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Original Research

Curriculum essentials of an entry-level PA doctoral degree

Kayingo, Gerald PhD, MBA, MMSc, PA-C; Gordes, Karen L. PhD, PT, DSc; Jun, Hyun-Jin PhD, MSW; Fleming, Shani MPH, PA-C; Kulo, Violet EdD, MS; Cawley, James F. MPH, PA-C

Author Information
doi: 10.1097/01.JAA.0000791472.67605.f8
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Abstract

The prospect of an entry-level terminal doctoral degree has gained increasing attention in the physician assistant (PA) profession.1 Moreover, new post-professional doctoral programs intended primarily for already-certified PAs have emerged.2 Globally, healthcare professions education is rapidly evolving to meet the increasing demands of patient care, shifting delivery models, technological advancements, and evolving epidemics.3 For example, medical schools now are incorporating healthcare delivery science as a new curricular subject. Schools also have moved to early exposure to longitudinal clinical clerkships and increasing numbers of programs are offering accelerated, 3-year medical degrees.4 Other professions, such as nursing, pharmacy, and physical therapy, have responded by moving to entry-level doctoral training with expanded practicing competencies.5

Although intense discussions about doctoral education have taken place in the PA profession, particularly around risks and benefits, little dialogue has focused on the essential competencies and curricular elements that would be appropriate for this level of PA education. This is similar to the curricular picture for several existing post-professional PA doctoral programs, which tend to have variable curricula without standardization for obtaining a degree. We wondered what an entry-level PA doctoral curriculum would look like. This study was undertaken to address the question of what curricular elements, training, and competencies would be desirable should the PA profession advance to an entry-level doctoral degree. For this study, entry-level terminal degree means the highest and final degree required to be licensed for clinical practice—for instance, a master's degree for PAs, PharmD for pharmacists, and DPT for physical therapists.

METHODS

This mixed-methods study consisted of a national cross-sectional survey and a series of semistructured interviews designed to capture stakeholders' views on the essential curricular elements for PA doctoral education. Survey study participants were recruited through two mechanisms: the American Academy of PAs' (AAPA's) PA Observations Service (www.aapa.org/research/pa-observations) and the Maryland Academy of Physician Assistants electronic mailing list. The survey instrument was beta-tested and recommendations were used to refine the survey before it was distributed to study participants through Qualtrics. The survey instrument was distributed to a random sample of 1,368 practicing PAs and PA students during June 2020; 636 surveys were completed, for a response rate of 46%.

For the semistructured interviews, we recruited a purposive sample of 38 interprofessional stakeholders including PA association leaders and members (n = 19, 50%), PA program directors and PA faculty (n = 9, 24%), non-PA academic leaders (deans, provosts, and presidents across health professions of nursing, medicine, pharmacy, and physical therapy, n = 6, 16%), physicians (n = 2, 5%), and PA employers (n = 2, 5%). The interview questions asked participants to provide commentary on curricular modifications needed if the PA profession transitioned to doctoral education.

The survey instrument and interview guide were grounded in the results of an interprofessional literature review examining the curricular changes associated with the doctoral transitions for nursing, pharmacy, and physical therapy professions as well as post-professional PA curricular offerings. (The Current Core Curricular Elements for Master's PA education is available at https://paeaonline.org/wp-content/uploads/2021/01/core_competencies-new-pa-graduates-092018.pdf.) The University of Maryland Baltimore Institutional Review Board approved this study.

Quantitative data analysis

Descriptive statistics were performed with survey questions coded as follows: strongly/somewhat disagree, 0; neutral, 1; and strongly/somewhat agree, 2. Logistic regression analysis (coded as 0 = disagree, 1 = agree; neutral was dropped due to insufficient data) was used to test the association between reported desired curricular elements/training/competencies if there was a transition to an entry-level doctoral degree relative to maintaining current curricular requirements. Independent variables were demographics, highest degree earned, length of practice as a PA, perception on whether a doctoral degree should be required, and perception if a doctoral degree should be offered but not required. The dependent variable was the perception of whether the current number of credits, depth, and breadth of master's level of PA training is sufficient for a doctoral degree.

