Plus, Minus, Interesting
Assignment
We have now explored the implications of a Clinical Doctorate from a wide range of perspectives. As a way to consolidate our exploration so far, let’s evaluate in detail the options that are on the table.
Each team has been assigned a different option. Your assignment is to make four lists on your marker board. Come up with 10 or more items in each list.
PLUS |
MINUS |
INTERESTING |
PROBLEMS SOLVED |
What are ten or more benefits of implementing this option? |
What are ten or more negatives about implementing this option? |
What are ten or more interesting ideas, insights, and possibilities offered by implementing this option? |
What are five or more problems that this option solves? |
You have 30 minutes to complete your work. You will report your lists to other groups.
Short cuts to the result of each team's work:
Team 1 | Team 2 | Team 3 | Team 5 | Team 6 | Team 7 | Team 8
Team 1: Mastery
Report
We looked at the Masters degree as the entry level degree. We would have to standardize all the PA programs to do this. Everyone would be at this level. That would give us some stability and standardization in the educational community. Having this as a terminal degree would make the argument of tenure a bit easier. It would be less expensive than a doctorate.
Doing this would increase costs. Our concern would be about decreasing diversity. Practicing PAs could go back to school to get a Masters. We could have a bridge for them to do that.
We don't know exactly what a Masters is - our thought is that it should be an MS.
83% of the programs already have Masters programs and 80% of practicing PAs already have Masters degrees.
The focus could be different in each programs. The capstone could have some leeway. Different programs have a research component or a project (a community project or a thesis). It's up to the program to figure out what that is. That gives some flexibility.
Public perception could be improved and it could create standardization. That would allow a uniform understanding of what a PA is. The professional identity would be clearer and accreditation would be easier.
DNPs may exploit the differential and the fact there is a lack of a doctorate in the PA world - that's a con.
The diversity issue has been an issue. The balance has changed in under-represented minorities. We're not any worse than medicine and we're not any better.
Current PAs that don't have a Masters would be required to get one and there would be a bridge for that. There would be a bridge from the associate or baccalaureate to the masters.
It would be mandatory to have a Masters degree.
When you give rights to a certain group of people it 'forces' others to do something.
Team 2: Emerging Reality
Report
We looked at having an optional post-graduate doctorate training. The entry level would be a masters with an optional doctorate.
The pros - this is a system we already have in place however there are no private sector residency programs and we'd have to create them. We would have increased education and skill sets. You would be rewarded for the time but we still have that question about, "why should you receive credit for residency when that's not done for physicians?"
This is optional so it would be a compromise.
The career options might increase. We thought it would be a positive because you could be specialized but that could also be a negative.
On the con side we aren't sure about how attractive it would be for applicants. Would anyone go for this?
We have 5000 graduates and only about 100 residency slots - that's interesting.
Admission requirements would be higher. We thought it would be a con for an established PA to go back to school so something like this would be favoring younger PAs.
It may be creating confusion in the field.
How are we going to accredit this? Are we going to create our own program to do that? We have an accrediting organization and we don't adhere to ACGME rules (accept practicing hours).
Would this result in financial reward for the person doing this? You will have to have a masters to do the doctorate.
This could mitigate problems with physicians.
Clinical training would be a positive. It would satisfy the 40% of the PAs that are interested in this. It could address the 'fear factor'.
This could meet the PA faculty supply/demand need.
The military came up with the solution called advanced, specialized training. That might solve a problem in the civilian world.
How many people have taken advantage of the NE program? We don't know.
We're kind of saying this would be for new grads. A lot of us have taken advantage of the NE program that has allowed us to get a masters degree. If someone develops a portable doctorate program and you can get credit for the work you are already doing that would be interesting.
You pay for getting college credit for the work you do at home. You also take classes online. That's a little bit of an idea - pay them to not do anything. YOur employer is doing the work.
It might work for education and admin and those parts could be done online.
If this is a clinical doctorate you will have to go somewhere to get that training. If it's an academic doctorate you can do that online.
If we have 40% of the people that want to do this but they don't want to leave their institution then make this like NE. There are a lot of criticism of the NE program. It doesn't expand clinical skills.
Team 3: What's Up Doc?
Report
Most of this is speculation since we don't have any data to support these ideas. Most of this we have no evidence for. This is making the clinical doctorate the entry-level degree.
