How Should We Prepare Students for Health Care Careers?

In the June issue of the Health Care Careers e-Letter , we asked, “To help college freshmen get a jump on their health care education, what should the model curriculum of a high school health science look like? What content should be included? What are the current gaps in learning that need to be addressed?” (These questions were also disseminated to members of the listserve of the National Association of Advisors for the Health Professions [NAAHP].)

In response, we received the following feedback from readers; identifying information has been removed. (Note: These views may not necessarily reflect those of the AMA.)

At our state university, we would see the ideal high school science program as one that produces basic math competency. All of our basic science course have shown that math preparation as measured by the ACT subscores is the main predictor of success, and our data indicate that students who are not fairly well prepared in math rarely even take the MCAT and uniformly do poorly if they do. 

Of course in my other life as a community college remedial math instructor I find that the premature introduction of calculators (which apparently now occurs somewhere in early/middle elementary school) results in a body of students that have no sense if results are close and no idea about the mechanics of solving basic problems and therefore no basis to begin learning algebraic manipulations.

For physics I would like to make sure that conceptual ideas are conveyed rather than just "plug and chug" mathematical questions.  That would certainly be better for the MCAT.

I would suggest bioethics. It would be good for high school students to grapple with the questions about the ethics of health science technology. I’m working to introduce palliative care/end of life discussions to young students in college and am finding that they’ve never thought of the importance of deciding not to turn to technology in end-of-life care.

I believe 16 year olds who say they want to go into health care need exposure to the realities and many different career options in the health sciences. To address this, I teach a health sciences exploration course.

A number of my students point to clinical rotations classes they took in high school as formative experiences in their pre-med journeys. Virtually all who took such classes seemed to get a lot out of them. Of course, it may be that only students with pre-med leanings ever take such classes, and of course I don’t hear from students who took those classes and then decided not to pursue medicine.
Still, I’m fully in favor of high school clinical classes. Without them, many students will be a year or two into college medical preparation before they step foot in a hospital or clinic to see how medicine is actually practiced.

I took AP Biology and Chemistry in high school (scoring 3 on both AP tests—I wasn’t a stellar student), 10 years ago, and haven’t taken a hard science class since. In college, I studied psych, literature, and education. I’ve always tended to be "nerdy"—I still read Discover and the Sci/Tech news articles—but I otherwise have no background in advanced bioscience.

I took a practice MCAT this year, from the AAMC web site, just to experience the test and offer better advising to students. I only scored in the 20th percentile on biological sciences. However, that score means that 20% of MCAT takers—mostly junior bioscience majors, I presume—scored lower than I did, based on my high school AP classes from 10 years ago.

Accordingly, I would not hesitate to recommend any number of AP or IB classes to pre-health students.

Gaps in science preparation are a huge problem in college and in medical school.

From my read on the ACT 2007 report, including state data:

• Each tough science course taken in high school raises the ACT science component score 1-2 points
• Only about three percent to 10 percent of Native American and African American students are prepared to make an A or B in a college biology course, compared to about 30 percent for white or Asian students.
• Students not taking tougher science courses (and math) are going to be behind and have lower grades in freshman and sophomore years

Sadly, these students with slightly lower scores and then lower grades are going to be funneled away from medical school paths by a number of internal and external mechanisms.

Science preparation must begin early, in elementary school--and we have to pay attention to birth to age 6 child development as well, which is the real factor behind top standardized test scores that set all of one's future in motion.

Over the years I have had several students who participated in a high school health occupations program run by the county public school system. The program included a shadowing/internship experience, such that students consistently had a very realistic understanding of the career that they wanted to follow and had been encouraged to think outside the box--as illustrated most dramatically by the student who said as a freshman that she wanted to be a manager of medical research lab. She went on to get a master's degree and has been working as a lab manager for several years.

To begin with, I suggest we clearly differentiate between "vocational" programs (eg LPN) and "pre-professional" programs that require undergraduate, and even graduate, education.

