Investigating a Clinical Doctorate

Clinical Doctorate Models

Jay: OK. Welcome back. There were a couple of things to mention. There was a concern about dessert not being there. There had better be some chocolate for dessert! It will be available at 2:30PM. One of the factors we try to consider is the energy of the group. We try to offset that by giving you dessert a little later. That will be available shortly.

I did hear concern that we are driving to solutions. Our model of doing these sorts of activities is to explore the options in order to understand the implications. That will include a non-option - no doctorate. We will include this round of work as support material to those recommendations. We want to make sure this has been a thorough vetting process of the options. We will evaluate whether or not these are good ideas.

We will present our work. Each team has five minutes to report. The idea is to have productive conversations in small groups and the ideas are being distributed and embedded by you taking them with you into your next team. Good ideas will remain strong and bubble up.

The order of reports will be the team that synthesized the scenarios to take us forward. They said they didn't do the assignment but did what they wanted to do.

Team 6 Report: Scenario Synthesis

Team 6: Michael Doll, Harry Pomeranz, Trisha Harris-Odimgbe, Freddi Segal-Gidan, Heather Trafton, Ted Ruback

Assignment

In the last round of work, teams developed a wide range of scenarios of possible futures for the PA Profession. Your task is to synthesize those scenarios into a smaller set of compelling scenarios.

Assignment – 80 minutes

Review the variables and the scenario posters that teams developed in the previous round of work. Your assignment is to synthesize the 28 scenarios on the posters into 3-6 scenarios for the future of the profession. These scenarios should have the following characteristics:

a) Distinctive – each scenario should be unique

b) Compelling – each scenario should be bold, challenging and interesting

c) Plausible – each scenario should be believable

d) Provocative – each scenario should elicit a response

e) Strategic Implications – each scenario should imply different actions and behaviors on the part of the PA Profession

Give each scenario that you select a catchy title and write a brief description. Describe the implications for the PA Profession of each scenario.

Note: This activity will have implications for AAPA and PAEA far beyond this exploration of the Clinical Doctorate. These scenarios can serve as a framework for a tremendous amount of future collaboration, exploration and policy decisions. Your work as a team is important, but it should also be considered a draft.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

We came up with six scenarios. We named some of them. One is called Mastery. We create all programs as Masters. If we were to do this one of the major things would be to support the programs that are not offering masters degrees currently. Those programs have a lot of diversity but we want those same students but at a masters level.

We would need to create a bridge program. Making sure the educators had a masters level degree.

We would need to recruit early to do this. We have to show that with a masters we are still providing quality care. We need to do PR and make sure everyone understands this.

Emerging Reality In this scenario we would have the same system but all post-residency programs would be a doctorate. We would need an accreditation program and these would be all clinical doctorates. We would need to partner with academic medical centers and medical schools in order to do this.

What's Up Doc? In this scenario there would be an entry level doctorate - what we have now but you pick a focus. To do this we'd have to educate our education staff and create partnerships. We'd need some legislation as well. In this scenario there would be an increase curriculum development and costs.

To Be or Not to Be At entry into your education process you would decide whether you wanted to focus on primary care or go into a specialty. Your clinical year would be in the sub-specialty. What would certification look like for that? As you enter primary care you would remain for three years or something like that.

London Bridge This scenario is about a bridge to a medical degree. You would have to do full residency. Physician group determination.

Stem Cell - in this scenario the PA profession would go away. Entry level would be 2.5 to 3 years of didactic learning and then you do residency. You would have four years of residency and a fellowship for a senior position.

Discussion

Do you feel this represents a comprehensive list of the possibilities on the table? Are there other options? Do nothing is an option! There is also do nothing but say more about it - there are a variety of things that people add on. Much to do about Nothing is the name!

Would that say you couldn't do a post-grad with a doctoral degree? Does that mean it doesn't exist accept in the Army. Yes - we do not offer a clinical doctorate. That is a recommendation not a determination!