Qualitative data analysis

The interview data and free-text responses from the survey were analyzed using an iterative process of deductive content analysis with predetermined codes. Three researchers independently analyzed the free-text responses with reference to the a priori theme, curricular modifications, which was derived from the comprehensive interprofessional literature review. Coding output from each reviewer was compared. Differences were discussed until a consensus was reached to ensure inter-rater reliability. The qualitative approach for this study was conducted according to best practices as outlined in Colorafi and Evans and Creswell and Guetterman.6,7

RESULTS

Table 1 presents the demographic characteristics of survey respondents. A majority of the survey respondents were practicing clinicians (82.8%), nonminority (82.2%), and master's level trained (74.9%). The length of practice ranged from less than 5 years (27.1%) to more than 25 years (5.8%). For the 38 semistructured interviews, most interviewees were PA association leaders and members (50.0%), followed by program directors and faculty (23.7%), academic leaders (15.8%), physicians (5.3%), and employers (5.3%), with most participants being male (65.8%).

TABLE 1. - Demographic characteristics of survey respondents
Totals vary because the number of respondents varied by question.
n %
Sex
   Female 433 68.5
   Male 199 31.5
Hispanic/Latinx
   Yes 47    7.4
   No 584 92.6
Race
   White 523 82.2
   Black 39    6.1
   American Indian/Alaska Native 6    0.9
   Asian 41    6.4
   Native Hawaiian/Pacific Islander 2    0.3
   Multirace 18    2.8
   Others 19    3.0
Educational attainment
   Associate degree 2    .3
   Bachelor's degree 97 15.3
   Master's degree 475 74.9
   Doctoral degree 60    9.5
Occupation
   Student 109 17.2
   PA clinician 524 82.8
Length of practice as PA
   Current student 107 16.9
   <5 years 172 27.1
   5-10 years 148 23.3
   11-25 years 169 26.7
   >25 years 37    5.8
   Non-PA 1    .2
Some of the PA clinicians reported additional professional roles such as faculty and administrators, but were counted as PA clinicians.

Quantitative results

When respondents were asked if the current number of credits, depth, and breadth of PA training offered in most PA programs to date are sufficient for a doctoral degree, 53% of respondents agreed (n = 338), 29% disagreed (n = 186), and 18% were neutral (n = 111). Subgroup analysis found no significant difference in response to this question based on race, ethnicity, educational level of respondent, clinician versus student status, or length of clinical practice. However, most participants who felt the depth and breadth of current PA training was sufficient also believed that a doctoral degree should be offered but not required (62.6%, P = .000) (Table 2).

TABLE 2. - Subgroup analysis on question of whether the current number of credits, depth, and breadth of PA training offered in most PA programs to date are sufficient for a doctoral degree
Disagree Neutral Agree X 2 (df) P
n % n % n %
Hispanic/Latinx
   Yes 16 34 3 6.4 28 59.6 4.35 (2) .114
   No 170 28.9 108 18.4 310 52.7
Race
   Black 12 30.8 9 23.1 18 46.2 1.17 (2) .558
   Non-Black 174 29.2 102 17.1 320 53.7
Highest degree earned
   Master's degree or lower 163 28.4 104 18.2 306 53.4 3.23 (2) .199
   Doctoral degree 23 38.3 7 11.7 30 50
Occupation
   Student 26 24.1 23 21.3 59 54.6 2.29 (2) .318
   PA clinician 159 30.3 88 16.8 277 52.9
Length of practice as PA
   <5 years 59 34.3 25 14.5 88 51.2 1.98 (2) .371
   ≥5 years 102 28.8 63 17.8 189 53.4
To be required
   Disagree 153 33.5 100 21.9 204 44.6 52.84 (4) .000
   Neutral 11 16.9 7 10.8 47 72.3
   Agree 21 18.8 4 3.6 87 77.7
To be offered but not be required
   Disagree 78 35.3 58 26.2 85 38.5 34.66 (4) .000
   Neutral 22 30.1 11 15.1 40 54.8
   Agree 85 25 42 12.4 213 62.6

To gain further insight into the strength of the association between variables, a logistic regression analysis was performed. Table 3 presents the results of the logistic regression analysis regarding perception if the current number of credits, depth, and breadth of PA training offered in most PA programs to date are sufficient for a doctoral degree, by the following independent variables: demographics, highest degree earned, length of practice as a PA, perception on whether a doctoral degree should be required, and perception of whether a doctoral degree should be offered but not required. There is a significant association between whether a respondent selected requiring/offering a PA doctoral degree (P < .000) and perception if the current number of credits, depth, and breadth of PA training offered in most PA programs to date are sufficient for a doctoral degree.

