Continuum of Competence
Jay: Next time you sit here please sit in a different place. We looked at the continuum of competence to see how two different approaches to a clinical doctorate might impact those stakeholders. We'll start with team two and go through to team 7 - then come back to team 1.
Short cuts to the result of each team's work: Team 1 | Team 2 | Team 3 | Team 4 | Team 5 | Team 6 | Team 7
Team 2 Report: Entry-Level PA Education
Team 2: Timi Agar Barwick, Patricia Guerra, Pamela Donohue, Cheryl Holmes, Kristen Will, Matt Dane Baker, William "Bill" Kohlhepp
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Clinical Doctorate would impact the various stakeholders during this stage of a PA’s development.
In your breakout area, you will find a slide with greater detail on your stage of the Continuum. This list of stakeholders, issues and key questions was created by the sponsor team in January, and should serve only as a starting point for your discussion.
Part 1: Entry-Level Doctorate
For the first part of this activity, list the major impacts on various stakeholders in this stage of the Continuum of implementing an Entry-Level Clinical Doctorate – meaning that the Clinical Doctorate is the minimum degree necessary to become a practicing PA. Please include both positive and negative impacts for each stakeholder.
Part 2: Post-Graduate Clinical Doctorate
For this part of the activity, again list the major impacts on various stakeholders in this stage of implementing a Post-Graduate Clinical Doctorate – meaning that PA’s can practice with a lower-level degree, but that a Clinical Doctorate is available to them later in their development of competence. Please include both positive and negative impacts for each stakeholder.
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
As you may recall our heroes got two assignments to do this round. We're talking about the impact for either an entry level or a post graduate doctorate in the early phases of PA life. As time gets closer to making a decision for whether to go to medical school or not it might be tougher to do. There might be different requirements. One outcome is that all the quality applicants go to medical school or it could actually increase the quality of our applicants.
Some applicants might think about settling but we could make a case that this might be more prestigious. We did this move once. The premise was to have an impact on the quality of applicants and we don't have the data to show that is what happened when we moved to masters degree.
We would need to know that people could economically afford this.
We didn't see too much change in the post-graduate doctorate degree. We don't have many role models to see this is a good thing.
There was a huge discussion in terms of entry level moving to a doctoral based on credit hours. The more doctoral programs you have might impact your carnegie classification. We might not have enough faculty at the doctoral level trained as PAs so we would need to provide support for existing faculty to move this way; we would possibly need to change RPA standards for this.
Team 3 Report: Early Career
Team 3: Major Patrick Sherman, Lisa Alexander, Freddi Segal-Gidan, John Houchins, Doug Scott, Kathleen O'Connell
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Clinical Doctorate would impact the various stakeholders during this stage of a PA’s development.
In your breakout area, you will find a slide with greater detail on your stage of the Continuum. This list of stakeholders, issues and key questions was created by the sponsor team in January, and should serve only as a starting point for your discussion.
Part 1: Entry-Level Doctorate
For the first part of this activity, list the major impacts on various stakeholders in this stage of the Continuum of implementing an Entry-Level Clinical Doctorate – meaning that the Clinical Doctorate is the minimum degree necessary to become a practicing PA. Please include both positive and negative impacts for each stakeholder.
Part 2: Post-Graduate Clinical Doctorate
For this part of the activity, again list the major impacts on various stakeholders in this stage of implementing a Post-Graduate Clinical Doctorate – meaning that PA’s can practice with a lower-level degree, but that a Clinical Doctorate is available to them later in their development of competence. Please include both positive and negative impacts for each stakeholder.
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
We maybe struggled more than the last group.
When we talked about an entry level degree we thought people probably already have a hard time explaining what they do and who they are and that might be harder if they come out with a doctoral degree. They might have an inflated expectation of their abilities. They are probably going to come out with fairly similar skills as a masters and they might not be as autonomous as they think they should be.
The mentorship might be similar. It could improve credibility and it might make credentialing easier?
We thought it might allow people to think about different career paths and possibly join hospital committees earlier on.
When we looked at the post-graduate degree we thought it would be like the Army and their residency program. They would do that right out of school. There was some general concerns about being pigeon holed too early on. If their degree was associated with that specialty would that help or hurt that?
Residency - specialty training would be more effective and efficient and it could add value to physicians sooner. Would that effect the certification if we did two more years of training?
If these programs now had doctors degrees would that be more attractive and encourage more residency which is more specialty based and not primary care?