The other thing is that institutions of higher learning make decisions independent of the profession and it's important that the profession makes the recommendation and supports it that but the reality is that institutions may pursue a degree and we have no control over that.

There was a concern that this group could do a lot of work and come out with a non-recommendation; we need to make a firm recommendation at the end what ever it is. We can also influence things outside of our control. Other professions have shown they can influence things outside of their control.

We have to be careful of not supporting something. Post-residency wasn't supported originally. We don't want to fractionate things even more than they are now. We don't want this to backfire.

I'm not aware of any program that is looking at a doctoral degree right now. The fact is that it was the Army where this was initiated but it could have happened anywhere. It might have made it easier that it happened there?

There is something unique about the military - the money is different, the commission is different; they are very clear about why they are doing this - but not many other programs have been this clear.

We're missing the piece of the purpose. Physical Therapy was real clear on the purpose. I'm not sure I've heard what the purpose of the civilian piece is. Once you know the purpose you can do these activities.

What was the PT purpose?

The purpose the military addressed is a generic need. Understanding there is a gap that needs to be addressed in a formal way. It happened to be emergency care and what they did was recognized that as they did this they should give academic credit as well. That same dynamic would occur if there was a gap out there that could help PAs be more effective and more readily move into situations they aren't in now. Then you can decide to provide the training and then provide the academic credits as well.

The stated reasons aren't clear but the discourse is clear. Control and prestige and the story behind the story is important to explore as well.

Our group struggled with that. What we need to write down is what a PA is. What are our goals for the profession in general and if we aren't meeting those goals then how do we achieve those goals? If we aren't meeting those goals then we should explore how to do that. We need to figure out how to get to our goals. We need to identify the goals and gaps - and how to get there. Would a clinical doctorate fix the gaps? Marketplace demand is another factor.

Goals - Gaps and Market Based Demands

The PT group said the amount of money needed in the conversion from masters to a clinical doctorate would be a billion dollars. That's modeling you can work with.

One thing that is most difficult about this is the notion that driving towards a higher level credentialing is a denigration of those that are already in practice. That has to be removed. That has happened before. What does the practice of delivering care demand and that needs to be relevant to where we are going. It could be challenging to remove your own personal views and have to separate that from your responsibility for preparing for the future.

It don't think it's a supplier issue. There may be other factors as well.

It's a good time to remind us of the difference between nursing and PA. We chose to be certified every 6 years. Re-certification is the route we chose. They chose a different route. Don't forget we continually argue about that model.

Can you get clinicians out there in a short time at low cost? To get people out there in a short time to be in practice is a tremendous goal to have.

Team 1 Report: Occupational Therapy

Team 1: Matt Dane Baker, Ann Davis, William "Bill" Kohlhepp, Cynthia B. Lord, Doug Wood, Rebecca Pinto, Pamela Donohue

Assignment

To help us better understand the implications of a clinical doctorate on the PA Profession, let’s explore the experiences of other professions. In your breakout area, you will find an overview of one profession’s clinical doctorate journey. Each team will look at a different profession. (Teams 5 and 6 have a different assignment.)

Part 1: Reading – 20 minutes

There should be a copy of the summary material for each person in your group. Take a few minutes to read the summary. The purpose of this reading is to understand the model that was developed by that profession.

Part 2: “Forced Fit” – 60 minutes

One technique for innovation is called a “Forced Fit” – where you take a solution to a different problem and use it as a template for solving your problem. What comes out of a forced fit exercise is rarely the final solution, but we do tend to generate some new insights and we often understand our problem in a new way.

Your assignment is to use this other profession’s Clinical Doctorate as a template for a Clinical Doctorate for the PA’s. If the PA Profession were to implement a Clinical Doctorate in this way, how would it work, and what would be the implications? Suspend judgment for now – the purpose of this activity is to explore how it could work.

a) First, build a model on your marker board of how the Clinical Doctorate for PA’s would work. When does it happen? Who is involved? How does it work?

b) Second, identify the implications of this model on all relevant stakeholders, including (but not limited to) PA students, practicing PA’s, PA programs, physicians, patients, other professions, PA organizations, etc.