TABLE 3. - Logistic regression model on question of whether the current number of credits, depth, and breadth of PA training offered in most PA programs to date are sufficient for a doctoral degree
Model evaluation: R2 = .14
Model OR 95% CI P
Hispanic/Latinx .92 .46-1.86 .82
Black (reference group: non-Black) .51 .23-1.12 .093
Doctoral degree (reference: master's degree or lower) .62 .34-1.13 .115
≥5 years (reference: ≤5 years) 1.1 .74-1.64 .628
To be required (reference: disagree) 3.85 2.27-6.55 .000
To be offered but not be required (reference: disagree) 2.39 1.66-3.45 .000

Overall, survey respondents agreed that transition to an entry-level PA doctoral degree would affect various aspects of the curriculum. About 75% of respondents indicated it would require new content, with about 50% of participants indicating it would require significant change to the curriculum, enhance rigor, and change the competencies of the new graduate (Table 4).

TABLE 4. - Survey responses on question of how an entry-level doctoral degree might affect various aspects of PA curriculum
Agree Neutral Disagree
n % n % n %
Changing the competencies of the new graduate 301 47.6 113 17.9 219 34.6
Enhancing the rigor 352 55.5 109 17.2 173 27.3
Requiring new content 476 75.1 72 11.4 86 13.6
Requiring significant change 357 56.5 117 18.5 158 25

Figure 1 shows responses when participants were asked which areas and competencies a doctoral degree would better-prepare students compared with a master's degree. Most respondents agreed that a doctoral degree would better-prepare students in research skills (70.2%), academic teaching skills (67.1%), program and policy development (57.1%), leadership (53.9%), and administration (52.9%) compared with a master's degree. Also, most respondents reported that a doctoral degree would better-prepare PA students in the competency areas of professional and legal aspects of healthcare and healthcare finance and systems. In contrast, most respondents disagreed that a doctoral degree would better-prepare PA students than a master's degree for the demands of working as a clinician, readiness for team-based-collaborative care, and clinical practice skills. Additionally, nearly half of respondents disagreed that a doctoral degree would better-prepare students in the competency of cultural humility.

F1-15
FIGURE 1.:
Survey responses on the question of which aspects and competencies a doctoral degree would better prepare PA students compared with a master's degree

When participants were further asked which curricular changes would be warranted if an entry-level PA doctoral degree is adopted, recommended curricular changes included additional content in research methodology, leadership and management, health systems/policy, and evidence-based practice; a change in the length of time to earn the degree also was recommended. Items identified as not high priority for curricular change were content delivery format (online, face-to-face, hybrid), program design, quality improvement, population health, mandatory residencies or fellowships, health technology, informatics, and longer clinical rotations.

Most respondents believed that a transition to an entry-level doctoral degree would likely affect prerequisites (Table 5). More than 50% of the participants indicated that two aspects of clinical training—length of clinical rotations and supervised clinical practice disciplines—were likely to change. However, less than 50% chose timing within the curriculum, learning outcomes, minimum credentials for preceptors, and increased use of simulations as likely to change. At the same time, 53% of respondents agreed that an entry-level doctoral degree would negatively affect the availability of clinical training sites. Additionally, respondents believed the entry-level doctoral degree would result in changes to the PA educator competencies (71%), PA educator credentials (81%), and that the PA educator shortage would worsen (73%).