Team 4 Report: Mid-Career
Team 4: Bill Leinweber, Major Craig V. Paige, Michael Doll, Harry Pomeranz, Dee Schilling, Dan Thibodeau
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Clinical Doctorate would impact the various stakeholders during this stage of a PA’s development.
In your breakout area, you will find a slide with greater detail on your stage of the Continuum. This list of stakeholders, issues and key questions was created by the sponsor team in January, and should serve only as a starting point for your discussion.
Part 1: Entry-Level Doctorate
For the first part of this activity, list the major impacts on various stakeholders in this stage of the Continuum of implementing an Entry-Level Clinical Doctorate – meaning that the Clinical Doctorate is the minimum degree necessary to become a practicing PA. Please include both positive and negative impacts for each stakeholder.
Part 2: Post-Graduate Clinical Doctorate
For this part of the activity, again list the major impacts on various stakeholders in this stage of implementing a Post-Graduate Clinical Doctorate – meaning that PA’s can practice with a lower-level degree, but that a Clinical Doctorate is available to them later in their development of competence. Please include both positive and negative impacts for each stakeholder.
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
When we looked at an entry level doctorate in mid-career and what it's effects would be. We looked at the stakeholders and pros and cons for each one. For the physicians it could be perceived as a pro as their expectations could change of the PA.
Other providers - comparing the new PA with a doctorate to the mid-level PA would that maybe give them more privileges? There could be some confusion with an 8 year staff PA and a new PA with a doctorate coming in.
There could be increased training but the con would be a fresh person not having the kind of experience the mid-career PA has. The academic association might not allow the mid-level PA to teach but would allow the doctorate level PA to teach. That could be a problem.
Is the employer going to see the doctorate coming in as having more experience? The doctorate might get more money but if we pay salaries based on experience then I can pay a doctorate less than a 10 year PA.
No real pros to the PAEA or PA programs. The con is not being able to teach at the doctorate level. That would be a disadvantage to me a as mid-career PA.
We would need CME to validate competency.
The pro about the NCCPA exam is that it validates competency - the con is, does it really?
AAPA - we would think that the new PA and the mid-level would be valued members. The other pro to the mid-level career PA is the DPA would be charged more membership fees.
Patients - DNP has equal and valued skills. If I am teaching the new PA how to put in a test tube it might be very confusing to the patient.
We didn't get through the other one - only some of it.
Team 5 Report: Late Career
Team 5: Alfrede Provilus, Ted Ruback, Trisha Harris-Odimgbe, Ben Robinson, Steven Lane
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Clinical Doctorate would impact the various stakeholders during this stage of a PA’s development.
In your breakout area, you will find a slide with greater detail on your stage of the Continuum. This list of stakeholders, issues and key questions was created by the sponsor team in January, and should serve only as a starting point for your discussion.
Part 1: Entry-Level Doctorate
For the first part of this activity, list the major impacts on various stakeholders in this stage of the Continuum of implementing an Entry-Level Clinical Doctorate – meaning that the Clinical Doctorate is the minimum degree necessary to become a practicing PA. Please include both positive and negative impacts for each stakeholder.
Part 2: Post-Graduate Clinical Doctorate
For this part of the activity, again list the major impacts on various stakeholders in this stage of implementing a Post-Graduate Clinical Doctorate – meaning that PA’s can practice with a lower-level degree, but that a Clinical Doctorate is available to them later in their development of competence. Please include both positive and negative impacts for each stakeholder.
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
This is a PA provider that has been in practice for 18 or more years.
How would an entry level doctorate impact them? There might be a lot of confusion using the doctoral title in the clinical setting? They might lose that provider if they have to go back to school or they could be forced into early retirement.
Physicians might be threatened by these new PAs? There will be some resistance. Older PAs - would they be grand fathered in? Would there be a bridge? Or would there be nothing at all for them?
If there is a bridge then they need to take time and they could lose wages if they have to go back to school.
There may be a negative impact legislatively. These PAs could be forced to consider early retirement? What am going to do to support my family?
Academic institutions might have increased costs and increased faculty but not necessarily increased resources to deal with these situations.
NCCPA - might have some impact.
A post-graduate degree might be confusing as well. In the work place there could be questions like, "aren't you a doctor now?"
Physicians would want you to have increased skills. Do they come back with more skills or go there with more skills? Preferential hiring is possible.
This is a person that has been working for awhile and what about the new guy? There might be resistance there. Why would they go back to school? They are established. They are retiring soon. Why would they want to change that?
They might be devalued? There might be pressure from employers to go back to school?
