Why It’s Time for a U.S. Part-time Cohort Model for the ND Degree
David Schleich, PhD
Recent catalysts help explain an increase in inquiries about part-time cohort-based second-degree completion track opportunities, not only for those who already possess a first-professional degree but also for those who are seeking admission into the first year. Many postsecondary institutions have long offered part-time professional degrees in specially packaged cohort models (e.g., the University of California, Berkeley, as early as 1996). So far, Association of Accredited Naturopathic Medical Colleges member programs (apart from Boucher Institute of Naturopathic Medicine, whose part-time track is under way in Vancouver, B.C.) have not. Let us review some of the reasons for adopting part-time delivery models at this time and explore a little about how they might work.
The Essential Nature of the Cohort Model (i.e., Needs of the Nontraditional Student as Customer)
Familiar issues arise when educational leaders consider a part-time cohort model to deliver professional programs. For example, curriculum designers want to know what attracts students to this learning path. They worry about departing too hastily from the well-known time-bound and place-bound classroom and about changing the role of the teacher. King (1993) at California State University, San Marcos, described as inevitable the moving of university and college teachers “From Sage on the Stage to Guide on the Side.” At the very dawning of the Internet, King sensed what was coming and began the search for acceptable ways to engage students as active learners on their own terms.
The architects of programs aimed at meeting what the learners need (not only content-wise and skills-wise but also convenience-wise and access-wise) invariably discover the part-time cohort model. They are usually eager to build the cohort quickly so that the learning pathway accumulates into a learning community from the get-go. Research also indicates that educators using this model are, even at the beginning of such an offering, ready with positive resources and suggestions for what happens to the individuals of the cohort once the program is completed.
In any case, the literature demonstrates that a cohort structure can definitely help in formation efforts for the naturopathic profession (Andres and Carpenter 1997, Billett 1998, Halpern 1994, Kroth 2000 and Stydinger and Dundes 2006). This model facilitates the development of strong classroom relationships that galvanize into enduring professional networks. Such networks and relationships are just what we need in the cranky competitive landscape of so-called integrative medicine these days. But there is more that makes the cohort approach attractive. For example, part-time ND students enter and exit the program with the same set of colleagues. Their collaborations support the growth of a close supportive network of people from various healthcare backgrounds. In fact, diversity within the cohort strengthens the potential of a strong positive learning community moving through a suite of courses and clinical training preparing them for a very special future. Course work includes attention to the art and science of practice management, blending both the theoretical and clinical aspects of professional practice that are applicable in diverse settings among communities across America.
As a backdrop to this potential for growth in ND numbers, the design and deployment of a part-time cohort-style learning track reflect a larger burgeoning demand for more flexible but rigorous programming in various professional fields such as business, the wider spectrum of health and behavioral sciences, engineering and education. In addition to the offerings of public universities in such fields, the remarkable growth of private education providers (such as Argosy, Apollo, Corinthian, Devry, ITT Educational Services and many others) mirrors this demand.
There are other reasons related to professional competition why the development of such program pathways is timely. At the same time that the American Medical Association (AMA) is busy trying to restrict the scope and legitimacy of naturopathic medicine, with the goal of protecting professional real estate and limiting competition, there is strong evidence of an impending and sustained demand spike for primary care physicians (PCPs). Meeting the opportunity to include more primary care NDs through current full-time program capacity in ND programs accredited by the Council on Naturopathic Medical Education will require more than our current applicant pools and graduation rates are providing. We must enhance our capacity to produce more graduates by the strategic careful expansion of numbers. An accredited well-designed part-time track can help in such a turbulent healthcare landscape.
Some observers considered that the January 2006 announcement by the AMA of its “industry consortium” known as the Scope of Practice Partnership (SOPP) constitutes a strategy to exclude NDs and chiropractors, in particular, from the inevitable growth in demand for PCPs. The AMA consortium initially included six national medical specialty societies and six state medical associations. SOPP is about fencing in such growth as exclusive for biomedicine; however, it has had the effect of stimulating more requests from existing healthcare professionals such as DCs and nursing professionals looking to expand their options. They are inquiring about the potential for a professional naturopathic medicine preparation track that includes allowances for prior learning assessment.
A related factor in the growth of interest in professional part-time cohorts was the October 2009 U.S. Department of Labor’s replacement of descriptive language for naturopathic medicine within its Dictionary of Occupational Titles (specifically the language under §29.1011 relating to the chiropractic profession and §29.1199.04 referring to naturopathic professionals), which makes more prominent use of the term physician to refer to these professions. A part-time learning program that renders the naturopathic scope available to holders of other first-professional degrees in the health sciences can boost ND entrants, not only helping with the PCP shortage but also growing the profession at an accelerated rate to meet demand.