TABLE 5. - Survey respondents on the question of perceived effect on prerequisites and how likely the entry-level PA doctoral degree would affect various pedagogical aspects of the profession
Likely Neutral Unlikely
n % n % n %
Prerequisites
   Entrance examination 300 47.7 195 31 134 21.3
   GPA 349 55.6 161 25.6 118 18.8
   GRE 289 45.9 191 30.4 149 23.7
   Prerequisite courses 378 60.1 131 20.8 120 19.1
   Previous clinical experience 329 52.6 155 24.8 142 22.7
Perceived effect on various elements
   Changing accreditation standards 496 78.6 75 11.9 60 9.5
   Changing the certification process 414 65.6 118 18.7 99 15.7
   Changing the recertification process 374 59.3 137 21.7 120 19
   Confusing the patient 477 75.8 75 11.9 77 12.2
   Enhancing leadership opportunities 443 70.4 100 15.9 86 13.7
   Enhancing scholarly production 404 64.3 133 21.2 91 14.5
   Enhancing scope of practice 268 42.6 141 22.4 220 35
   Affecting ROI of student 236 37.6 143 22.8 249 39.6
   Increasing caliber of faculty 262 41.8 181 28.9 184 29.3
   Increasing diversity 60 9.6 148 23.6 419 66.8
   Shifting practice setting to primary care 61 9.8 204 32.6 360 57.6
   Shifting practice setting to specialized care 288 45.9 218 34.7 122 19.4
   Shifting practice setting to urban, rural, or underserved locations 65 10.4 242 38.6 320 51

To further understand how doctoral education would affect accreditation, certification, and clinical practice, participants were asked to rank how likely an entry-level PA doctoral degree would affect various pedagogical elements of the profession. Most respondents disagreed that the entry-level doctoral degree would increase diversity or encourage PAs to practice primary care orin urban, rural, or underserved locations (Table 5). Yet, an ample percentage of the respondents (46%) believed a transition would likely generate a shift in practice setting to specialized care. Although respondents identified a high likelihood that a doctoral degree would enhance leadership opportunities, they also expected that it would change accreditation standards and certification processes and confuse patients.

If the PA profession decides to adopt the doctoral degree as a terminal degree, most respondents favored a bridge program model (working clinically to doctorate, 69%), followed by master's to doctorate (18%) and bachelor's to doctorate (13%). If the entry-level doctoral degree is adopted, the following nomenclature was rank-ordered highest to least preferred by survey respondents: Doctor of Medical Science (DMSc, 24%), Doctor of Physician Assistant Studies (DPAS, 22%), Doctor of Medical Science (DMS, 21%), Doctor of Physician Assistant Practice (DPAP, 11%), Doctor of Physician Assistant (DPA, 11%), Doctor of Science in Physician Assistant Studies (DScPAS, 7%), with the least preferred title being the Doctor of Health Science (DHSc, 4%).

QUALITATIVE RESULTS

Deductive content analysis was performed on responses expressed by the various stakeholders interviewed when responding to the question, “What curricular changes and/or graduate competency changes, if any, would be warranted or necessary with a change to an entry-level PA doctorate?” Key themes that emerged and were consistent across groups were curricular enhancements in research, evidence-based practice, leadership, and health systems. Further, recommendations were made to require a capstone project that would be evidence-based but not of the caliber of a dissertation.

An analysis of the free-text responses from the quantitative survey revealed that respondents felt a doctoral degree should include increased clinical exposure; additional curricular content in leadership, research, education; and a deeper breadth of didactic instruction. Regarding increased clinical exposure, survey participants recommended the addition of residencies, fellowships, or longer clinical rotations. Participants suggested that leadership in healthcare administration, the business of medicine, and management should be incorporated into doctoral education. Another category of interest was public health, specifically focusing on minority health, health disparities, and social determinants of health. Respondents also recommended incorporating research and academia as doctoral essentials. Many responses recommended options for different educational tracks.

LIMITATIONS

The electronic mailing list used for survey deployment may not be representative of practicing PA participants nationally. The selection of academic leaders, PA education leaders, and program directors for semistructured interviews could have introduced certain political or educational biases related to content and curriculum. The variation in comments provided by participants may have been influenced by the experience of the participant in PA education and in accordance with their leadership level and trajectory.

Although our results are based on a national level, cross-sectional study with a robust response rate, some stakeholder groups such as physicians and some minority groups were underrepresented. In addition, the study was limited due to variability in the number of survey responses per question. Nevertheless, the findings from the quantitative cross-sectional survey were consistent with the qualitative interview responses. To our knowledge, this is the first rigorous study to uncover stakeholder perspective on potential PA doctoral curriculum essentials.