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

We had a long conversation on what the rationale for even looking at this in the profession was. In OT there is a middle man. Someone prescribes that. They had some autonomy and financial reasons for going this way. There was also a perception of having a whole new set of skills.

We had a robust conversation about those motivations for PAs. Our reasons don't fit that. It's enough of a reason to scan and see what other people are doing and whether it fits. The model for OT may be harder to fit.

They looked at it through in a detailed manner. They came up with all of the above! They have two models that exist - an entry level model and a post-professional model.

For the entry level you have a bachelors and you go - but you are not an OT until you go to school for 3 years and you come out as an OTD and then you do some research and other things.

They also have a post-professional OTD and they have a Master's degree. They run from 30 to 45 credits post-masters. That's done part time and online and that will get them an OTD.

We would have to say every entry level program would be some didactic and evidence based medicine and some clinical rotations that are purely elective. The post professional model would be open and involve a variety of courses - bio-informatics and evidenced based medicine and those sorts of things.

Team 2 Report: Physical Therapy

Team 2: Fred Sadler, Donna Sewell, Brian A. Timm, Justine Strand, Dee Schilling, Kristen Will, Kathleen O'Connell

Assignment

Part 1: Reading – 20 minutes

Part 2: “Forced Fit” – 60 minutes

a) First, build a model on your marker board of how the Clinical Doctorate for PA’s would work. When does it happen? Who is involved? How does it work?

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

This was our attempt to force this into a model. It is very similar to the OT model. Is it a bachelors degree and then entry into a certificate. It's similar. That's the entry - they become an OT and they can be a doctor of physical therapy.

People working go back and do anywhere from 12 extra credits to however many they need for a doctoral degree. We talked about credits and how much you need. You need between 95 to 195 didactic hours and from 28 to 32 weeks of clinical experience in the doctoral program (on up to 35 to 45 weeks). The current PA programs are doing that amount now.

We did the when, who, and how for this.

Entry level would need to be in place in 5 years versus 15 years for the transition for buy-in. We would need to get a lot of people aligned and bought in to do this. We would need accreditation and faculty and institutions and regulatory boards and clinicians and PA students and the same would be needed for the transition buy-in. The practicing PA would need that buy-in even more.

Some programs would have to close or redevelop new curriculum and didactic courses in things like Business Administration to do this. Even specialized training - maybe you take extra classes - would need to be considered.

There would be more clinical hours and electives, and for that you need increased faculty and staff (which we don't have a lot of now). Would you integrate the faculty into a fast-track doctoral program to make this work?

There would be the same issues for the transition.

Pros = it forces facilitation and partnerships. Every time you redo curriculum it gets better. These programs make a lot of money. We would improve clinical skills - increased autonomy possibly. We are doing the work and then would we be at the same level as Nurse Practitioners?

Cons = It might decrease the applicant pool. We don't know if we have faculty. Do we need doctorially trained faculty?

Implications = curriculum development, and the faculty. More clinical rotations would be needed; a shift from the competency based model is possible. Reactions from physicians; confusion by the public. Backlash.

The OT actually provides additional masters programs that lend itself to higher learning and increased faculty positions.

PT has a 2020 mandate that all practicing PTs will be at the doctoral level. That has huge implications on practitioners that have been out there for 20 to 30 years.

One of the schools did it and there you go. That's what started us down this path. The amount of time we were already putting in lended to it. The chiropractor and athletic trainer and massage therapist have autonomy. We have people that can't come in to see us but they could see a massage therapist.

What was your motivation to make people go back to school? How can you force practicing people to go back and get more education?

You have to change the licensing laws and we have set the groundwork for that to be done by 2020.