Specialty organizations may be able to create programs and increase the number of specialty PAs and that could be a pro or a con. There might need to be a specialty certification.
Team 6 Report: Non-Clinical Roles
Team 6: Felix Nwamaghinna, Rebecca Pinto, Heather Trafton, James Brand, Dawn Morton-Rias, Dick Knapp
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Clinical Doctorate would impact the various stakeholders during this stage of a PA’s development.
In your breakout area, you will find a slide with greater detail on your stage of the Continuum. This list of stakeholders, issues and key questions was created by the sponsor team in January, and should serve only as a starting point for your discussion.
Part 1: Entry-Level Doctorate
For the first part of this activity, list the major impacts on various stakeholders in this stage of the Continuum of implementing an Entry-Level Clinical Doctorate – meaning that the Clinical Doctorate is the minimum degree necessary to become a practicing PA. Please include both positive and negative impacts for each stakeholder.
Part 2: Post-Graduate Clinical Doctorate
For this part of the activity, again list the major impacts on various stakeholders in this stage of implementing a Post-Graduate Clinical Doctorate – meaning that PA’s can practice with a lower-level degree, but that a Clinical Doctorate is available to them later in their development of competence. Please include both positive and negative impacts for each stakeholder.
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
We looked at impacts on things like administrative staff. You are less likely to have a diverse group of students and a less diverse faculty. The skill sets might be different and they might have more responsibilities. There would be challenges coming up with credit courses.
Research - less costly education. There could be less pay with a doctoral qualification.
For the teaching staff you might require a doctoral level training which would be logistically challenging. There might be less pay for teaching.
It adds burden to the faculty.
We thought that degrees do matter eventually. It could also open up opportunities to teach other disciplines.
When we considered the post graduate degree we thought there might be more focused students and a more diverse population. There could be more people going into research and more practiced based learning. There could be a two tiered system.
Key faculty would have a doctoral degree. There might be no possibility of tenured tracks at medical centers.
Team 7 Report: MD/DO Bridge
Team 7: Susan Scott, Dan McNeill, Doug Wood, Fred Sadler, Justine Strand, Cynthia B. Lord
Assignment
The Continuum of Competence model represents a rough framework within which we can explore the implications of a Clinical Doctorate. Each group in this round of work is being asked to focus on only one stage of the Continuum. Your challenge is to explore how a Bridge Program to an MD/DO would impact stakeholders throughout a PA’s development.
Using the current Continuum of Competence as a framework, build a model for a Bridge Program for PA’s to enter Medical School. Use the following questions to help stimulate your discussions:
- At what point(s) in a PA’s career would this happen?
- What would be the new phases of the PA’s development path?
- Who would be involved in each of those phases?
- What new roles or responsibilities would need to be created?
- What issues or questions are associated with each phase?
You have 60 minutes to complete this activity, at which point you will report your work to the rest of the group.
Report
We were asked to develop a model of an MD/DO bridge and we looked at the other group's work as well. What point in a career would this be valuable? Earlier in the career is the right point.
What would this look like? We said it would be 1 year of basic science and 2 clinical years and we would also create a new curriculum. We might negotiate with a medical school to try to pilot a program like this and customize it to work. We want to choose a school with a PA and an MD program already.
The specialties could be things like: primary care, geriatrics, OBGYN, etc.
Preceptors might benefit from something like this.
The big questions is who would come to something like this? Would it create dissatisfaction?
Then we looked at the other option - maybe don't do something like this?
It would cost a lot of money and a lot of time. We already have some of this and it would take people away from the workforce. We have worked hard to get people that want to be PAs early in their careers and now we would be dealing with medical school rejects.
Team 1 Report: What's the Problem?
Team 1: Dana Sayre Stanhope, Bob McNellis, Ayeshia Ellington Pompey, Donna Sewell, Brian A. Timm, Geraldine "Polly" Bednash, Ann Davis
Report
These folks were originally supposed to look at one phase of the continuum but we changed the assignment so it's now, what's the problem we are trying to solve?
We tried to address some of the things that have come up during the session so far. We thought about the potential problems that a doctorate might be a solution for. We are trying to keep parity with other professions. There are some underlying thoughts about the perception of what a PA is. Would it improve respect? What about salaries?
The number of credit hours we have already are similar to many doctoral degrees. We are already between 80 and 100 credit hours and that's similar to what's out there. Maybe we aren't being recognized for the training we already do?
