic that is addressed in Chapter 6) and those who make reim- bursement decisions. There are a number of techniques that schools have used to attract students. Among them are the use of professional recruiters, giving faculty release time to visit high school counselors and students, the distribution of videotapes about the school, and undertaking national promotions (e.g., Lab Week, fostered by the American Society for Medical Technology). Unfortunately, such efforts to influence students' career choices toward an allied health field have not been systematically documented or evaluated. Many psychological and social theories of career choice and career de- velopment have emerged over the years to explain how individual career development unfolds over the life span. These theories suggest the diffi- culties of intervening in a complex process. Career development is shaped by an interplay of psychological attributes, knowledge about training re- quirements, educational and occupational opportunities, genetic and child- hood influences, evolving personalities, and patterns of traits that individuals express cognitively and psychologically in their choice behavior. Research related to career development finds that, like all human behavior, it is a highly complex process and is part of the total fabric of personality (Lent et al., 1986~. Most of the existing approaches to career development are based on limited samples of relatively privileged persons. The samples typically have been composed of men rather than of women, and the approaches to career development in general have been addressed to persons in the middle range of socioeconomic characteristics. Consequently, these ap- proaches tend to emphasize the continuous and progressive aspects of career development that are possible primarily for persons who are rela-

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164 ALLIED HEALTH SERVICES tively free to choose any career and for whom both psychological and economic resources are available. Such criteria do not necessarily fit women and minorities (Fitzgerald and Crites, 1980~. The impact of several variables (including parental socioeconomic status ESES1, academic achievement, and sex) on both selection and persistence in career choice has been investigated in an attempt to determine who is being recruited into professions in general. These variables were used to analyze responses from the U.S. Department of Education's 1972 National Longitudinal Study and recent follow-up surveys. Results showed that chil- dren of high-SES parents were four times more likely than children of low-SES parents to engage in professional study at the baccalaureate level and six times more likely to participate in or complete professional training at the graduate level. The SES level of parents did not have as much effect on the aspirations of children, however; children of high-SES families were only twice as likely to wish for a professional career as their contemporaries from low-SES families. Researchers have concluded that the idea of sub- stantial social and economic mobility in the United States has been exag- gerated and is difficult to achieve. Only 2 percent of young people from low-SES homes were in graduate-level professional programs 7 years after high school, despite large federal student aid programs and numerous corporate and foundation programs to stimulate opportunities in the professions (Miller, 19861. In general, the career choice literature does not provide detailed guid- ance for recruitment efforts. Yet several implications for specific planning . . Interventions can he seen. The concepts that people are only economic animals and that work is chosen only for the livelihood it offers are too simplistic. Work also provides a means for meeting the needs of social interaction, dignity, self-esteem, self-identification, and other forms of psychological gratification. Personal, educational, occupational, or career maturation comprises complex learning processes that begin in early childhood and continue . throughout life. Choice occurs not at a point in time but in relation to antecedent experiences and future alternatives. Career information must include not only objective factors such as earning possibilities, training requirements, and numbers of positions avail- able but the social and psychological aspects of careers as well. Career choice is frequently a compromise between the attractiveness of an alternative, the likelihood of attaining it, and the costs of attaining it (Herr and Cramer, 1984~. In sum, the literature on career choice is suggestive rather than pre- scriptive for recruitment tactics. Long-range efforts must take into account

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 165 the need to make individuals aware of careers at an early stage. If women continue to predominate in many of the allied health fields, we must learn more about the dynamics of their career choice behavior. Successful student recruitment efforts generally depend on positive mar- ket signals emanating from the world of work. In the next chapter the committee discusses actions that employers must take to improve the cir- cumstances of allied health personnel in work settings in which the per- ceptions of unsatisfactory careers accurately reflect reality. However, to the extent that potential students incorrectly believe that a career is unsatis- factory, the problem may require improved communication. Local con- sortia of professional association members, employer representatives, and educators should be formed to devise recruitment strategies based on com- munity needs, characteristics, and resources. These consortia should target nontraditional audiences, tailoring the message and method of commu- nication to each. A marketing plan geared to attracting newly unemployed workers from a local industry, for example, should not be the same as one that seeks to attract displaced homemakers or handicapped high school students. The demand for technically oriented people is growing in many sectors of the economy. One study predicts that The jobs that will be created between 1987 and 2000 will be substantially different from those in existence today. A number of jobs in the least-skilled job classes will disappear, while high-skilled professions will grow rapidly. Overall the skill mix of the economy will be moving rapidly upscale, with most new jobs demanding more education and higher levels of language, math and reasoning skills. (Hudson In- stitute, 1987) More specifically, more than half of the new jobs created between 1984 and the year 2000 will need some high school education. Nearly a third will require a college degree; today, only 22 percent of occupations require a college degree (Hudson Institute, 19871. The health care industry is not the only industry that is beginning to understand that one of the challenges of the future will be to position themselves favorably in the competition for the supply of educated, technically able workers. For some allied health fields, there are already indications that potential practitioners are being lost to other professions. It is clear that educators, employers, and the professional associations must act if they want to maintain or increase their share of the work force. The process of change is necessarily interactive. If employers succeed in making allied health employment more attractive, educational institutions will experience increases in the size and quality of the applicant pool. Yet, circularly, the extent to which employers are able to alter the conditions of employment depends in part on the education that workers have received.