That demand is expressed dramatically in the growth of the healthcare needs of roughly 76 million baby boomers who will leave the workforce between 2008 and 2030. There is bubbling political alarm among federal government, state authorities, health administrators and health leaders because 53% of active physicians (excluding residents and fellows) in the United States are 50 years or older. Kletke et al. (1998) were concerned about these numbers a dozen years ago. Even then, their analysis predicted that the number of active U.S. physicians would increase more than 20% between 1995 and 2010. They reported that a growing body of evidence suggested that physicians were going to retire at “earlier ages,” attributing such a shift to “changes in relative earnings, growing concerns about the loss of professional autonomy, and the inability or unwillingness to compete in the new managed care environment” (Kletke et al., 91).
Just what this landscape looks like close-up is relevant to thoughtful projections about what can occur should NDs be increasingly accepted as PCPs. There is a kind of perfect storm of demand and opportunity brewing, and the inclusion of part-time cohorts preparing NDs to take up the challenge could be very timely indeed.Physicians and surgeons held about 661,400 jobs in 2008; approximately 12% were self-employed (Table). About 53% of wage-and-salary physicians and surgeons worked in offices of physicians, and 19% were employed by hospitals. Others practiced in educational services, outpatient care centers and federal, state and local governments.
What is particularly notable is that growing numbers of physicians are partners or wage-and-salary employees of group practices. Organized as clinics or as associations of physicians, medical groups are increasingly attracted to multidisciplinary environments, which recently have begun to include integrative medicine practitioners. At the same time as the need for NDs among such settings grows, allopathic physicians are retiring earlier than in previous years. In fact, related projections indicate that the demand for new U.S. PCPs will reach 300,000 in this decade alone. Coupled with this demographic are data indicating that medical students are not opting for family care or general practice at a time when demand for the general practice PCP is rising. In fact, the percentage of seniors graduating from U.S. medical schools and choosing residency slots in family medicine has declined 53.7% from 1997. The need for family physicians is expected to skyrocket. According to the 2006 Physician Workforce Report by the American Academy of Family Physicians, the nation will need more than 140,000 new physicians who are committed to family practice by 2020.Indeed, strategic documents regarding career and workforce planning indicate than an aging population will boost demand at the same time that patient demand for primary care is on the rise (Figure). According to the U.S. Census Bureau, Americans 65 years and older have increased by more than 5.5 million between 1996 and 2010. In contrast to the general population, they will generate about twice as many office visits to physicians, almost three times as many discharges from short-stay hospitals and almost three times as many diagnostic, therapeutic and surgical procedures, says the National Center for Health Statistics.
Thus, the terrain in which part-time cohort delivery models for ND programs can thrive looks very promising. Let us turn now from what are the potential market considerations to whether these offerings are valid in terms of accepted adult learning theory.As with many other education systems, at the same time that demand accumulates and is sustained across this period, student competition to enter many first-professional programs will be heavy, and admissions for traditional program pathways frequently will be restricted to only the most qualified candidates. Although there is no numerus clausus system in the United States, the relevant professional associations and state authorities are actively concerned about maintaining the quality of professional studies and about balancing the number of students admitted and graduated and the number of accredited programs with the economic and social need for professional services. Foreign applicants in some programs will likely discover that study slots allocated for non–U.S. citizens are very few and that the chances of qualifying to remain and practice in the United States are marginal.
Accepted Adult Learning Theory Rationale for the Part-time Cohort-Style Degree Offerings
Important in any thinking about the need for and the design of these part-time learning pathways is research about adult learning theory. These studies help us understand the nature of cohort students and design meaningful learning experiences for them. The theoretical frameworks available for our review have wide application among professional and graduate studies in American higher education (Andres and Carpenter 1997, Holt 2003, Campbell 1984, Merriam et al. 2007 and Stydinger and Dundes 2006). They include considerations of relevance, practicality, motivation and transformation within the design of educational tracks and learning outcome goals. Most of the theories were developed 20 years ago for adults learning in traditional settings but are now densely incorporated into curriculum planning and strategic program development. Various theories (Cross 1981, Freire 1970, Kidd 1973, Knowles 1977 and 1980, Knox 1980, McClusky 1963, Jarvis 1987, Mezirow et al. 1990, Mezirow 1991, 1995 and 1996 and Houle 1972, 1973 and 1980) are available, and most have something to offer educators in the development and teaching of degree programs that are not offered in the traditional daytime full-time mode.