I am not happy with either of the above labels. Brain surgery is a vocation, but most people think of "vocational" as training that prepares students to enter the workforce at age 18. An LPN is a professional, too, but the training given to LPNs does not typically prepare them well for college classwork. I assume that most people on this list would be involved with "pre-professional" education rather than "vocational" education.

If I could deliver a message to high school students whose goals are to attend college and there prepare for health careers ranging from occupational therapy, physical therapy, physician assistant, medical technology, and nursing to pharmacy, medicine, dentistry, etc, that message would include:

• Study as many different sciences as you can (a year each of biology, chemistry, physics and geology)
• Take as much mathematics as you can
• Study a foreign language as many years as you can
• Develop as many computer skills as you can

At least here in Ohio, the most neglected math discipline is trigonometry, with some high schools not teaching it at all, and some schools folding it in as a small component of "advanced math." Over half of the "pre-med" and "pre-allied health" students we accept end up having to take remedial trig in college.

We use a self-paced modular format to teach our medical assisting and associated programs. Small groups, one-on-one teaching, hands-on as well as online courses. We use multiple techniques including technology to reach all learning styles.

Teaching a student to become a life-long independent learner, with intense support and encouragement in a nontraditional format, increases success--especially for those who were less successful in the traditional high school educational format, where one must fit the square peg in a round hole, so to speak.

For a course in high school dealing with health care, the student should be knowledgeable in the following:

• First aid and preventive medicine (for adults and children)
• Understanding of basic lab tests and what is normal, including Hgb, HCT, WBC, and cholesterol (HDL, LDL and Triglycerides)
• Know how to give a shot, how to take blood pressure, and (since home care is becoming so important in the US now) how to change IV bags

Even if the student does not pursue a career in health care, these skills will help them better handle situations that life may present.

Many high school health care career hopefuls are focused mainly on becoming pediatricians or nurses, and the allied health occupations are not within their interest levels. High school instructors would be advised to offer an objective overview of all opportunities in health care, rather than just emphasizing physicians and nurses.

Also, the service learning component is a splendid way for students to capture real-life experiences. My students are required to perform 97 hours of service learning during their 12-month program. Responses are very positive. 

For more information on high school health science curricula, educators should check out the National Consortium on Health Sciences and Technology Education. This very active group of high school educators has developed national foundation standards for high school health science education.

What we find to be the most helpful asset in applicants for our graduate programs in school counseling, school psychology, and community mental health counseling is experience. Any and all related experience that an applicant has, whether volunteer or paid, part time or full time, helps us to know that the applicant has taken the time to fully explore the field and is knowledgeable about the career choice being made.

In addition, we love to see that our applicants have spent time interviewing and shadowing some professionals in their field of interest: For example, spending a day with a school counselor at the middle school level and then another day with either a high school or elementary school counselor. We like them to be able to tell us what a typical day for a person in this profession is and why that fits with who they are and their future goals.

On the flip side, nothing decreases our interest faster than applicants who tell us that they will work really hard because they really want this job because they want to help people and yet they can tell us nothing about what a person in their field of interest actually does, and they have never taken the time to find out.

Speaking as faculty director of a health professions advising office, we need students who have been exposed to the myriad variety of professions in the health care field. Too many are only familiar with the physician and nurse as career opportunities. As a result, the nursing department is inundated, and those who are pre-med are not aware of viable alternative careers.

Many of the minorities who we would like to recruit into medical careers see the sciences as too difficult and do not have adequate skills in basic math and English. To help solve this issue, we work closely with community college advisors and collaborate with a health careers charter school and local high school health career clubs. However, time, money, and student motivation are persistent issues.

Although we are behind in this effort compared to most states, we are working in Texas to develop dual college-high school credit courses and implement Tech Prep models into programs of study under the US Department of Education health cluster. We have also developed new high school exit outcomes, which are posted on the Texas Higher Education Coordinating Board Web site.

One mechanism we use in our state is Marketable Skills Achievement Awards, such as EMT-Basic, certified nurse aide, medical office assistant, and central processing tech, which can be started in high school and completed during the summer after graduation from high school. These awards are 7 to 14 semester credit hours and afford the student workforce skills. The students can work part-time and continue college work on an associate degree.