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166 ALLIED HEALTH SERVICES The committee recommends that educational institutions, in close col- laboration with employers and professional associations, organize for the recruitment of students. They should seek persons from less traditional applicant pools minorities, older students, career changers, those al- ready employed in health care, men (for fields in which they are under- represented), and individuals with handicapping conditions. Minorities Two major societal problems underlie concerns about minority partici- pation in allied health careers, leading the committee to devote special attention to this issue. First, as several recent public policy documents have stated, minority populations in the United States have comparatively poor health statuses and use fewer health care resources relative to their needs (U.S. Department of Health and Human Services, 1985~. Although a causal relationship be- tween the supply of minority practitioners and improved minority health care and health status is difficult to validate, minority health care workers are more likely to work in geographic areas and at delivery sites that serve minority and other disadvantaged patients. Officials interviewed at three inner-city hospitals, including two public hospitals, said that minorities are at least 50 percent of their total allied health work force. Moreover, data extracted from facility records show that this pattern is relatively uniform across such different fields as clinical laboratory technology, physical and occupational therapy, dietetics, and medical records (Booker, 1987~. Second, there is a lack of parity throughout American society between whites and nonwhites in professional positions. To the extent that the allied health fields can provide improved career opportunities for minorities, a double benefit will occur: education programs will be better able to maintain enrollments, and personnel shortages may be alleviated in underserved geographic areas and institutions that serve poor minority populations. To supplement a review of the literature on the representation of mi- norities in allied health fields, the committee conducted extensive interviews with deans and faculty of 10 schools active in the National Society for Allied Health (an organization committed to increasing the participation of black and other disadvantaged minorities in allied health practice, education, and administration). Other schools were added in an attempt to broaden the information base. A school known to have a predominantly Hispanic stu- dent body and structured activities to recruit Hispanics to allied health programs was selected, as was a school in an area with a large American Indian population. Finally, a nonminority school in the South was added because it boasts the largest number of allied health programs on a single campus and has been actively involved in minority allied health recruitment

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 167 and retention efforts for some time (Booker, 1987~. Pertinent information from these interviews will be referred to in our discussion of minorities in allied health education. Table 5-2 presents estimates of racial and ethnic characteristics of allied health personnel based on the results of an analysis of the 1980 census. The data show that minority personnel are underrepresented, relative to their representation in the U.S. labor force, in the 10 allied health fields studied by the committee and particularly in the fields requiring higher education. CAHEA reports that over the entire range of the fields it accredits the racial mix of students enrolled during 1986-1987 generally mirrored the racial mix of the U.S. population. Blacks represented 11 percent of total enrollments, Hispanics, 6 percent, and American Indians, about 2 percent. What these data fail to reveal is that minorities are overrepresented in fields requiring less education and underrepresented in fields requiring more education. The extent to which minorities have a higher departure rate from programs and careers is not known. Several professional associations in fields requiring baccalaureate and advanced degrees have commented on the need for greater efforts to increase the number of minority students. For example, the 1984 Study Commission of the American Dietetics As- . . . soaatlon noted: While no effort has been made in the past to restrict other racial groups, or males, from the profession, little has been done to make the profession more attractive to them, nor has any strong effort been made to recruit them. The 1984 Study Commission believes such an effort is overdue. TABLE 3-2 Distribution of Personnel (Percentage) in Selected Allied Health Occupations by Race or Ethnic Origin, 1980 Minority White (not of White Other Occupation Spanish origin) Black (Spanish origin) Minoritya Laboratory technician 79.5 11.1 3.3 6.2 Dental hygienist 95.4 1.6 1.6 1.3 Dietitian 84.6 6.7 1.9 8.0 Medical record technician 84.4 9.5 2.2 3.9 Occupational therapist 94.7 2.1 0.9 2.4 Physical therapist 93.4 3.3 1.1 2.0 Radiologic technician 86.2 7.7 3.7 2.4 Respiratory therapist 82.1 10.0 4.9 3.1 Speech and hearing therapist 92.9 4.3 1.5 1.3 aThese figures include American Indians, Japanese, Chinese, and other Asians or Pacific Islanders. SOURCE: Health Resources and Services Administration (1984).

