For the PA profession, continuing debate about doctoral degrees, like the arrival of a PA doctoral program, is inevitable. With pressure mounting from the increasing number of institutions implementing doctorate of nursing practice programs and other clinical doctorates, it is only a matter of time before some educational institution sees a similar market for PAs. I say market, because higher education is fundamentally a business and thus is always in the market for new markets.

For a competency-based profession that clings to that structure and still is adjusting to the master's as the entry-level degree, the introduction of a PA doctoral degree will unleash a stream of reactions likely to range from annoyed to convulsive. Yet it will be only the latest of the health professions to introduce a clinical doctorate (as opposed to the traditional academically based doctorate), and it marks an increasingly controversial trend in U.S. higher education.

Doctorates: Who Drives Interest?

A few generalizations about the clinical doctorate degree in the health professions: Clinical doctorates in several of the health professions have emerged primarily from the professions' organizations and not from the rank and file. This certainly is the case in advanced practice nursing.¹ Practitioners in the field are unenthusiastic, and similar sentiments have been observed thus far in the PA profession. Another point is that institutions of higher education clearly have a vested interest in offering clinical doctorates, because they tend to increase enrollment and thus tuition and, since many use distance education technology, are low-overhead operations. For these institutions, it is a good business. As one article puts it, "Professional organizations want to raise the status of their professions; universities want their enrollments to increase, or at least not to decline. Neither side can objectively evaluate clinical doctorates."²

Traditionally, professions attempt to ensure the quality of new professionals by requiring them to pass a licensing exam and by allowing only graduates of accredited programs to take the exam. Yet this requirement is not always tied to the receipt of an academic degree, as we have seen in the PA profession for the past 40 years.

The organizations of some professions-for example, physical therapists-have pushed for clinical doctorates even though members' support of such degrees has been lukewarm. The organizations argue that doctorates raise the status of the profession to the highest level, on a par with physicians, dentists, pharmacists and now with most other health care professions.

Questions About Implementation

Critics note that clinical doctorates often are little more than fluffed-up master's degrees. Typically, little or no research is required for clinical doctorates, and educational institutions in some professions other than that of PAs generally seem to have lowered their standards for the conferring of such degrees, seemingly at the behest of the professions' organizations. Many universities have been willing to offer clinical doctorates, in spite of their reservations about the degrees' academic credibility, because they fear if they do not, students in the field will attend other universities that do.²

Staffing is another practical consideration. All educational institutions considering sponsoring a PA doctorate would require that the faculty have doctoral preparation themselves. That would pose a problem, since there are few doctorally prepared PA faculty as it stands now. Results of a recent survey of PA programs revealed a projection of "minimal growth in the number of doctorally prepared faculty beyond 2010."³

The PA profession historically has been degree-adverse, basing its educational standards on competency measures rather than on the attainment of any particular academic degree. That has changed to some extent over the past 15 years with the movement to the master's degree, which has become the de facto entry-level PA degree.

In some professions, the accrediting organization plays a role in determining the degree or degrees within the profession. In the PA profession, this certainly is not the case. The position of the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and its predecessor organizations was, wisely, to refrain from specifying any type of academic degree for PA education, and it laid low in the profession's wrangling over the master's degree. Only near the end of the debate did ARC-PA indicate that PA education should be on the post-baccalaureate level.

How Now, Doctor PA?

Doctoral degrees for PAs could take several configurations. One obviously would be an entry-level doctorate, probably a three-year curriculum that adds some additional course work to the standard PA curriculum. Another would be a so-called "completion" degree, an add-on model intended for PAs in practice who hold a master's degree. Yet another could be conferring a doctorate upon completion of a postgraduate residency program. The question is whether any of these programs would provide graduates with any more clinical capabilities than they can obtain now in non-doctoral education.

A notion that seems to loom over this doctoral discussion is the movement, already well under way, of advanced practice nurses obtaining doctoral degrees. Lest anyone doubt the intent of the nursing profession, APNs have declared that the nursing practice doctorate will legitimize them to become fully independent practitioners in primary care.¹ While many PAs will decry the PA doctorate and will resist the idea of doing it simply because the NPs are doing it, nonetheless it will be difficult for the PA profession to sit idly by while APNs obtain doctorate degrees and attempt to establish themselves as America's primary care providers.

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.

References

1. Mundinger MO. Advanced practice nurses: the preferred primary care providers for the 21st century. In: Showstack J, Rothman AA, Hassmiller SB, eds. The Future of Primary Care. San Francisco, Calif: Jossey-Bass; 2004:chap 7.

2. Siler WL, Randolph DS. A clinical look at clinical doctorates. Chron High Educ. 2006;52(46):B12.

3. Orcutt VL, Hildebrand A, Jones PE. The doctoral pipeline in physician assistant education. Journal of Physician Assistant Education. 2006;17(1):6-9.