There is some potential that this might standardize current PA education. We could increase the skill sets. There could be greater prestige. Would it increase compensation? Some people believe it would.
Most of us get doctorates later in our career so with this younger people could be attracted to this earlier.
The number one thing is that it would level the playing field.
The cons are it would increase the length of time and the cost. It might impact diversity. The title confusion is something we've talked about. Will there be enough faculty? Would it have a trickle down affect and would there be an impact on clinical sites?
Legislation - would new legislation be passed requiring this?
Doctors are not in favor of this. Would this be a disincentive to go to rural or under served areas?
In our history we've been humble and we've known we are a dependent practitioner. Would going to a doctorate change that?
Would there be an increase of time? UC is actively developing a 3 year Baccalaureate to MD program. So the time thing could be challenged.
The humility of the profession - people are attracted to the profession because they know that there is a pay issue (we're not going to make as much money) but the time element may be the same as a doctor.
This possibly allows you to be a fuller member of the team.
You were talking about impacting legislation but could this also impact insurance companies and the way they look to reimburse? Do you have to have a doctorate to get full reimbursement? There are cons if you don't do it and there are cons if you do it. It's a double edged sword.
We already have provider status. In PharmD everyone is now a Pharm D and the institutions are making people get a higher doctorate to be higher than their associates.
The interesting thing is that this is an emotional and a knee jerk reaction. It's forcing the conversation. There is resistance among most PAs but we're getting encouragement.
The market may drive this no matter what we do. This could become diminished if doctorates become available online.
There could be a diminishment of prestige.
Other professions are not happy they did this. The nurse practitioners are the only ones that are encouraging us to do this.
Problems solved: Most think it would help with respect. The main thing is to maintain competitiveness
We will end this discussion! that's the number one problem we solve.
Team 5: London Bridge
Report
We tackled the MD/DO Bridge program.
The pros would be: We’re unclear how many would exactly go. My class had 5 PAs that went to medical school. It’s not a huge number, it’s 4%. It’s was a way to shorten their training. This idea is popular in the blogosphere because it satisfies a need.
It’s a way for people to make a career choice. Creating this in a medical school would require innovative curricular techniques. You might have to create a special track, which might have benefits across the entire medical school. It allows a good clinician to be happier.
It takes longer to train. It now takes you 5 years instead of 4. What would be the motivation for a med school to do this? Would they be willing to give up tuition? They would have to work with LCME to get a program approved? The curriculum committee might have to change. And it could be a pain in the ass. And there is no net new clinician produced. But you have created a new health care provider, which does not address the provider shortage.
It might make an interesting experiment for a med school to try this? You could evaluate it every step along the way; assess people before they came in and after they finish. If you had grant funding, it could be a way to increase providers in areas where there are shortages. Some PAs already go back to med school, but it is still the most expensive way to become a doc. It could be useful to test people in USMLE one and two in this kind of a process.
The problem we’re trying to solve is that some PAs want it. It would be an answer to the question of a clinical doctorate, instead of a separate PA doctorate.
If you've gone through PA school, and worked as a PA, and then you go to medical school after 10 years, would you be a much better physician because your skills would be more refined? Yes. My sister did that, and she was an exceptional student, and she’s a better physician because of it. Her interpersonal skills were very astute. She was very patient-centered.
Why a separate track in med school? Could that create a second class citizen?
Yes, we heard two models yesterday. Our group agreed that it needed to be a separate track, and that could be a con.
This is similar to articulation of people in different tracks. Some schools keep them separate, and some schools integrate them. The ones that integrate them, the PAs shoot ahead, and threaten the entry level students.
If we could bring PA students in who had all these life experiences, they could facilitate the clinical assessment courses for other students.
Team 6: Stem Cell
Report
This means generally that everyone starts off as a PA and then differentiates.
Everyone starts off with a baccalaureate. At month 28 people can branch off and become a PA, or they can stay in residency to become an MD.
People who choose to continue to go forward can complete 12 additional months, about 40 months total, or 3.5 years of medical school. So the whole thing is 36 – 42 months.
You can get a limited generalist license as an MD at that point. Or you can stay on the train for 3 – 8 years more and do a residency.
The PA is still dependent. The MD is not dependent, as a generalist.