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168 ALLIED HEALTH SERVICES Past Efforts to Increase Minority Participation The Federal Government The federal government first initiated programs to encourage "culturally or economically disadvantaged individuals" to enter allied health as part of the 1970 health manpower legislation (P.L. 91-519~. This statute was extended in 1973 by the Comprehensive Health Manpower Act (P.L. 92- 157) and the Health Programs Extension Act (P.L. 93-45) and in 1976 by the Health Professions Educational Assistance Act (P.L. 94-484~. Later, an administrative decision was made to provide support for projects that em- phasized the recruitment and retention of minorities as well as the disad- vantaged (Carpenter, 1982~. Between fiscal years 1972 and 1977 approximately $20 million of a total of nearly $191 million of grants awarded for allied health were allocated for programs targeting minority and disadvantaged populations. Between 1978 and 1981, under P.L. 94-484, a larger share of the total but a smaller amount was awarded for project activities to assist disadvantaged allied health students (Carpenter, 1982~. By fiscal year 1982 the only federal funding of any magnitude that was available for minority recruitment and retention in allied health training was the Health Careers Opportunity Program (HCOP). HCOP has five objectives: (1) recruitment, (2) preliminary education (noncredit), (3) fa- cilitation of entry, (4) retention, and (5) information dissemination. Ex- amples of HCOP activities include career fairs; faculty counseling; tutoring; summer enrichment programs to enhance mathematics, science, and com- munication skills; and linkage arrangements among undergraduate schools such as historically black colleges and universities (HBCUs), community colleges, and high schools. Between fiscal years 1982 and 1987 the number of allied health grants under HCOP increased steadily, as did the funds that were awarded. Of the $60 million or more awarded since fiscal year 1985, $5.37 million has gone to allied health programs. The proportion awarded each year to allied health r~rncrr~m~ race. from .6 percent to nearly 10 percent during this 3- year period (W. Holland, Division of Disadvantaged Assistance, Health Resources and Services Administration, personal communication, 1987~. The Area Health Education Centers (AHEC) Program assists health professions schools in improving the distribution, supply, quality, utiliza- tion, and efficiency of health care personnel in the health care service delivery system by encouraging the regionalization of professional edu- cation. The program has no legislative mandate to recruit and retain mi- norities, but it has explicitly encouraged such activities. In fiscal year 1987, AHECs in Arizona, New Mexico, Texas, California, Oklahoma, and at three black medical schools Drew (Los Angeles), Meharry (Nashville), and 11~_~$ r ~_~4 shiv ~ eve _ ~ ~

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 169 Morehouse (Atlanta) were cited by AHEC officials as having active com- mitments to training professionals to serve Hispanic, Indian, and black populations. The AHEC financial investment in the recruitment and re- tention of minority allied health students and workers was not obtainable from available program data (Area Health Education Centers Program, 1987). States The health professions education programmatic resources of most states have been devoted to increasing the supply of minority physicians and dentists, but a few states support initiatives for minorities in allied health training. For example, Connecticut funds the Health Sciences Cluster Pro- gram, which exposes high school students to allied health professions; economically disadvantaged students in allied health in Georgia are eligible for a small grant program, the Regents Opportunity Grant Program (Man- dex, Inc., 1987~. New York State has developed an action plan to improve minority access to the licensed professions (including dental hygiene, speech- language pathology and audiology, physical therapy, and occupational therapy), the core of which is a comprehensive effort to improve curriculum development and teaching in mathematics and science in grades 7 through 12. In addition, the state offers financial assistance to allied health students willing to work in state agencies after graduation (New York State Education Department, Bureau of Higher and Professional Education Testing, 1985~. Allied health is rarely specifically identified in state legislation for targeted funding. Several investigators report being unable to ascertain the amount spent for allied health education because these funds are not distinguished from appropriations for "medical education." Of the 13 allied health pro- gram officials interviewed (Mandex, 1987), only one reported that the program received funds for minority recruitment and retention through a line item in the state budget. Private Foundations Private organizations also see merit in encouraging minorities to select health care careers. The Josiah Macy, Jr., and Robert Wood Johnson foun- dations have been quite active in these efforts. However, Robert Wood Johnson Foundation staff report that current activities do not include allied health professions. Macy has sponsored some allied health professions training, but its primary focus, after more than 20 years of involvement in minority health professions education, is still physicians. The Macy ex- perience is worth describing in some detail because of its potential appli- cability to allied health education. (The following description is taken from Bleich L1986, 19871.j .

