Degrees of Latitude: Real Issues Behind Clinical Doctorates

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”