Our health science and emergency services programs are using simulation with high-tech mannequins in campus labs in which students must employ critical thinking to care for a patient in a specific case scenario. Debriefing after the exercise is the most important part. Since we are a community college and don't have physician assistant or medical education, we encourage our program medical directors to come in and play the physician part when ever they can. We film the simulation and pipe it into a classroom nearby or can it for online use.

We have also found that interdisciplinary simulations involving students from multiple programs (such as nursing, paramedic, and respiratory therapy) provide more benefits to learning, and we hope such education will help to break down the silos within the health care teams with which our graduates will work.

Finally, I would mention the Institute of Medicine's Health Professions Education: A Bridge to Quality (2003), which recommends five core competencies for all health professions, one of which is high-performance work teams. The report also recommends moving away from didactic lectures and instituting more interactive teaching strategies, such as problem-based learning. 

The single most important step we can take is to encourage middle-school students to enroll in rigorous math and science courses. Students who take only the minimum requirements in middle- and high school have seriously limited their options for careers in the health professions.

Our youth need more opportunities to explore the many careers in health care as part of their regular school day. Some places are doing just that, but teachers have so many objectives to meet that exposing kids to careers in science, health, and even medicine may be given less attention.

When children are exposed to science through gross human anatomy, it stimulates interest in the microanatomy, (biology, histology, and chemistry, to name a few). Children are intimidated by the details of any subject matter, and if they are not "gifted or talented" they may not be encouraged to challenge themselves. After all, the smartest and brightest typically get the attention of educators. But there are students in the other 80 percent that have enough interest, desire, and curiosity to become a member of our future health care workforce.

I have done a great deal of recruiting in the past, targeting college, high school, and middle school students. Here are some of the strategies I have found to be successful as well as my personal perceptions of the educational gaps in the pre-professional pipeline.

Recruitment into health sciences

• Science fair awards for junior and senior high school students at regional and state levels, focused on projects relative to my discipline. I provided 1st, 2nd, and 3rd place ribbons and certificates. After a few times, the students were looking for me to come by. Some of what they did was brilliant. It was almost scary what they achieved when challenged and given the opportunities
• Show-and-tell career fairs with demonstrations and hands-on activities that the students could either see or even do themselves.
• Visits to the schools to meet with the science classes, to show such videos as the Jane Doe film and Code Red in Arkansas. Instead of a bunch of talking heads about each of the allied health disciplines, the Jane Doe film showed the story of a woman who had been in an auto accident and all the different types of professionals who helped her recover, including EMS, respiratory care, laboratory, radiologic technology, physical therapy, etc. Code Red in Arkansas was a local TV documentary about the medical technology shortage in the 1990s.I went on a radio show to talk about the program.
• Faculty-led science lectures to high school classes on topics high school teachers were required to cover but were not well versed in, eg, AIDS.
• Publications like the cartoon books in doctor’s offices about lab tests, and publications from the various national professional organizations.
• Keeping in close contact with applicants via pre-professional advising and recommending what pre-professional courses to take
• A t-shirt design contest to promote a particular health profession.
• Part-time tracks for working students.
• Career ladders for students who have training in related or lower level disciplines so they don’t have to keep starting over and repeating information they have already mastered. (They will walk away otherwise.)
• Cutting the bottom rung of the career ladder into small enough pieces such that economically and academically disadvantaged students can take the first step, get a foundation, get some confidence, and climb the ladder as they are capable.
• Taking the education to the students. Don’t expect the students to get to the education, especially with gas prices so high. Many rural area students will not or cannot leave their homes for school. They can’t cross three mountains and two rivers in the winter, etc. They can’t leave spouses and children to move half-way across the state.

At one school where I did the most intensive recruitment, the program had about 9 students, many struggling, and a lower than national pass rate on the exam when I took over as chair. After intensive recruitment, including many of the strategies above, we had over 30 students per class and 100% pass rate two years in a row. So I have to believe that many of these strategies work.