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 195 investigate models in which academic institutions have succeeded in broadening their financial base through such mechanisms as faculty prac- tice plans, extension courses, and industry relationships. The national organizations should also hold workshops to help institutions implement the models and to disseminate information. In undertaking revenue-generating enterprises, however, allied health deans will confront and possibly exacerbate a problem they have faced before. Faculty resources currently are stretched thin to control costs, and the excessive teaching load leaves little time for faculty to engage in scholarly activity, research, and college committee work. Yet these activities constitute a major portion of the traditional evaluation criteria for faculty promotion and tenure. Consequently, they are the preferred nonteaching activities pursued by faculty wishing to advance their academic careers. Maintaining state-of-the-art clinical competence further adds to the faculty's already excessive work load. Indeed, the committee heard a number of deans complain of the difficulties their faculty members face in maintaining clin- ical skills and of the concomitant impact of these difficulties on preparing students for the labor market. To ensure that the clinical competence of allied health faculty is main- tained, the institutional award system must accommodate clinical compe- tence because faculty allocate what little nonteaching time they have to those activities that are highly rewarded. The committee recommends that institutions that offer allied health academic programs reward and en- courage faculty clinical competence. Clinical practice that sustains this competence should be made a requirement for promotion. It is noteworthy that this concern about the reward system is also one that medical educators have been forced to confront. As the president of the Association of American Medical Colleges has observed, "Despite the realization that teacher-clinicians are essential ingredients of medical fa- cilities, the need is often not recognized by the parent universities whose appointments and promotion policies leave no niche for the clinician- teacher to receive proper recognition" (Petersdorf, 1987~. Preparing Students for Tomorrow's,iobs In principle, sound educational planning would dictate that academic institutions base their program offerings on an understanding of the knowl- edge, skills, and socialization required of their graduates not only for today's health care labor market but for the future as well. By extension, statewide higher education planning should take into account the mix and distribution of personnel at different educational levels that will be needed across the state. Confounding efforts at such rational planning, however, are a lack of clear signals from the labor market about future human

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196 ALLIED HEALTH SERVICES resource needs and continuing controversy about matching education to the requirements of the health care delivery system. Reflecting this controversy, an allied health education advisory committee in Texas highlighted a series of concerns that often surface when such groups view the broad spectrum of allied health fields (Allied Health Ed- ucation Advisory Committee, 1980~: . the growing amount of narrow specialization at all degree levels; the requirements of some professional groups for higher levels of training for professional entry credentials; difficulties with the transfer of credits to implement the career ladder concept; the most appropriate levels of training for various kinds of allied health personnel; and differences in the programs needed to prepare practitioners, master clinicians, teachers, researchers, and managers. Ironically, these issues are of concern today because, in the past, edu- cational institutions have responded to student and employer demands. Associate degree and certificate programs were developed to provide stu- dents who were unwilling or unable to spend 4 years in school before entering the work force an opportunity to enter a field in which those workers with traditional higher credentials were in short supply. Academic health centers and 4-year colleges, in addition to community colleges, sought to meet the needs of their own and local hospitals with 2-year programs. Students with baccalaureates in other than health care fields were accom- modated with certificate programs so they could pursue allied health ca- reers. Students who were interested in careers in respiratory therapy, dental hygiene, and radiography, which were principally offered at the associate degree level, found themselves able to enroll in programs that also allowed them to obtain baccalaureate degrees. The result of these developments was the opening of allied health occupations to a wider range of partici- pants. Having accommodated the needs of different student markets and em- ployers who were either experiencing shortages in some personnel cate- gories or who were attempting to structure their staffing with personnel of different educational levels, the educational system is now faced, not surprisingly, with a state of untidiness that planners find uncomfortable. Further complicating matters is the growing availability of graduate train- ing. Although advanced degrees have long been accepted as appropriate preparation for faculty, administrators, and researchers, there is greater skepticism about graduate work when it comes to the elevation of a field's entry-level qualifications or efforts to develop specialities.

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 197 The committee acknowledges this great diversity in educational quali- fications but finds that a public policy problem requiring attention may not exist. The diversity in and of itself is not a problem. The test of whether specialization and changing qualifications or standards are dysfunctional is twofold: (1) Is there wastefulness in student educational investments? (2) Is the educational system responsive to society's need for a manpower supply that permits the health care system to function efficiently and pro- vide care of the desired quality? Educational Investments by Students To open a new education program and admit a class implies a contract with students that contains certain assurances. No school can guarantee a student a job nor can it guarantee that skills and knowledge acquired in its programs will be marketable in perpetuity. Nevertheless, the committee believes that schools have the responsibility to ensure that (1) professional education is training for a specific, "real" occupation at the end of the line; (2) the program's general education content is sufficiently balanced by occupation-specif~c skills; (3) if, and when, students wish career advance- ment through education, there is a relatively efficient pathway to follow; and (4) there is a realistic balance between the role aspirations of professions with the realities of day-to-day work. In fulfilling their responsibilities to students, educational decision makers face a number of dilemmas. "Real" fobs There are numerous job titles under the umbrella of allied health. Not all of them need to have separate, formal academic programs. Yet educators must be sensitive to changing technology and disease patterns that may warrant such recent developments as genetic counselors and MRI . . tec unmans. The Southern Regional Education Board (1980) has recommended- and the committee concurs that academic institutions contemplating the development of new allied health specialities ask themselves three practice- related questions: Are there any legal or professional restrictions on the new practitioners that will tend to inhibit employers from hiring these graduates? Is the new speciality sufficiently different from existing specialities to justify the development of a new educational program? What degree of liability does the supervisor of the new practitioners assume? Liberal Education Faculty in professional or technically oriented pro- grams in higher education face a continuing struggle to reconcile the de- mands of academia for scholarship and general education with pressures

