What should a bridge program look like?

[SHU-CH]

Hi Everyone -

 

My university is in the very early stages of opening a medical (MD) school in partnership with a local healthcare system. I mean very early - the search for a Dean has not yet begun. We are moving into a new facility with a school of nursing and the MD curriculum will be developed essentially from scratch. I am told there is going to be heavy emphasis on interprofessional collaboration and primary care.

 

As the process moves forward, I will be in a lot of conversations. It appears that the drivers of the process are looking to be innovative. There is a small possibility that I might someday find myself in a position to pitch a bridge program. So my question is this:

 

What would a practical bridge program look like?

 

By "practical," I mean something that you might be interested in doing but would still be acceptable to LCME. I expect many of the rate limiting factors will be related to LCME standards, and I am also not sure how practical it would be to abbreviate much of the basic sciences for someone who needs to take USMLE Step 1. If there is even a glimmer of hope, I want to be sure to have a decent looking proposal ready to go at the right time. Your thoughts are much appreciated.

[PACdan]

18 months, full time. (12 months of MS1/MS2 sciences/pathophysiology, 3 months dedicated Step I prep, 3 months of extra FP/IM rotations).

 

Med schools seem to be giving months of MS2 now dedicated to Step I prep. All I hear/see is the students reviewing U-world, FA, and Pathoma daily.

 

For the graduate of a modern, 100+ credit hour, 27-month master's PA program, this brings them inline with most med schools. Could probably sell it best if matching was limited to primary care internships/residencies. Then expand it in the future. Can't see anyone arguing that the 27-months of PA + 18-months of med bridge doesn't add up to medical school in terms of courses and rotations.

 

This is verbatim what myself and two classmates discussed with 3 of our med school colleagues when we compared curricula.

 

A min. work requirement of 1-2 years, full-time as a PA-C may make for stronger applicants, but I have no data on this.

 

At 45 months total it doesn't incentivize people thinking it's a "med school short cut", especially compared to 3-year programs. It's only 3 months shy of the 48 months in a traditional 4-year school, of which we know that MS4 is largely devoid of academic/clinical courses.

[db_pavnp]

Can't see anyone arguing that the 27-months of PA + 18-months of med bridge doesn't add up to medical school in terms of courses and rotations.

 

The thing is, though, I feel someone did make that argument and the LECOM "bridge" was born, which seems to contain very little "bridge" at all.  Or they didn't try very hard.  PAs want significant credit for work performed and the powers that be want to grant no credit.

[Guest Paula]

I agree with MS 1 and the above poster. Just make sure the PA is represented and that the school of nursing does not get a foothold in the door for a NP to MD program and PAs are forgotten.

[cop to pa]

AAMC has a "handbook of academic medicine" that goes into the curricula of accredited medical schools. I'd get that, fill the gaps between it and PA curricula (and where PA practical experience can't fill in) and sell it that way. AAMC is who needs to be made happy, so I start from the top down, not the bottom up.

 

I hate bureaucracy, but these bridge programs are bureaucracy driven. If you try and fight it, you'll fail. Look at everyway the medical elite will try and fight it and have counters with data for it.

 

That's my .02 at any rate.

[EMEDPA]

in a perfect world PA and MD coursework would be dually accredited as PA2/MS3 for example so all pa coursework could be counted towards MD requirements.

My understanding is that LCME requirements require a min of 3 yrs for an approved medschool program. This is what LECOM has done by granting 1 yr of credit for the ms3 year.

I believe many of the courses taken during pa1 could meet full requirements for medschool. ethics, physical diagnosis, and history taking. care of the dying patient. biopsycho-social issues in health care, etc.

That being said, PAs would need to complete 100% of ms1, parts of ms2, and an abbreviated clinical year. If credit was given where credit was due I believe a bridge with 16 months of didactic and 8 months of clinicals would prepare a pa very well to enter the match and begin residency.

[SHU-CH]

That being said, PAs would need to complete 100% of ms1, parts of ms2, and an abbreviated clinical year. 

 

This is along the lines of what I was thinking.

 

Other threads on bridge programs have indicated an LCME three year minimum. This might be the biggest obstacle to work with. With PAEA and AAMC finally in the same building there will hopefully be some growing synergy in medical education. 