High school content and gaps in the instructional pipeline

The biggest gap, from my perspective, is that the students are not learning critical thinking. They are primarily taught and tested for rote memory. They need to compare and contrast, look at cause and effect, draw conclusions, synthesize, evaluate, etc. This has to do with instructional strategies instead of courses per se. They need to learn how to make rational, logical presentations and arguments. This can be taught as part of English courses where they have to write papers, but it can also be incorporated into most courses. Don’t just ask them what they think--ask them why they think that. Is it a cohesive argument? Logic (rational, deductive, and inductive reasoning) can be included in high school courses and can be a stand- alone prerequisite with college classes. (I know it can be done because that is the way my education was structured.)

In addition to changing instructional strategies, there are courses that pre-health science students need:

• 1 year biology
• 1 year chemistry
• At least 3 years of math, including basic and advanced algebra and geometry
• Physics - recommended
• Trigonometry - recommended (especially if they take physics)
• Advanced biology - recommended (or anatomy and physiology)
• English
• Speech
• Computer sciences
• Social studies and history
• Adequate reading levels (many college students have a reading comprehension in the lower 25th percentile. It is a wonder that they manage to get through. Studies have shown that the problem with math is not just math ability or fear of math [which does exist] but difficulty with reading. They can’t read and understand the word problems. Math is also linked with ability to follow directions and rules, which is very important in the health professions. Can they read and interpret charts, graphs, diagrams, etc? Do they question the validity of what they hear and read? We’re back to instructional strategies again, right where we came in.

The subject of professional behaviors (attendance, interaction with patient or other health care worker, dress code, etc) needs to be addressed early on or be incorporated into the curriculum.

In this age of technology supreme, I do not know if we can overcome some of the gaps that have emerged in college preparatory education, ie, if you continually text message, can you emerge as a competent speller?

The three areas that I see as very important are developing very good reading skills, the ability to write, and critical thinking. These, along with the other subject areas that are essential, build the platform for a successful college career and subsequent health professions preparation.

• There is a gross misunderstanding of how medical bills are paid. Undergraduates, medical students, and even physicians often have a poor comprehension of how insurance companies operate with regard to reimbursements.
• Most are unclear as to what services are covered by Medicare versus Medicaid, what the reimbursements are like (very, very poor), and who are the recipients of each type.
• They do not know what CPT or ICD9 codes are nor how they apply to getting paid.
• They are not aware of all the federal, state, and local regulatory agencies that oversee health care and how these impact the services they might provide. This not only includes compliance issues and HIPAA rules, but also how various agencies regulate health care products, equipment, reagents, etc.
• Many health care workers eventually reach a level of experience where more responsibility is placed on them. Most have received little or no training regarding management and general business basics. For example:
  • Financial management
  • Interviewing, hiring, and other recruitment requirements
  • Other personnel issues (progressive discipline, performance appraisals, team development, etc)
  • Basic marketing skills
  • Basic supervisory skills
  • Facilitating meetings, making presentations
  • Continuing education, including training and teaching skills

Certainly anatomy, as well as medical terminology for both clerical and clinical workers, is a requirement. And in today's world, basic coding for survival. But why not explore bringing experienced clerical medical workers who have been exposed to the medical world into the clinical aspect to see if this might be where we find the future clinical "newbies?"

A thought is to have the students obtain a certification (medical assistant, licensed vocational nurse, emergency medicine technician) prior to graduating. This would give them a jump start on a good summer job in health care. The second thought is to provide HIPAA training, with a certificate--once again so they may find it easier to volunteer or work in a health care setting.

High schools should offer human anatomy and physiology and medical terminology. An additional consideration might include CNA courses at a very basic level. We like the idea of graduating students having some patient care experience in a real-world setting prior to beginning their formal educations as medical care providers.