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198 ALLIED HEALTH SERVICES from employers and accrediting bodies to prepare students for technolog- ically demanding jobs. The argument on the side of liberal education is that the educational program ought to be providing preparation for life and not just for a specific job. Graduates must be prepared to respond to the inevitable changes that will occur in society. Many educators feel the pressure that is exerted by employers (especially employers in fields that require familiarity with instrumentation) to influ- ence programs to produce graduates who do not need extensive orienta- tion. Even at the community college level, which has had a strong tradition of job orientation, there is concern about the appropriate mix of general education and technical/clinical course work. In one small survey, 25 allied health community college deans reported proportions of general education to technicallclinical course work credits that ranged from 8 percent to 35 percent, with an average of 22 percent (Kaminski, 19871. In the name of responsiveness to a changing society, general education courses compete with pressures to incorporate such areas of study as geriatrics, computer applications, multicompetency, and clinical experience in alternative sites of care. The committee is sympathetic to the dilemmas faced by curriculum plan- ners. Yet it is also concerned that students receive an educational foun- dation on which they can build a career if they so desire. Part of this foundation entails developing the capacity for and an interest in lifelong learning. A further, important benefit of such a foundation is that, if current skills become obsolete, practitioners have a base on which they can develop an alternative career. Articulation Allied health dean Elizabeth King from Eastern Michigan University describes two hypothetical students to illustrate the personal dimensions of the problems of articulation, the process by which students achieve upward educational transitions among academic programs (King, 1985~. One student, having worked 7 years as a certified occupational therapy assistant "with a love of the profession and a conscious decision to build upon her current skills," is confused and disillusioned when denied the opportunity to transfer her professionally related course work toward an occupational therapy degree. Meanwhile, another student with an as- sociate degree in general studies, hearing about the good job prospects for occupational therapists but having little knowledge about what occupational therapists do, is advised by the senior college that all of his courses will transfer and he can complete the degree in 2 years. In general, states have strongly promoted the concept of multiple entry and exit points in health careers to minimize the loss of student time in moving through certificate, associate, and baccalaureate programs. Without