[EMEDPA]

I would also vote for no MCAT and abbreviated pre-req requirements , like LECOM has done.

[primadonna22274]

Actually it was the MS4 year that was granted credit. We still had to do all of the MS3 cores and pass all of the 6 shelf exams to progress. Very little room was left for electives but we had some latitude in medicine selectives (I did nephro, hospice/palliative and geriatric inpatient instead of 3 mos general IM.

There was some WHO requirement that any accredited medical school must be a minimum of 132 weeks. This often is cited as "3 years" which if you do the math it obviously is not. APAP has zero time for vacation so it is intense but it did save me 1 yr and approx 60k.

There is a great deal of redundancy between M1 and M2. We only had about 2 wk dedicated study time for level 1 and none for level 2 in APAP but I made my own study time for level 1 and didn't need any for 2.

Probably another 6 mos could be shaved but it wouldn't make the school more money and the bottom line is it must be 132 wk minimum to meet WHO accreditation standards.

I'm very doubtful that any accrediting body would see clear to grant significant prior credit for PA school in medical school...but then I'm a skeptic in general.

[EMEDPA]

don't you think fluff courses like ethics, etc could be given credit? also courses that are exactly the same like history taking and physical diagnosis?I agree that all of MS1 needs to be included in any bridge program so that one could pass step 1.

[primadonna22274]

By my second year APAP folks could test out of H&P. That was great.

We got no such pass on ethics etc. Heck I had to spend an entire Saturday learning the LECOM way to do sensitive patient exams. 8000 paps/pelvics over 12 years apparently didn't count.

[SocialMedicine]

Sorry to do this. Not what you were looking for. 

 

I would hate to see PAEA and talented PA academics putting much effort into something like this. Expand the PA profession. This health system needs innovation in the form of a cheaper and versatile healthcare workforce. Not another handful of MDs, already done with PA school and have been practicing, with even huger debt and as some would argue over education. It makes no sense from a policy perspective. It is counter productive.

 

Why dont you promote the PA profession instead with this opportunity. See how in the early infrastructure you can create opportunities for PA to have ladder faculty appointments, maybe a PA/DHSC can have a dual appt w a medicine department are start researching health outcomes especially those relevant to PA practice. Lets do things that promote the PA profession rather than make it a stepping stone to MD. I do not want to see PAEA or AAPA spend one cent on exploring bridge programs. lets make it clear we are the innovation and PA practice needs to be expanded not bridged. And I will continue to push that agenda in all areas I work.  

[primadonna22274]

^^^wise words.

[PACdan]

...That being said, PAs would need to complete 100% of ms1, parts of ms2, and an abbreviated clinical year. If credit was given where credit was due I believe a bridge with 16 months of didactic and 8 months of clinicals would prepare a pa very well to enter the match and begin residency.

 

Why 8 months of extra rotations? Why not just make up the difference in avg. clinical hours between PA and MD. They don't have 8 extra months on top of us.

 

Realistically, to meet the 132 week standard, credit has to be given for courses in PA school to make it worth it to me. Some stuff is exactly the same, some is not. Add it up and deduct bridging credit from the 132 weeks. Otherwise, not worth it.

[EMEDPA]

8 months is fairly close to the difference if you assume pa2=ms3 and 4 months of ms 4 = interviewing and vacation blocks.

[blueridge]

What does the medical school of the future look like anyway?  Interesting:

 

http://www.ama-assn.org/ama/pub/about-ama/strategic-focus/accelerating-change-in-medical-education.page

http://www.ama-assn.org/ama/pub/news/news/2015/2015-04-13-ama-initiative-reshape-medical-education.page

http://blogs.wsj.com/experts/2015/02/17/video-how-to-fix-medical-education/

 

As the World Health Organization calls for innovation in medical education (including recognizing prior relevant experience) an innovative and strong yet accelerated PA bridge/pathway to physician could be built to fly.  With the appropriate hurdles and sound design, the naysayers' rebuttals will ring hollow.   

[EMEDPA]

we would first need a group of physicians who believe that some pa coursework is identical to md/do coursework. the only folks who believe this so far are folks like the director at lecom's apap program who have done both. I would be interested to learn how many physicians who were previously pas are involved in medical education nationwide. I bet it's a pretty small number. most pas who go back to school have specific clinical objectives in mind(want to be a surgon, want to be an er doc, etc). very few folks want to go to medschool to become full time clinical faculty at a medschool. I'm guessing we are talking about a single digit to describe that # of individuals nationwide. I would wager most are DOs also.