The masters degree was haphazardly implemented. The attempt here is to set the course that would be best for the profession. The current training doesn't have enough science training in it. Maybe adding a doctoral level would add rigor?
There seems to be a growing demand for specialized skills and additional training may be necessary? That could an answer to that problem.
Healthcare is so fragmented and if we could provide coordination to care that could be good.
Some ideas are a primary care doctorate. That would be 3 years of medical school and 4 years of residency training; a general degree in residency.
Some of the goals - what would we maintain? Autonomy of practice. Flexibility and customizability of PA training. Flexibility is one of the key features of the profession. We could debate about the profession's flexibility or the flexibility of the individual. The individual can obtain the training to fit into the clinical setting.
Pluralism - the doctorate could just be one of many ways to expand knowledge.
We want to preserve team based care and we want to maintain clinical competence.
Gaps - the nurses had some gaps; Len pointed out the gaps in the Army approach. What gaps do we have? Growth of new knowledge might demand new needs?
At graduation, some really feel unprepared for certain specialties.
The primary care system is falling apart.
Independent practice is the gorilla in the room. The fear of conflict with physicians is something we're not talking about.
This board is laying out the goals of this session. Where we have been - we started out training PAs in general medicine. What we are doing now is everything. Where do we want to be? Systemic improvements and integrated care to serve the healthcare needs of the nation.
Comment: we always talk about OJT (on the job training). I'd like to recommend we re frame that and say that is advanced training in the clinical setting. Let's move towards that!
Discussion
Jay: Thank you very much! We threw this team together and maybe another team should do this same exercise?
I'm still fumbling around. What problem would a clinical doctorate solve? or what problem is the profession trying to solve?
What's the elephant in the room - is there a problem? Do we have a hammer and we're looking for a nail?
The label is trying to solve a problem. I don't think we are looking at a body of work. How can we meet the needs of our patients and what are we lacking to do that? We're being asked to do more every year as time goes on. This doctorate has muddied the waters.
There is a proliferation of a clinical doctorate and we're being painted into a corner. If we don't come up with a comprehensive response our fear is that it will be used as a weapon. I think we can make a case for our quality and what we already deliver. To have an implication that we're not doing our job or we're inadequate isn't right. We will be prevented from doing what we do well already.
I need to address the point that physicians don't get academic credit for residency.
As medicine advances and clinical challenges emerge are we training PAs to meet the knowledge and the gaps that are there? Think about HIV aids. No one could have predicted the challenges the system would experience. PAs filled many gaps without specialty training in those areas. I wonder if those challenges are clinical? No. They are more system driven and how PAs can adapt to those challenges. Do we need more education to meet those challenges?
I would agree. We need some evidence and some research. The masters degree was an emotional response. We should do this based on some solid research. We don't need a degree for lifelong learning. We don't need a piece of paper to do this.
You have this thing that has been started and you are trying to figure out whether you need what's been done? You have to decide which way you are working. Is there any consistency in the group?
I beg to differ. We're saying the same thing. MDs don't get a degree for their residency but we feel like we value what we do and that doesn't mean society does. I may agree with you but they don't need another degree and other disciplines are getting it. What we feel might not be the issue. We take into account the system and the legislators and all of this.
Our purpose in coming together is that there is a doctorate in existence and we saw what happened for the masters degree. Do we create a policy statement? Is there a purpose for a doctorate? Is there a gap that would be addressed by a doctorate? Let's have a thoughtful approach to this.
Let's not forget the patient. To my perspective that should be what decides what to do. I understand the professional pressures and the dollars. The military was responding to patient needs. Let's look at the right thing - the clinical piece. Is there a gap that we aren't meeting?
The gap is that there isn't adequate care in this country and we haven't sold ourselves properly. The answer is to focus inside and position ourselves to meet the growing unmet needs. What have we not done to provide the data so that congress isn't telling us they want more of us?
The research question is a good one. We have anecdotal information and if we had some best practice models and data that shows the gap - if there is one - that would help. There is a whole lot of information about the efficacy of PAs on the team.
I would like us to address something of the concept of independent practice. I have the impression that some of the driving force is to allow independent practice. I know there is concern for access to care - there is an important consideration for that approach. We're not comfortable talking about it. Should a DPA and a DNP lead to independent practice in primary care? If the answer is yes then we should do that and develop a strategy to go that way.
To move this way there would be a legitimate gap that could be filled by trained PAs at a doctoral level. To preserve the current position is another reason to do it. Competing with other professionals is another reason to do it. What are payers and institutions going to think? That is based on fear and not data.