What these higher-education theorists and researchers tell us is that a carefully planned cohort will respond to well-known learner-centered guidelines for the education of adults who are interested in professional credentials. Cross, Knowles and others have established that adult learners recognize the necessity of the education they are about to undertake and are looking for programs that give them realistic, pragmatic and sustainable access.
- Adults recognize that they are responsible for their own decisions and their own lives. Retention rates are very high as a result.
- Adults enter an educational experience with more and different experience than youths. The need for prior learning assessment and the requirement of a cohort model predicated on service and respect for the learner are essential elements of such part-time tracks.
- Adults are more eager to learn elements that they must know to cope effectively with their real-life situations and expect to apply their new knowledge and skills quickly on graduation.
- Adults are life centered (or task centered or problem centered) in their orientation to learning.
- While adults are responsive to some external motivators (e.g., better jobs, higher salaries and promotions), the most potent motivators are internal pressures (i.e., the desire for increased job satisfaction, self-esteem and quality of life).
The applicability of Knowles’ theory to these modes of offering is shown through the learners’ desire for control, flexibility and feedback. Adult learners value the idea of a “convenient and flexible format and schedule.” For such adults, the role of being a learner is secondary to their other life roles (e.g., practicing professionals, working adults, parents, siblings or caretakers). They want course expectations to be clear and expect pertinent course content to be up-to-date.
In the early 1980s, higher education theorist Cross (1981) provided a framework for considering how adults learn though her characteristics of adult learners model. She identifies two classes of variables, personal characteristics and situational characteristics. The personal characteristics include aging, life stages and developmental stages. The situational characteristics include part-time or full-time learning and voluntary or compulsory learning. Throughout their lives, adults have varying degrees of readiness and ability for learning. The model by Cross reflects the learners’ need for flexibility and control. The theory of margin by McClusky (1963) is particularly relevant for adult learners: M = L / P. His formula states that the learner’s margin for learning (M) is determined by his or her load (demands of living [L]) in relationship to his or her power (or resources [P]). As a psychologist, McClusky recognized that learning is influenced by the adult’s life roles and situations. Learning fits into the margins after the loads are satisfied. Both internal and external factors can decrease the learner’s load and/or increase his or her power.
Mezirow et al. (1990) developed the theory of perspective transformation, which emphasized how critical it is that curriculum must address the changes that occur within the learner during his or her educational experience. This understanding of the nature of significant adult learning provides the educator with a rationale for selecting appropriate educational practices and for actively resisting social and cultural forces that distort and delimit adult learning (Mezirow 1997). The cohort approach addresses this understanding very successfully.
Barriers Addressed by a Part-time Cohort Model for the ND Program
A part-time cohort model recognizes that the best way to motivate adult learners is simply to enhance their reasons for enrolling and to decrease the barriers. Part-time programming pathways will recognize the cohort learners as follows:
- Overall, the particular value of cohort learning is the direct sustained experience of the cohort working together and learning together. However, cohort models need to be carefully constructed because the weighting of content over method is dominant in our learning models for naturopathic medical education.These part-time learners are autonomous and self-directed.
- These part-time learners have accumulated a foundation of life experiences and knowledge that will invariably include related professional experience, family responsibilities and previous education. They need to connect learning to this knowledge and experience base.
- These part-time learners are goal oriented. The classification of goals and course objectives must be done early in the course.
- These part-time learners are relevancy oriented. Therefore, learning will be applicable to their professional work objectives, and theories and concepts will be related to a setting that is familiar to participants.
- These part-time learners are practical, expecting the curriculum to explicitly link content and learning outcomes to the professional work goals ahead.
- These part-time learners demand respect, treatment as equals in experience and knowledge and opportunity to voice their opinions freely in class.
The mechanics of the assumption of time-bound and place-bound learning, coupled with the primacy of content over quantifiable skills outcomes, means that cohort models will not develop organically. Current ND program curriculum mechanics invariably constrain student capabilities. The actual experience of learning is a function of the design of the learning itself. Thus, the design, shape and framework of the learning and the mechanism of the cohort experience (what the group does together and how the group supports the individual within a learning community) are critical elements for successful cohort learning to happen. Fosnot (1996) emphasizes how powerful a focus of the learner’s attention and tasks on application or practical matters can be. The cohort model lends itself beautifully to such a perspective.
David Schleich, PhD is President and CEO of NCNM, former President of Truestar Health, and former CEO and President of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as Vice President Academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia), and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).
American Academy of Family Physicians. 2006 Physician Workforce Report.