General skills that are essential in our profession (electroneurodiagnostic technology):

• Good foundation in math
• Writing skills
• Communication skills
• Critical thinking skills
• Computer skills 

Medical subjects that may facilitate rapid assimilation of END technology students into accelerated learning situations:

• Human anatomy and physiology
• Very basic medical terminology
• Very basic patient care skills, such as how to do vital signs, etc. (I am amazed at how many students enroll in an END program and find that they are uncomfortable touching people as caregivers, so this would give them a sense of that experience)
• Health care career overview: shadowing various medical professions, followed by written analysis of their experiences
• Human psychology and understanding of "age-appropriate care," from pediatrics to geriatrics, and an overview of major psychological disorders

I suppose this sounds pretty standard, but I cannot stress enough how important these basic skills are.

We are exploring offering a for-credit medical careers discovery course at participating high schools through our local community college. The course will incorporate substantial clinical opportunities for the enrolled students. Students will:

• Practice phlebotomy with a practice arm
• Practice sterile procedures in a mock surgical suite
• Practice radiographic positioning of chest and extremities
• Learn to take vitals in the practice labs
• Shadow a health professional in the hospital

In addition, the course will teach about HIPAA, accreditation, and ethics. Our goal is to get students excited about health care as a career and to help them narrow their focus of interest.

I would recommend that students interested in health care careers spend some time shadowing professionals in all of the health professions that they may not even be aware of, such as:

• Physical therapy
• Occupational therapy
• Physician assistant
• Midwifery
• Diagnostic medical imaging
• Medical Informatics

Very often, students in high school who are interested in a health care career think only of medicine and nursing because this is all that they've been exposed to. They may know of physical therapy if they or a family member was ever injured and required it. They have probably never heard of occupational therapy.

And knowing about these careers long before applying to college is very important. Today, it takes 7 years to become a physical therapist--4 years of college and 3 years of physical therapy school. However, savvy high schoolers who know a bit about physical therapy will know to apply to colleges that will allow them to finish in 6 years instead of 7. Some colleges, such as the University at Buffalo and the New York Institute of Technology, will admit freshman who can finish their undergraduate and Doctor of Physical Therapy training in 6 years, but the students must enroll as freshman to do this. SUNY Downstate offers a BS/DPT program, through which competitive college students with 80 college credits (including specific course prerequisites) can be admitted and, within 3 years, be awarded a bachelor's degree in health sciences and a Doctor of Physical Therapy degree. So they can finish all of their training in 6 years instead of 7.
 
Also, students who shadow health care professionals may be able to make career decisions earlier to allow them to start early in college with taking the right prerequisites to apply to these professional programs. They may also look for opportunities to observe classes in the professional programs in which they are interested.

One additional piece of advice: In their first semester of college, students shouldn't load up on science courses, eg, taking both Chem I and Calculus I. They should spend the first semester taking courses that they know that they will do well in, and courses in content areas that they enjoy. This will give them a chance to acclimate to the college environment, which is much more challenging than any high school in terms of course requirements.

In April the MassAHEC Network (AHEC: "Area Health Education Center" ) hosted a conference, Health Care Pathways: Connecting Education with Careers at the UMass Medical School. The idea for the conference was conceived after MassAHEC received several phone calls from middle and high school teachers seeking resources to help make their lessons on health care occupations more reality based, interactive, and engaging.

The result was an event that brought in 80+ teachers, guidance counselors, and administrators from a broad statewide mix for a day of lesson demonstrations, lectures, vendor displays, and networking. The conference centered on connecting science and health education with careers in demand. In addition, panelists addressed how to leverage community-based resources by building mutual partnerships with hospitals and public health departments, expand students’ awareness of the variety of health-related careers in demand, and develop interactive curricula that engage students. Participants received a resource book serving as a comprehensive instructional tool, complete with online teaching and career development resources, classroom lessons, a guide to designing case-based projects, and tips on planning a health careers expo. All presentations, along with a portion of the resource book, are posted on the MassAHEC site.

Because some health professions programs are 1 year or less, a solid foundation in basic sciences to be used in critical thinking is essential. In fact, I would like to see high schools incorporate active use of the information, ie, applying not memorizing.