[ToppDog]

Sorry to do this. Not what you were looking for. 

 

I would hate to see PAEA and talented PA academics putting much effort into something like this. Expand the PA profession. This health system needs innovation in the form of a cheaper and versatile healthcare workforce. Not another handful of MDs, already done with PA school and have been practicing, with even huger debt and as some would argue over education. It makes no sense from a policy perspective. It is counter productive.

 

Why dont you promote the PA profession instead with this opportunity. See how in the early infrastructure you can create opportunities for PA to have ladder faculty appointments, maybe a PA/DHSC can have a dual appt w a medicine department are start researching health outcomes especially those relevant to PA practice. Lets do things that promote the PA profession rather than make it a stepping stone to MD. I do not want to see PAEA or AAPA spend one cent on exploring bridge programs. lets make it clear we are the innovation and PA practice needs to be expanded not bridged. And I will continue to push that agenda in all areas I work.  

 

The founders of the PA profession wanted to see PAs with experience go on to become MD's until the AMA came in to protect their turf.  I see this as an attempt to honor the promise to those pioneering PAs who have paved the way.  While I also agree that the PA scope should be expanded, I see no reason why that expansion shouldn't include a PA/MD bridge, especially in primary care areas where traditional medical students do not want to go.  The better answer to the primary care MD shortage has been right here all along, & it's about time some schools start looking at it, instead of leaving the void to be filled by NPs.

[EMEDPA]

Well said Topp!

I agree that we could easily fill this void. I think if a 2 yr program with guaranteed admission into a primary care residency were created, maybe with some mechanism for loan repayment as well, that you would have PAs lining up to apply. even in my late 40s I would apply to such a program if I didn't have to take the mcat or any additional prereqs. I would love being a full scope rural fp doc who covers clinic, the ER, does OB including sections, and a variety of extended scope procedures like treadmills, vasectomies, etc

[PACdan]

8 months is fairly close to the difference if you assume pa2=ms3 and 4 months of ms 4 = interviewing and vacation blocks.

 

From my limited, anecdotal experience, I've known some MS4s that had a couple required courses, a few electives, and nothing else but interviewing or "journal review". Not saying everyone has a slack M4 year, but one guy was done in November.

 

I doubt we'd ever get fair course recognition. It's just a turf/ego war. There are many, many things that need to be expounded upon, but not letting us subtract the pure overlap is...dumb.

[SocialMedicine]

Disagree with topp big time.

 

The historical goals of our profession matter little at this point. It is a VERY different profession. No longer are we entering community college certificate programs with minimal debt on the GI bill. This is now a masters profession with a different curriculum. Not knocking a certificate program ... more demonstrating the increased cost and depth of our medical education. Those practicing as a PA have increased scope of practice. I do not think any early PA pioneers saw the ACA referencing PAs as primary care providers. Although I could be wrong since I did not poll them.

 

Enahncing a PA to MD bridge will damage the profession. Public opinion matters. See the drama over the distance education program at Yale.

 

We are not a stepping stone. I practice with autonomy as do many on this board. I do so in a cost effective manner with good outcomes. I (PA) am the solution to our catastrophic healthcare system. The US physician centric model of care is not sustainable. This is proven. Medical school will change dramatically if MDs are to continue to provide mass health care. The NP/PA will rise if they do not do this ... and will likely rise to some extent anyways if they do. Our health system cannot afford to re train an already talented workforce at a cost of 150+k.

 

We do not need more PAs taking out another 150 k for a medical doctorate ontop of PA loans and home mortgage. On a population basis this does not make fiscal sense. It does not solve problems in healthcare. By the time these programs are implemented many of the workforce shortage predictions (which by the way seem to be specific to certain areas of medicine such as primary care and DO NOT take into account the EXPLOSION of PA and NP programs) will be changed tremendously. This baby boomer generation over the next 20 years is the issue. Our population is not growing w/ great speed at this point.