Training everyone the same for the first 28 months gives tremendous opportunities for inter-education Everyone would get the same core curriculum. There would be a boost in acceptance of the PA role if we do something like this.
There are economies of scale as well. Everyone starts off the same.
This can only be done in medical schools or academic health centers. It would require very large classes.
There is a more defined career ladder. You can get off the train any time you want.
Rather than highlighting the degree, it’s about the time. If you stay longer, you get a higher degree and scope of practice. It also allows you to delay your career decision.
If we did this, we could put all PA educators out of business. But there would need to be PA role models in the system.
On the Con side, I think PA applicants are different than medical school applicants. As long as we have a differentiation in the admissions process it could be ok. Everyone would have to take the MCAT, and some would not want to go that route.
Today the way we train PA students is different. I’ve always felt we should train differently, so I have some concerns about having the training be the same. But this will allow for people to choose different paths.
What we’re solving is that we take the whole degree issue out of the equation. I think there is potential for some built-in respect, having been through the same curriculum. Our program combines the anatomy program with the med students, and we think this helps. There are some programs like Iowa where PAs take most courses with Med students.
The 28 months includes clinical work.
Medical school is 48 months. But medical schools are considering shortening it. The 4th year of medical school is useless, so we just built that concept into it to come up with 3.5 years. One of the pros is that we can get more people in primary care this way. You’re going to get a generalist. But a lot of insurers want board certification. This person would have to be adopted into certification and credentialing and into hospitals.
Team 7: Much Ado About Nothing
Report
No Change – No Doctoral Degree
What are the advantages of changing nothing? “First, do no harm.” This is a moment of opportunity for our profession – this is a chance to redefine ourselves. Patients don't care as long as they get good care. We have an open and diverse model that has proven itself to be adaptable over the last forty years. This is a chance to build solidarity. We can invest resources in developing the profession rather than developing doctorate programs. This is a chance to focus on the good of society and not ourselves.
What are the disadvantages? It will build confusion among different types of providers for outsiders. Students feel they need higher degrees. This doesn't address the needs of the huge percentage of PAs who practice in specialties – there’s a gap in knowledge from our training to the needs of specialty practice.
What is interesting about this approach? Things may evolve without our input anyway. Maybe this is just something that will happen in the military? We feel that there are other, more pressing needs in the profession.
What problems does this solve? It fills an analysis vacuum. It does NOT solve the problem of higher compensation or increased autonomy. This approach does maintain our ability as a profession to respond quickly to market forces and health care needs. There are still other pathways to knowledge.
There are a number of things to do in the context of “doing nothing”. Better communications and branding. Better endorsements from medicine. Work with CMS. More funding for programs and students. Do more research into the PA field. Enhance HIT training. We need to develop enhanced training opportunities for specialty practice.
We should make other academic options more available for PAs – other residencies and doctorate programs.
Do we already have the credits required for a doctorate degree? What else would need to be added to our programs to make them doctorates?
Team 8: Gaps/Future Gaps
Report
We created a list of reasons why we shouldn't do it. We started with some themes, because we have been so successful in settings where we were placed, others have seen the PA model for that setting. As we move to new practice settings, it seems that we may not be preparing PAs for these settings.
A concern is that maybe every PA program is not training every PA for every setting in which they may need to practice.
Outside forces are driving this conversation, but we need to set the course ourselves. As we’re looking at the need for different vehicles, we need to rely on other educational vehicles.
What is it that PAs are doing, and how does the educational model work? People need a way to assess our education process and results. We felt that there is a disconnect between the need for knowledge and skills, and for a piece of paper. The investment needs some form of recognition. This opened new opportunities. Is it training that opened the door, or the degree? We weren't sure.
We talked about a strategy to engage physicians in the conversation. We need to train physicians to provide the additional training. We need to make a statement that a generalist fund of knowledge is key to helping us adapt to primary care and specialty. The current language is not acceptable. We need to prepare PAs for emerging health care needs. We should make a statement about the terminal degree for PAs.
We need to embrace innovation.
The physician paradigm is, the more degrees you get, the further you are from patient care, and we thought that was a bad thing for the PA profession.
There are lots of ways for people to get new skills. When we trained there was no HIV. Now there are lots of PAs working in HIV care. As we look at the evolving diseases, we know we will need new training settings. These do not have to be connected to a degree.