As the dean of several allied health programs in a private college, I see students with a vast array of skills and expectations who come to the college with the dream of becoming a health care professional. Too often, they are unsuccessful due to their inability to meet the rigor of the requirements for the program. Accordingly, the nation needs to better prepare high school students who wish to pursue careers in health care.

First, the best preparation the high school can offer is to help the student learn to study...and to study to learn. The biggest challenge we have in health science is not the level of knowledge the student brings to the classroom, but rather the level of study skills. Too often student success is blocked by their inability to study to learn, not memorize for a test.

Second, in preparation for health care specifically, students should be exposed to the world of health care through observation or virtual reality in any way possible prior to college entrance. In our community we offer a Health Science Camp each summer, organized by the public school, the local hospital, and our college. It is a day camp for students grades 6-8. Students spend 3 days in observation and in many cases some hands-on time, seeing many of the occupations in the health care arena.

On the first day they spend a morning in the college's veterinary training lab, learning about the roles of a veterinary technician and veterinarian, practicing bandaging and other "skills" on the animal mannequins. Then it's on to the medical assistant lab, where they are exposed to the role of an MA and learn to take a blood pressure, practice removing sutures on the mannequin, and practice proper hand washing technique. Next are registered nurse, paramedic, surgical technology, etc. for similar observation and hands-on opportunities. The next two days they go through various departments of the local hospital, again having the opportunity to observe and talk to professionals in the field. The students are issued scrubs to wear each day as their camp gear. They receive certificates for having successfully attempted to take a blood pressure, etc. Feedback is positive and it exposes the students to a variety of careers within the field.
The third thing high schools can do for students, to prepare them for the fast pace of learning required in health care programs, is to provide learning opportunities and to maintain high standards for students in the basics of math, reading, and writing. Again, many students are not able to perform at college entry level in these basic skills, and consequently they struggle as they need to take college preparedness courses their first quarter/semester.

An emphasis on fast-track training through continuing education programs would assist in developing an interest in health care, provide a means of training, and allow students to work in a health care setting while attending long-term college programs. Also, the tuition assistance from employers helps the student through school.

For example, our phlebotomy program can be completed in two semesters with a 3-week clinical at a hospital. I have had many pre-nursing students start on this path and have observed their interest levels increase dramatically regarding health care. Conversely, they may decide that working with patients or handling body fluids is not a match for them, so their nursing program spot may go to another, more interested student.

Richland College, for example, is working with local high schools to articulate its programs and increase interest in healthcare. It offers fast track training in:

• Medical Assistant
• Pharmacy Technician
• Phlebotomy Technician
• Medical Insurance Coding and Billing
• Medical Transcription
• Medical Office Technology
• Health Unit Coordinator

• What should the model curriculum of a high school health science look like? First, it should be created from an introductory level perspective as a prologue to the health industry. It should primarily expose students to the different types of health careers, and include the different types of duties each health professional typically performs, and where a person might work in the industry (hospital, clinic, physician's office, etc). It should also include the type of coursework that students can anticipate taking once in a program in college. A curriculum like this could be particularly helpful to underrepresented minorities. It should also be stressed that academic achievement is important in these career paths.
• What content should be included? Job shadowing in health technology, CPR course, nutrition, stress management, introduction to health care careers, biology, etc.
• What are the current gaps in learning that need to be addressed? A pre-health enrichment program will go far regarding student association with each career path. Many students entering college do not have a realistic view of what a job in the health care industry entails. Because of the great variety of disciplines, it is important for students to understand what their strengths and interests are and seek out a career accordingly. For example, individuals who enjoy being organized and are good with follow-up, but may not enjoy working with patients on a day-to-day basis, would be better suited for a career in medical records, coding, office management, health administration, etc. On the other hand, an individual who likes working with patients, is detail oriented, and would enjoy helping or doing surgical procedures would be better suited as a medical assistant, LPN/RN, physician assistant, or physician. 

High school curricla should also include conflict resolution through the development of "emotional/social intelligence."