 

Do you really think these bridge people are going to go into family medicine and do EXACTLY what they could have done before going to med school ? I recognize primamadonna did this. However, she seems like a pretty unique extraordinary person and I suspect her primary care patients are VERY lucky. These are people who will go into specialty care. Why would I spend 150k over 6-7 years of school/residency to make 30k more a year in outpatient internal medicine? I would cosnider it if I wanted to travel the EROAD on park ave.

 

Unless you actualy have data (doesnt exist) over what PA to MD bridge students will do post grad (solve primary care shortage) and unless you understand workforce and patient demand trends do not weigh in on this issue in that manner.

[EMEDPA]

I believe a pa to md bridge would actually improve our reputation because folks would see that we already have a lot of overlap in what we do. folks might say " pa school is very much like medschool because they already do 50% of the work and if they want to go back to medschool they only have to do 2 more years". you could structure a pa bridge program so that folks were required to match to primary care. thew texas primary care medschool, program already does this. I believe their diplomas even say something about primary care on them. for someone who wants to do full scope rural primary care their scope of practice would be much wider as a doc than as a pa. how many pas do you know in 2015 doing ALL of the following colonoscopies, full scope ob with c-sections, vasectomies, solo er and icu coverage, etc.

in urban primary care I agree the current scope is the same, however once you get into rural and underserved environments the advantages of physician over pa become more pronounced.also if you look at a field like general surgery(which is currently falling out of favor with med school grads) a doc can do MUCH more than a pa. how many pas do you know who can take emergency surgical call and remove an appendix as primary surgeon.

[SocialMedicine]

its true 19% of our population live in 90% of America. I have not worked in rural medicine and to be honest the family trained MDs I see do what I do. I wonder what % Of family medicine trained MDs practice to the full extent of their license? I am going to guess under 5%. I could be wrong. But you are correct a family trained MD is ideal for those settings. Maybe PAs should be trained to do sigmoidoscopy or colonoscopy ? But when you describe such a training program you are not necessarily training those family MDs. Are you going to limit the bridge program for family trained MDs who will work in rural medicine ? I hate to say it but most lawyers and doctor do not want to live and work in rural america. I do not see the plan you describe improving the dearth or rural medicine or primary care in US cities. PA school is more than 50% of MD school ... at least where I was trained. We can agree to disagree on this. I save my hyperbole for this conversation instead of the online programs one. I have a buddy who did an MS and MD. He is 220k in debt. This is what most MD bridge debt will look like in my opinion. I am sure you do emedpa ... but for some of the new grad PA or prePAs here ... do you realise what that is paid back over a 15 year period ? You could be looking at 600k. Good luck paying that off in north dakota. That is a lot of colonoscopies which I could forsee being reimbursed at a family medicine rate knowing insurance companies.Before I jump in and support bridge programs at the sacrifice of my profession I want to see some actual data and modelling that these people will actually benefit the underserved populations who might benefit from a family medicine MD

[EMEDPA]

if you work in N dakota the govt pays off your loans for you.

I think the way to make this work is tie the bridge to a requirement to do primary care or general surgery + a built in residency and loan repayment program to encourage 5+ years work in underserved areas. make it essentially free. maybe even set it up like the nhsc scholars program so folks get a living stipend wwhen in school....

[Guest Paula]

Once again, the real problem with the PA profession is its dependence on the physician and the ongoing required supervision that paints us as forever assistants.

 

The real innovation for PAs will be autonomous practices, with licenses not tied to a physician,, and the ability to get hired anywhere without all the legal mumbo jumbo our profession clings so tightly to. 

 

PA programs, PAEA, AAPA, NCCPA, etc. could join together and put forth a solution that PAs who chose primary care, commit to rural and underserved, inner-city areas will be independent of the physician, and could propose an additional 12 month primary care residency after PA school.  Test us and then set us loose who pass the exam.  Physicians then are free to choose their desires of specialty practice and PAs now are the primary care providers of the nation.  I think if something like this ever happens it would need to have government support to force the issue so AMA and ACGME could not howl like wolves under the moon. 

 

It's not that hard to figure out, except it is because we have so many people who cannot get their minds out of the box. 

 

While I support a PA/MD/DO bridge, it is not the answer for everyone, but my idea could work for those of us who are willing and able to serve the rural and underserved areas.  Just set us free!