Fill in the blanks is what is needed in transition. We decided to clarify the difference between the doctoral students and the other levels. The focus in the doctoral level degree versus the masters or below - below is focused on treatment and in a doctoral program we are focusing on diagnostics. That's the difference.

The difference is the push for autonomy and that's different for us. I feel like I am autonomous but not independent. That's a crucial difference between a PT and a PA.

There may be implications - we want to be sure about the level people know what a PA is and what we do.

A profession can make a recommendation but they can't make it happen. You have to have legislation changes to make things happen. People have the right to practice. There are constitutional issues to consider as well.

People do not have direct access. Those clients aren't being able to sustain themselves.

Team 3 Report: Nurse Practitioners

Team 3: Geraldine "Polly" Bednash, Bill Leinweber, Ayeshia Ellington Pompey, Cheryl Holmes, Patricia Guerra, Steven Lane, Dick Knapp

Assignment

Part 1: Reading – 20 minutes

Part 2: “Forced Fit” – 60 minutes

a) First, build a model on your marker board of how the Clinical Doctorate for PA’s would work. When does it happen? Who is involved? How does it work?

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

The nurse practitioner model is that by 2015 all new people would have to have a DNP. You would have to have an RN and have a masters degree. Whether they do a bridge is optional.

Using that model for PA would require a DPA at a point in time (say 2020); curriculum design would look at the gaps and then put it into the model of PA competencies. This would include systems based practice, more emphasis on health IT, the team concepts; the bridge program would add those gaps as well.

We realized there is a difference between when nurse practitioners talk about specialties and when PAs talk about specialties. They are talking about population and not specialty practices.

The program would need more robust specialty rotations; more clinical decision making (possibly independent). Get your generalist training and then get your DPA?

The pros - higher level of skills and by being doctorially prepared would relieve the burden of specialty based training on the job.

Will this impact the diversity of the profession? Would it impact the movement between specialties? There will be an impact on faculty. Will we abandon primary care? There might be more costs and student debt incurred.

There is the physician concern about movement towards more independence.

We need to collaborate with physicians on this. We would need a transition plan that brings the major organizations together. Stakeholders barely got started. With ARCPA we have to work on the standards of education. PAEA would have to deal with faculty recruitment and clinical sites.

CME and member benefits are implicated.

Team 4 Report: Social Work

Team 4: Dana Sayre Stanhope, Bob McNellis, Susan Scott, Patti Pagels, Maura Polansky, Lisa Alexander, John Houchins

Assignment

Part 1: Reading – 20 minutes

Part 2: “Forced Fit” – 60 minutes

a) First, build a model on your marker board of how the Clinical Doctorate for PA’s would work. When does it happen? Who is involved? How does it work?

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

In the social work model if we were to fit us into this it would be an optional post - graduate degree. It would only be for those interested in it. It would be institutionally determined - each institution would decide if that is something they want to offer. They had a lot of latitude on how they set that up.

It was prescribed. 2 years full time - taking people out of practice.

The reason would be to create stewards of the profession. It would include the history of the progression and how your profession fits into the overarching system. It would prepare you for career advancement in many areas. You could put tracks in if you wanted to. They could do a health policy component too.

It's not about patient care but about the other pieces of an advanced degree. If you talk about existing programs it would be to get more practicing folks. It's more to give them an overall perspective on the practice and a broad sense.

There is latitude in this approach.

PA students would have options - they could go all the way through and get a doctorate in whatever area they thought fit them. Practicing PAs would not be required to do this.

It's relevant but it takes people out of the practice arena. There would be limited opportunities to improve patient care. They would show up with on the job training. What are the cost benefits? We could be better players in the healthcare arena. We would have that degree and could sit at the table and maybe talk about who we are better and what we can do.

The physicians might feel threatened. Maybe we understand systems based practice and how to bring additional revenues into a practice? It minimizes the threat of the degree.

It may remove clinicians from the work force.