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 199 strong mandates or incentives, however, such programs have difficulty overcoming some inherent barriers. King discusses a number of them. For example, curricular problems occur in judging the compatibility of didactic and clinical program content, which makes it difficult to assess advanced placement. There is also, at times, a lack of communication between aca- demic affairs and admissions offices to work out problems regarding credit transfer policies. Finally, and perhaps most important, faculty professional biases, in King's view, "the most insidious barrier," create an environment of"undiscussable tension." These biases label community college students as "technically" trained and lacking in problem-solving experiences. The committee recommends that alternative pathways to entry-level practice be encouraged when feasible. State higher education coordinat- ing authorities and legislative committee.; .c;holil~l inelet ^^ Fl~v;~:l:~. :_ ~1~:~1 ~ _L.1' ~ _ ~ ~ mu '''uo''~y between community colleges and baccalaureate pro- grams. Role Congruence There is continuing tension between health care ad- ministrators and professional groups over the tendency of a field to assume more sophisticated or broader responsibilities and the perception of em- ployers (or payers) as to the legitimate and vale fi,nctionc chat no tm be performed for patients. D~:~1 ~~ I ~ o ~ ,~ * ~11~ LllCtL 11~ Lo Rena associations and program faculty see their responsibilities .. . ~ . . . . "O L11~ =~1111111~, mu ~~111t, of tilelr alsclpllne. 1 nls process is reflected in curriculum content and reinforced by accreditation. Health care admin- istrators become concerned when they believe curriculum is being used as a precursor to expanding the legal scope of Rhino and r~imh,~r~f~r , . ~ . ~ ;~; Infix n~t1nlr~rr q - ^ car Ar ~1~;~ Al ~~ Al ~~ ~1_-_ ~ ~ ~^~.~~ ~~11L witnout recognition ot: what Is possible or likely In practice. They also become concerned when they believe that an occupation is at the same time abandoning "hands-on" patient care for "nrr~f,~ion~l" r~~ OCR for page 159
200 ALLIED HEALTH SERVICES resources it needs to function well. Indeed, the rationale for the committee's support of public intervention in allied health supply issues is based on its belief that the link between services and education needs to be strength- ened. In determining their program offerings, allied health educators are cau- tioned by state higher education leaders and health care administrators to avoid overtraining in both curriculum content and in length and level of preparation. On the other side are the professions who caution against too little training and who strive to elevate educational standards through li- censure, program accreditation, and reimbursement standards. The committee has heard arguments by the first group that raising educational qualifications is not only expensive to the student but to the educational and health care systems as well, both of which are attempting to control costs. Furthermore, proponents of this view contend that "ed- ucation creep" exacerbates shortages by lengthening the time required to prepare an individual for work. They also contend that there is little evi- dence to suggest that current levels of education are creating care problems. Counterarguments are most often based on the expanding knowledge base that practitioners need to master and the limited time available in the curriculum for such mastery. New sites of care, such as in the home or in independent office practice, require a level of judgment that can only be achieved with increased education. Those concerned with an adequate supply of practitioners point to the higher labor force participation rates and longer tenure of those who have already attained the higher credential. This committee encountered a number of these types of controversies among the allied health fields. Some examples include physical therapists attempting to establish the master's degree as the entry-level standard, role delineation debates among baccalaureate medical technologists and 2-year medical laboratory technicians, proposals to limit the educational routes to entry-level dietetics, and the movement of respiratory therapy to a bac- calaureate entry-level standard. The case for promoting a single optimal level of education is an exceedingly difficult one to make on empirical grounds. For example, when an IOM committee explored the controversy over the three educational tracks leading to the registered nurse credential (associate degree, diploma, and baccalaureate), it was unable to find con- vincing evidence on the difference of performance among the graduates (Institute of Medicine, 1983~. The committee neither endorses nor refutes the position of parties on either side of these debates. In view of the lack of objective empirical evidence and the limited scope of the present study, the committee could not justify offering conclusions that might influence the outcome of these controversies. The committee does suggest, however, that those making . .

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 201 decisions ensure that changing existing practice will not limit the supply of practitioners nor make care excessively costly. From the committee's perspective the only sensible response to the mov- ing targets of health care system change and the lack of certainty about how to match education to future needs is a continuing feedback loop between education and practice. Graduate follow-up studies that incor- porate employer perceptions are the most direct measures of how well the curriculum is preparing students. The aim of these studies, however, need not be solely to tailor education to employer perceptions of need. Rather, it should be the start of a dialogue. If students are not applying their educational experiences fully, the problem may at times rest with the work environment. A dialogue could potentially lead to a mutually beneficial set of activities involving more participation from health care managers in curriculum design and greater involvement of educators in health services research with practical application to clinical settings. Various models are available for institutionalizing such interactions. In some education programs, allied health education and services are jointly administered by the same corporate entity. An example is Rush University in Chicago where education and services are unified. Where this is not feasible, the industry advisory boards common to many community colleges can be used. Faculty practice plans or clinical affiliations may also be a starting point to stimulate collaboration. In those fields in which instrumentation plays a major role in job func- tioning, industry/faculty collaboration provides a largely untapped re- source. Manufacturers ultimately have a stake in human resources because investments by health facilities in technological innovations may be seriously jeopardized if there is a lack of adequately prepared personnel. Manufac- turers should consider collaborating with educational institutions in creative ways for example, the use of equipment, faculty-industry research proj- ects, short-term employment opportunities as a means of ensuring an appropriate human resource infrastructure to assist technology transfer. Yet some stimulus is necessary to overcome the inertia of dealing with these difficult issues of collaboration. The committee sees a role both for states and private foundations in providing that stimulus. State legislatures should establish special bodies whose primary purpose would be to ad- dress state and local issues in the education and employment of allied health personnel. Private foundations should support university-based centers for allied health studies and policy to provide a critical mass of researchers and resources to advance technology assessment, health care services research, and human resource utilization. States have a major role in allied health education by virtue of their support of public colleges and universities. In addition to this influence,

