Most PAs do not care to even think about doctoral degrees.

Judging from the reaction to my column ("Doctorate Nurses and Credential Creep") in ADVANCE's November-December's issue describing the decision of the nurse practitioner profession to move toward the doctorate in nursing practice (DNP) as its entry-level credential, PAs remain firmly committed to their competency-based heritage.

Having just gone through the controversy of the master's degree as the appropriate entry-level credential, PAs are just not ready to contemplate the notion of a clinical professional doctorate. That said, there are some significant rumblings within the PA profession in reaction to the news of the DNP degree.

Everyone's a Doctor

The NP profession's step is only the latest in a trend among nonphysician health care professions, including physical therapists (DPT), psychologists (PsyD), optometrists (OD), pharmacists (PharmD), audiologists (AuD), chiropractors (DC) and podiatrists (DPM). Over the past several decades, each of these health professions has decided to elevate its entry-level credential to the doctoral degree.

Why have these professions taken this step? For most of these professions, advancing to a doctoral degree does not mark a radical shift in basic roles-that is, their clinical duties are not substantially different with the addition of a doctoral degree. The underlying motivation is based more in the attainment of professional status and the desire to achieve recognition as full-fledged members of the health professions.

These professions' movements appear to cause substantial controversy, particularly among rank-and-file clinical practitioners, and it seems are driven primarily by professional leaders and academics who are convinced that a move to the doctorate is a means of advancing the profession. A clear component of this phenomenon is a "keeping up with the Joneses" mentality, where the professions attempt to maintain equal status and professional recognition by engaging in credential creep.

A case in point is the PT profession. The evolution of the PA profession has similarities to that of the PT profession. PT emerged following World War II and the polio epidemic of the 1940s and '50s and evolved from a certificate-based occupation to a profession that is now well on its way establishing itself on the doctoral level. PT went through the steps of baccalaureate preparation in the 1960s and '70s, and in 1979 the House of Delegates of the American Physical Therapy Association adopted a resolution to require a post-baccalaureate degree to enter the field by 1990. For the next decade, this decision met with strong opposition from PT practitioners and educators, citing the insufficient supply of trained faculty, a shortage of therapists and the uncertain impact of pending health care reform as reasons not to require a higher degree. Nonetheless, PT education in the 1980s largely moved to the master's degree, and in 1992 the University of Southern California began the first so-called "transitional" DPT program in the United States. The transition is still in progress and remains contentious.¹

Another interesting aspect in the movement of health professions to the doctorate is the process of who is making that decision. In NPs' case, the decision to move to the DNP seems to have come from "on high,"-that is, the decision has been made primarily by the professions' academic and association leaders whose expectations are that academic programs will follow this direction. This appears similar to the experience of the PT profession, where the motivation for a professional doctorate did not emanate from the practitioners in the field.

Is the Doctorate Right for PAs?

In the PA profession, what are the possible reasons to even ponder a doctoral degree as the entry-level degree? One could argue that it does seem to be a logical evolutionary step for a health profession in modern society. Our education is now for the most part on the master's level, and it seems logical to some to grant a doctoral degree to PAs who receive master's degrees. Many PA students now are pursuing courses of study approaching anticipated requirements for a professional doctorate, including original research and other advanced academic requirements.

Another obvious reason is the "because it is there" factor. As we have seen, the PA profession is now just about the only nonphysician health profession not at the doctoral level. With NPs now there, and the frequent comparisons of the two professions, many outside of the PA profession will think that it is only a matter of time before PAs take a similar step.

Questions regarding doctoral degrees for PAs pose very complex issues. One is that there are already two doctoral degrees in medicine (MD and DO), which is the basic discipline of the PA profession. What would the designers of PA doctoral programs plan to do to address this conflicting circumstance?

Another issue is that the PA profession still appears to cherish the competency-based model, one that has served the profession well over its first four decades of existence. Many PAs in practice do not feel a need for an advanced degree of any sort in order for them to remain competent and effective clinicians. The issue of an entry-level doctoral degree for PAs may be one that PAs will have to deal with, albeit reluctantly. In the near future it is probable that some educational institutions will introduce an entry-level PA doctoral degree, and that the initial reaction within the profession will be one of condemnation. Some may attempt to marginalize those programs and their graduates.

Clearly, this issue will be one where many years will pass before any consensus can emerge. Is it premature to ask if it deserves more study and consideration?

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

Reference

1. Plack, MM, Wong CK. The evolution of the doctorate of physical therapy: moving beyond the controversy. Journal of Physical Therapy Education. 2002;16:48-59.