A goal would be to say we are not going to do that this year.
I have a fundamental question. Should we be telling people what are legitimate options for achieving more knowledge and skills? Philosophically I believe we should create the most options for the most people.
By making a decision and by not making a decision we are making a judgment on why people would make a decision. We can't begin to estimate that people's desires are legitimate or not. We need flexibility. If that makes you happy and you can contribute to the profession and to care that's great. I don't see the threat in that.
I know there is fear of disenfranchised but I feel we are strong enough to open the door and this won't collapse us.
Bob and I have talked about this. When you think about a doctorate that implies ownership in a field of practice that no one can claim. We don't have ownership in medicine. That should strike a major chord with us. We are going to consider a doctorate where we don't have ownership?
We have a responsibility to uphold that. Just because you can't get a DPA doesn't mean you can't get an advanced degree in other things. There is no preventing that.
I just got a doctorate. It's in public health. We're not creating a faux degree. Just like these other professions have the right to do that we have a right to say the same things about the masters level. We have the right to say the masters is what we offer as a terminal degree and that doesn't prevent anyone from doing anything.
We are separate and that's why it's not an articulation model? Now we're saying we're apart and there is some conflict there about how you see yourself professionally.
What does it mean to have a doctorate? You are there in terms of credit already. I don't understand what the resistance is and what the aversion is. There is something that isn't being talked about.
More training is what we like but the name and the label is what is in conflict.
The gap we are looking for - we wanted to treat patients that's what we do. We practice dependently with physicians. If we have some bridge the only gap it fills is to independent practice. We are still going to provide patient care. Why not focus on a bridge so we don't confuse providers and patients.
I did my dissertation on the identity of the PA profession. The identity themes that arose and one of the few themes consistent over time was the linkages to organized medicine and the dedication to patient care. As we brainstorm what is best for us and this profession we seem to have turned inward somewhat. In the past we might have looked towards our partners. We should direct our efforts towards improving patient care.
We have a new generation of people coming into this profession and it would be interesting to know what their expectations are. We had no clue what the future would hold. I looked at the data from students and they didn't seem overwhelmingly interested in the clinical doctorate.
At our organizational meeting some time ago we made a policy statement. We do not want to support the doctoral degree as an entry level degree at all. We didn't discuss a post-graduate degree or another degree. We do not support this as an entry level degree.
I have a doctorate and I only introduce myself as a physician's assistant. Why would PAs call themselves doctors? PAs in the Army are proud to be a PA. Normally we say we are a PA.
I have a doctoral degree and I see patients and I'm a researcher. I refer to myself as a doctor in research and as a PA in practice. There is confusion in the workplace with my colleagues when I do this. There is the potential there and patients need to know that I function as a PA and I do this other work as a doctor.
That confusion exists whether or not you have biased on the role you play. We need to change the culture to understand the difference between doctors and physicians. There are doctors all over the hospital. We have to change the culture to see that you can be a doctor of a variety of different things.
If it aint broke don't fix it. PAs have an 89% satisfaction rate from your practicing colleagues and I would say be proud of what you are already doing. Compared to these other professions you don't find PAs running around wishing they were another profession or had another degree. The reason the degree was given in the Army was that it would be fun and it helps them with their deployment of PAs so they can deploy them longer. Just change the rules and regulations to do the same thing - you don't need a doctorate degree to do that.
If there was any move towards independent practice you would need to change the legislation in every state. We've already won professionally and if we sell ourselves better and keep doing what you are doing things will be fine.
Jay: I'd like to move us to our next activity. The previous round the scenario team developed 6 scenarios and I'd like to offer the opportunity to evaluate these different options. We did our best to type up a cheat sheet for you.
Can you please explain what these are?
The next activity you will select the group you want to work on. We will end at 6PM or earlier. We will do plus minus interesting in this round. What problems does this solve could be the 8th team. We're going to explain what these scenarios are.
1) All programs move to a masters and a post residency training. All programs move towards a masters.
2) Optional program - post graduate doctoral residency within the current system we have now. The Army Way.
3) Entry level doctoral plus or minus a focus on education research
4) All masters but you decide if you do primary care or a specialty. Split entry of a masters in primary care or a specialty - at a masters level.
5) Bridge to MD
6) Redoing the entire system and everyone enters as a clinician and there are different levels of education.
7) No changes is team 7.
8) What are the gaps that a doctoral degree fills (gaps and future gaps)?
Come up and sign up for a team and then sit back down.
We'll take about half an hour. You task is to come up with 4 lists.