It seemed like social workers needed additional prestige. There wasn't any external need. No clear improvement of clinical skills and it may take people out of the faculty pipeline.

Some people thought that people coming in with doctorates of different types give them a richness and a diversity. If they streamlined into one thing they would lose that diversity.

Team 5 Report: MD/DO Bridge

Team 5: Ben Robinson, James Brand, Dan Thibodeau, Doug Scott, Alfrede Provilus, Major Craig V. Paige

Assignment

To help us better understand the implications of a clinical doctorate on the PA Profession, teams in this round will explore the experiences of other professions. Your assignment is to build a model of a “bridge program” for PA’s to enter into Medical School.

Assignment – 80 minutes

A popular idea among PA’s in our surveys was a “bridge program” to facilitate PA’s transitioning into Medical Schools. This approach designates the MD/DO as the terminal degree for Physician Assistants to become “doctors”.

a) First, build a model on your marker board of how the Bridge Program for PA’s would work. When does it happen? Who is involved? How does it work?

b) Second, identify the implications of this model on all relevant stakeholders, including (but not limited to) PA students, practicing PA’s, medical schools, physicians, patients, other professions, PA organizations, etc.

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

If we had a bridge to an MD or DO school the prerequisites would be you would have to go through an accredited program, graduate, take PANS, get certified and practice a few years as a PA. Once you finish that we had a suggestion to apply and gain acceptance and take USMLE step 2 and that qualifies you for some clinical practice. If you were accepted and passed USMLE step 2 you would go to medical school and do the same 2 years of didactic education. After that you would pass step 1 and have one year of clinical rotations. That would allow you to qualify and apply for residence.

That was the model we used.

USMLE step 2 - we felt the clinical practice would be evaluated and that gives you an expedited pathway into residency.

Looking at the pros we said it would satisfy the needs of the PA society and other professions. It could decrease the cost of medical school by decreasing the length by 1 year. This could possibly improve access?

You would have a more improved resident and that would improve the MD / PA relationship. You are only talking about one year less with this model.

The implementation factors are huge. Accreditation is important and the other buy-in would have to come from medical schools themselves. There are many programs that don't have an affiliation with medical schools. How would we bridge that?

We're talking about a large amount of school tuition. This might dilute the number of practicing PAs.

Could this resolve workforce issues? Could we direct these applicants into primary care?

This really makes the MD/DO less attractive to the residency match. If they come right out of medical school versus a PA that is more attractive because they have some experience that could be an issue.

The two years of the didactic learning is that needed? Could they have faster tracks? Are there programs doing this now within the US? No.

One size does not fit all. Some schools have strong basic sciences and others not as strong. Can we say it's a one for one? No.

One option we threw out is, "could this be advanced placement? Could you test out?"

One of our concerns was this was a compromise to get AMA, and AOA and ACGME and AAMC all buy in. These PAs have had equal or better clinical experience in two years than a medical school student has in 4 years. You would need a lot of buy-in for this to happen.

There could be an online format for courses that you haven't had. For the courses you have taken there could be some review board and if you pass the USMLE then that's a threshold that supports moving on.

2 years didactic seems long in that world.

Medical schools are moving away from the didactic as well. One size will not fit all in this model.

One thing that irked me about this model is policy makers challenging us to make people repeat learning they already have. Why do we make them do it again? If you need to assess it go ahead and do that. Some states actually mandate that we give people x number of credits if they have been in a community college course.

Legislation might want to get involved. We are hearing that we don't want people to be in college for more than 4 years.

Are we creating a separate medical school for PAs? Who would accredit that? Are we are talking about giving people credit for things they have done? Will they match into a residency program? Those two years of basic sciences would match medical school to get buy-in from stakeholders.

The bridge idea has come up countless times. This is a very important thing to consider. This is a partial solution to the shortage of physicians but it doesn't seem to fit any issues that PAs are facing as a profession.

There were a lot of comments about doing a bridge in the survey. It's a direct response to the doctoral degree for PAs and the MD or DO is a way to do this.