Andres, Lesley and Susan Carpenter. “Today’s Higher Education Students: Issues of Admission, Retention, Transfer, and Attrition in Relation to Changing Student Demographics.” December 1997. Centre for Policy Studies in Education, University of British Columbia. October 12, 2007. http://www.bccat.bc.ca/pubs/today.pdf.
Billett, S. “Ontogeny and Participation in Communities of Practice: A Socio-Cognitive View of Adult Development.” Studies in the Education of Adults. 30 (1), 1998: 21. September 15, 2008. Academic Search Elite database.
Bureau of Labor Statistics, National Center for Health Statistics, U.S. Census Bureau. “Occupational Outlook Handbook, 2010-11 Edition.” August 22, 2010. http://www.bls.gov/oco/ocos074.htm.
Campbell, D. The New Majority: Adult Learners in the University. Edmonton: University of Alberta Press, 1984.
Center for Health Policy Research. Chicago: American Medical Association.
Cross, K. Patricia. Adults as Learners. San Francisco: Jossey-Bass, 1981.
Fosnot, C. T. ed. Constructivism: Theory, Perspective, and Practice. New York: Teachers College Press, 1996.
Freire, P. Pedagogy of the Oppressed. New York: Continuum, 1970.
Halpern, D. F. Changing College Classrooms: New Teaching and Learning Strategies for an Increasingly Complex World. San Francisco: Jossey-Bass, 1994.
Holt, Nicholas L. “Representation, Legitimation, and Autoethnography: An Autoethnographic Writing Story.” International Journal of Qualitative Methods. 2 (1), 2003. September 18, 2008. http://www.ualberta.ca/~iiqm/backissues/2_1/pdf/holt.pdf.
Houle, C. O. The Design of Education. San Francisco: Jossey-Bass, 1972.
Houle, C. O. The External Degree. San Francisco: Jossey-Bass, 1973.
Houle, C. O. Continuing Learning in the Professions. San Francisco: Jossey-Bass, 1980.
Jarvis, P. Adult Learning in the Social Context. London: Croom Helm, 1987. Model revisited and summarized in Jarvis, P. Adult and Continuing Education: Theory and Practice. 2nd ed. London: Routledge, 1995.
Kidd, J. R. How Adults Learn. New York: Association Press, 1973.
King, A. “From Sage on the Stage to Guide on the Side.” College Teaching. 41 (1), 1993: 30-5.
Kletke P, J. Escarce, D. Polsky and G. D. Wozniak. “Proceedings From the Association for Health Services Research Meeting.” Abstr Book Assoc Health Serv Res Meet. 15, 1998: 91.
Knowles, M. S. The Adult Education Movement in the United States. Malabar, Fla: Krieger, 1977.
Knowles, M. S. The Modern Practice of Adult Education: From Pedagogy to Andragogy. Englewood Cliffs, NJ: Prentice Hall/Cambridge, 1980.
Knox, A. B. “Proficiency Theory of Adult Learning.” Contemporary Educational Psychology. 5, 1980: 378-404.
Kozulin, A. “Vygotsky’s Theory in the Classroom: Introduction.” European Journal of Psychology of Education–EJPE. 19 (1), 2004: 3-7. September 15, 2008. Academic Search Elite database.
Kroth, M. “Life Mission and Adult Learning.” Adult Education Quarterly. 50 (2), 2000.
McClusky, H. Y. “The Course of the Adult Life Span.” Psychology of Adults. Ed. W. C. Hallenbeck. Chicago: Adult Education Association of the U.S.A, 1963.
Merriam, Sharon B, Rosemary S. Caffarella and Lisa M. Baumgartner. Learning in Adulthood: A Comprehensive Guide. 3rd ed. San Francisco: Jossey-Bass, 2007.
Mezirow, J. Transformative Dimensions of Adult Learning. San Francisco: Jossey-Bass, 1991.
Mezirow, J. “Transformative Theory of Adult Learning.” In Defense of the Lifeworld. Ed. M. Welton. Albany: State University of New York Press, 1995.
Mezirow, J. “Contemporary Paradigms of Learning.” Adult Education Quarterly. 46 (3), 1996: 158-72.
Mezirow, J. and associates eds. Fostering Critical Reflection in Adulthood. San Francisco: Jossey-Bass, 1990.
Stydinger, Nelson and Lauren Dundes. “Over the Hill? A Nontraditional Undergraduate Student’s Uphill Battle.” College Quarterly. 9 (2), 2006. September 16, 2007. http://www.senecac.on.ca/quarterly/2006-vol09-num02-spring/stydinger_dundes.html.