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202 ALLIED HEALTH SERVICES they are frequently drawn into debates over licensure issues that involve changing scopes of practice and the licensing of new occupations. (These regulatory issues are discussed in Chapter 7.) Private foundations could have a major impact on the future of allied health education and practice by creating centers of excellence in a few academic institutions. Many advantages might be gained by coalescing a core research faculty that also provides services. These mutually reenforc- ing activities would enhance the quality of research and patient care. Fur- thermore, these centers might then be a resource to other allied health education programs regionally or nationally. The committee believes that the interest of state legislatures and private foundations in the endeavors we describe will be kindled and sustained only by a continuing federal presence in the concerns of allied health education and practice. For this reason, the committee makes the following recommendation about the federal leadership: The Depa'-l~nent of Health and Human Services should maintain an organizational focal point on allied health personnel to implement the grant programs recommended in this report, to coordinate the recommended work of the interagency data task force (recommended in Chapter 2), and to facilitate commu- nication between state legislative committees and the federal government. REFERENCES Allied Health Education Advisory Committee. 1980. Guiding Concepts for the '80s. CB Study Paper 29. Austin: Coordinating Board, Texas College and University System. Amatayakul, M.K. 1987. Report from the AMRA Manpower Survey. journal of the Amer- ican Medical Record Association 58(3):25-36. American Dietetic Association. 1985. A New Look at the Profession of Dietetics, Report of the 1984 Study Commission on Dietetics. Chicago: American Dietetic Association. American Occupational Therapy Association. 1987. Member Data Survey. Interim Report No.1. Rockville, Md.: American Occupational Therapy Association. American Physical Therapy Association. 1985. The Plan to Address the Faculty Shortage in Physical Therapy Education. Final Report of the Task Force on Faculty Shortage in Physical Therapy Education. Alexandria, Va: American Physical Therapy Associ- ation. September. American Physical Therapy Association. 1987. Active Membership Profile Study. Alex- andria, Va.: American Physical Therapy Association. Area Health Education Centers Program. 1987. Health Issues Working Group on Health Professions: Program Inventory. Rockville, Md.: Health Resources and Services Ad- ministration. February. Astin, A. W. 1985. Minorities in American Higher Education. San Francisco: Jossey-Bass. Bisconti, A. 1981. National and State Profiles of Collegiate Allied Health Education.1979- 80. Hyattsville, Md.: Health Resources Administration. Bleich, M. 1986. Enhancing Opportunities in Science, Mathematics, and Health Profes- sions: An Invitational Conference. Reno, Nev.: Macy Foundation. July. Bleich, M. 1987. Strengthening Support Networks for Minorities in Health Science Ca- reers: A National Symposium. New York: Macy Foundation. January. Booker, N. 1987. Minorities and Allied Health Educaiton. Background paper prepared

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ED UCATIONAL POLICY'S ROLE IN INFLUENCING S UPPLY 203 for the IOM Committee to Study the Role of Allied Health Personnel. Washington, D.C. Bowen, D. 1988. Dental hygiene: A devloping discipline? Dental Hygiene 62(1):23-24. Broski, D. C., R. E. Olson, and A. A. Savage. 1985. Increasing research productivity in university-based colleges of allied health. Journal of Allied Health 14(1):160-162. Brown, R. 1987. Perfusionists: A Case Study. Background paper prepared for the IOM Committee to Study the Role of Allied Health Personnel. Washington, D.C. Bureau of Health Manpower, Health Resources Administration. 1979. A Report on Allied Health Personnel. November 26. Washington, D.C.: U.S. Government Printing Office. CAHEA (Committee on Allied Health Education and Accreditation). 1987a. Allied Health Education Directory, 1987, 15th ed. Chicago: American Medical Association. CAHEA 1987b. Voluntary Program Withdrawals from CAHEA Accreditation, 1983-87. Chicago: American Medical Association. CAHEA. In press. Carpenter, H. 1982. Disadvantaged in the Health Resources Administration's allied health training programs: A historical review. Health Resources Administration, Washington, D.C. June. The Circle, Inc. 1987. Revitalizing Pharmacy and Allied Health Professions Education for Minorities and the Disadvantaged. Rockville, Md.: Health Resources and Services Administration. College of Health Deans. 1987. Unpublished survey data. Cooperative Institutional Research Program. 1987. 1987 Freshman Survey Renort. Los Angeles: University of California, Los Angeles. Covey, P., and I. Burke. 1987. Research and the mission of schools of allied health. Journal of Allied Health 16(February):1-5. Fitzgerald, L. F., and I. O. Crites. 1980. Toward a career psychology of women: What do we know? What do we need to know? Journal of Counseling Psychology 27:44-62. Flack, H. 1982. Minorities in Allied Health Education. Rockville, Md.: Office of Health Resources Opportunity, Health Resources Administration. August. Freeland, T. E., and M. A. Gonyea. 1985. Financing Allied Health Clinical Education. Report prepared for the Health Resources and Services Administration, Rockville, Md. Garrison, H., and P. Brown. 1985. Minority Access to Research Careers: An Evaluation of the Honors Undergraduate Research Training Program. Committee on National Needs for Biomedical and Behavioral Personnel. Washington, D.C.: National Acad- emy Press. Gonzales, C. 1987. Minority Biomedical Research Program. Bethesda, Md.: Division of Research Resources, National Institutes of Health. March. Health Professions Report. 1988. Social work schools' enrollment increases, but trend not universal. Whitaker Newsletters, Inc. (New Jersey) 17(2): 2-~. Health Resources and Services Administration. 1984. An In-Depth Examination of the 1980 Decennial Census Employment Data for Health Occupations: Comprehensive Report. ODAM Report No. 16-84. Washington, D.C.: Government Printing Office. July. Health Resources and Services Administration.1986. Report to the President and Congress on the Status of Health Personnel in the United States. Rockville, Md: Health Re- sources and Services Administration. Health Resources and Services Administration. 1987. Report to Congress on Nursing and Other Health Professions Educational Programs Reimbursed Under Medicare. Rock- ville, Md.: Health Resources and Services Administration. December. Hedrick, H. 1985. Discontinuation of allied health schools and programs. Is there a pattern? Journal of Allied Health 14(1): 159- 160. -/ - --r