It would have been helpful to have another model out there.

For all the talk about the specialty training - what has happened to more specialization? That's created part of the problem. I'm talking about structurally. You aren't an orthopedist but you are a hand and hip doc now?

Has that resulted in a reduction of mortality? Has it resulted in higher costs and better patient outcomes?

Team 7 Report: Army EM Postgraduate Doctorate

Team 7: Major Patrick Sherman, Felix Nwamaghinna, Dawn Morton-Rias, Timi Agar Barwick, Dan McNeill

Assignment

Part 1: Reading – 20 minutes

Part 2: “Forced Fit” – 60 minutes

a) First, build a model on your marker board of how the Clinical Doctorate for PA’s would work. When does it happen? Who is involved? How does it work?

c) Plus-Minus-Interesting – Finally, create a list of the pro’s of this model, the con’s of this model, and the interesting insights you had or features of this model.

Your team will be invited to lunch during this round of work. At the end of this round, you will share your work with the other groups.

Report

Ours is the best. Thank you.

We started out detailing the current requirements and their structure. In order to do this you need an MS degree, experience, GRE, and a sponsoring institution. That didn't have to do with the GPA but the GRE. There were requirements that we would not face. For instance, sign off by your commander. They also have a specific patient focus - mostly males of a younger age.

They have 18 months and a required research component particularly with the surgery component.

If you compare what we are giving in post-graduate residency programs there is no difference yet they are receiving a certificate of completion while the Army folks are receiving a doctorate.

All residency programs would already qualify for doctorate level training.

The pros have been said before. It fills a gap in healthcare. The perception of patients and physicians could be a plus.

The con is the cost and perception is that it would polarize the profession. By the year 2012 or 2020 it may unify the profession - we just don't know.

We would require an MS and 18 to 24 months of training. It's not a 4 year deal but a 2 year deal. Add the masters plus the additional 18 to 24 months and that equals 4 years. Experience is required here but we talked about no experience as well.

Different institutional focuses would be surgery, EM or primary care? The curriculum would be intense and research would be institution specific.

We don't know about an applicant pool here. There could be none or a lot.

Who pays? Are they going to pay tuition or are they going to be paid to go to school?

Introduction to the Continuum Model

Jay: We've been working with the National Alliance of Physician Competence. It's a real organizational mess.

We're also working with ABNS on some research issues regarding certification.

We have another lens to look through yet today.

We met in January and we developed a framework we call the continuum of competence. We did something like this with the physician group and it seemed appropriate here as well. This is a rough outline of how competence is developed and maintained throughout the life of the PA.

There are several phases. Pre-PA education and then a decision point. There is a didactic phase, a clinical phase, you get certified, licensed, and move into practice. The first six years are developing and working closely with a mentor. We call the mid-career different - more established and more confident and establishing a peer relationship with the physician you work with.

Late-career you might even reach some level of mastery.

Throughout your career there are these other paths that one might take. You might take on leadership roles and non-clinical roles. For many PAs that becomes the focus outside of the clinical work. Throughout your career there are these additional resources to enhance your skills.

We've plugged in here the potential for some clinical doctorate.

Each of these phases have a whole bunch of stakeholders. Each of these phases of a career has a number of issues associated with it today. Some of them might be things you've brought up today.

We've divided you up into groups to focus on each of these phases and look at issues identified by the sponsors. Are those the issues? What other things are PAs and other stakeholders struggling with? What would be the implications of an entry level degree and then look at a post-graduate option as well.

Based on our last conversation we thought we would have team 2 take two phases at the same time. Team 1 will have a different assignment about identifying the gaps in knowledge and skills involved in future practice. What's the need? What are the gaps, what are the goals, and what problem does this solve?

Team 7 you can look at the bridge model and map it or adjust it to show how this would change if there was a bridge program. We've got about an hour to do this. Take a look outside as well.

Physician Assistant Collaborative Design Session