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204 ALLIED HEALTH SERVICES Herr, E. L., and S. Cramer. 1984. Career Guidance and Counseling Through the Life Span. Boston: Little, Brown. Holcomb, l. D., D. W. Evans, W. P. Buckner, and L. D. Ponder. 1987. A longitudinal evaluation of graduate programs in allied health education and administration. ~our- nal of Allied Health 16(2): 119- 133. Hudson Institute. 1987. Workforce 2000: Work and Workers for the 21st Century. In- dianapolis, Ind.: Hudson Institute. June. Institute of Medicine. 1983. Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C.: National Academy Press. Kaminski, G. 1987. Allied Health Study: Two Year College Survey. Unpublished paper. Cincinnati Technical College. King, E. 1985. Articulation of allied health education. Pp. 126-139 in Review of Allied Health Education: 5. I. Hamburg, ed. Lexington, Ky.: University Press of Kentucky. La Alla Management Corporation. 1984. An Assessment of Preparatory Activities for the Health Careers Opportunity Program: Final Report. Rockville, Md.: Health Resources and Services Administration. Lent, R., S. Brown, and K. Lark. 1986. Comparison of three theoretically derived variables in predicting career and academic behavior: self-efficacy, interest congruence, and consequent thinking. Journal of Counseling Psychology 34(3):293-298. Lewin and Associates. 1987. Hospital Decision-Making About Offering Health Professions Clinical Education Opportunities and the Effects of Payment Policies on These De- cisions. Final Report. Rockville, Md.: Health Resources and Services Administration. May. Ludlow, C. L. 1986. The Research Career Ladder in Human Communication Sciences and Disorders. Bethesda, Md.: National Institutes of Health. Malone, P. 1979. Creating New Allied Health Programs: Considerations and Constraints. Atlanta: Southern Regional Education Board. Mandex, Inc. 1987. An Assessment of State Support for Health Professions Education Programs: Final Report. Rockville, Md.: Health Resources and Services Administra- tion. June. Mathematica Policy Research, Inc. 1987. Draft final report on exploration of trends and changes in clinical education in the preparation of allied health professions. Wash- ington, D.C. June 30. Miller, I. D. 1986. Multivariate models to predict the selection of and persistence in a career in the professions. Paper presented to the 1986 annual meeting of the American Educational Resource Association, San Francisco, April 17. Mingle, I. 1987. Trends in Higher Education Participation and Success. Publ. No. MP- 87-2. Denver, Colo.: Education Commission of the States and State Higher Education Executive Officers. Missouri Coordinating Board for Higher Education. 1986. Recommendations to the Com- mittee on Academic Affairs regarding "State-Level Review of Existing Programs in Health Sciences Education." Jefferson City, Mo. April. O ~ National Commission on Allied Health Education. 1980. The Future of Allied Health Education: New Alliances for the 1980s. San Francisco: ~ossey-Bass. New York State Education Department, Bureau of Higher and Professional Education Testing. 1985. Program Guidelines. Albany: New York State Education Department. Newman, F. 1985. Higher Education and the American Resurgence. Princeton, No.: Carnegie Foundation for the Advancement of Teaching. Parks, R. B., and H. L. Hedrick, 1988. Program directors' perspectives regarding CAHEA- accredited allied health education. Summary of a 1987 survey. Allied Health Education Directory, 16th ed. Chicago: American Medical Association.

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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY 205 Perrin, K. L. 1987. Remarks at the Symposium on the Future of Allied Health Education, Susquchanna University, Selinsgrove, Penn., April. Petersdorf, R. G. 1987. A report on the establishment. Journal of Medical Education 621 (February): 126-132. Southern Regional Education Board. 1980. Planning and Designing Allied Health Edu- cation for Program Review. Atlanta, Ga. U.S. Department of Health and Human Services. 1985. Report to the Secretary's Task Force on Black and Minority Health. Washington, D.C.: U.S. Government Printing Office. August.