FURTHER RESEARCH

A key question relates to how PA programs can transition to an entry-level doctoral degree while maintaining the current depth and breadth of curricular content. Other questions include whether to limit increases in credit hours and associated program length and cost. Should the profession move toward an entry-level doctorate, each sponsoring institution will need to tackle these issues. We suggest that the Physician Assistant Education Association take the lead in developing potential models or guidelines to assist programs in how to approach this curricular change.

DISCUSSION

Spurred on by the emergence of PA-specific post-professional doctoral degree offerings, the debate on the entry-level doctorate has resurfaced.8 A recent AAPA report noted that “it is time for the profession to create an organized strategy on the next evolution of PA education that will ensure continued professional viability while upholding professional integrity.”9 Examination of the curriculum elements of current PA doctoral degree programs is a relevant component of this discussion. Analysis of existing post-professional PA doctoral programs and other doctoral health profession programs (nursing, pharmacy, PT) showed several common themes related to curricular modifications.2,10,11 Although the structure and design of these programs varies, a commonality was a required core component with optional tracks. Some programs are coupled with clinical residencies and fellowship. The rigor of required research differs by program, and the majority did not require a dissertation. Core essentials included clinical skills, writing, research methods, ethics, and healthcare system science; example tracks included leadership, advanced clinical education, administration, and research. Beyond these, our national PA-specific survey showed that a PA doctoral degree should include increased clinical exposure; additional curricular content in leadership, research, and education; and a deeper breadth of didactic instruction. Most respondents agreed that a doctoral degree would better-prepare students in research skills, academic teaching skills, program and policy development, and leadership and administration, all of which are increasingly incorporated in medical education. Most respondents reported that a doctoral degree would better-prepare PA students in the competency areas of professional and legal aspects of healthcare. One interpretation of these findings is that PAs recognize these topics as essential for furtherance of their own professional careers as well as advancement of the PA profession.

More than half (53%) of respondents felt that the current number of credits, depth, and breadth of PA educational programs are sufficient for a doctoral degree, a concept that underpins the philosophy of existing PA-specific post-professional doctoral degree programs. A related study recently found that 60% of survey respondents agreed that an entry-level doctoral degree would cause more harm than good and a majority (82%) strongly agreed that it should not be required.12

CONCLUSIONS

As the debate on PA doctoral education continues, many questions remain unanswered, including the ideal curricular model, the potential return on investment (ROI), risks and benefits of a transition, and the overall effect it would have on the PA profession. This study found a clear indication that significant curricular changes will be required if the profession transitions to an entry-level terminal doctoral degree. If a transition should occur, PA education will be challenged to evolve and develop more advanced curricular models. This mixed-method study provides guidance for constructing future doctoral curricula essentials and competencies.

REFERENCES

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5. Seegmiller JG, Nasypany A, Kahanov L, et al. Trends in doctoral education among healthcare professions: an integrative research review. Athlet Train Educ J. 2015;10(1):47–56.
6. Colorafi KJ, Evans B. Qualitative descriptive methods in health science research. HERD. 2016;9(4):16–25.
7. Creswell JW, Guetterman TC. Educational Research: Planning, Conducting, and Evaluating Qualitative Research. Upper Saddle River, NJ: Pearsons Education; 2019.
8. Fleming S, Gordes KL, Kayingo G, et al. An exploration into the PA entry-level doctoral degree: a report to the PAEA Board of Directors. Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore, Baltimore, MD, August 2020.
9. American Academy of PAs. Research into an entry-level doctorate across four health professions. Alexandria, VA, 2020. www.aapa.org/tag/doctorate. Accessed July 12, 2021.
10. Plack MM, Wong C. The evolution of the doctorate of physical therapy: moving beyond the controversy. J Phys Ther Educ. 2002;16(1):48–59.
11. Martsolf GR, Auerbach DI, Spetz J, et al. Doctor of nursing practice by 2015: an examination of nursing schools' decisions to offer a doctor of nursing practice degree. Nurs Outlook. 2015;63(2):219–226.
12. Kulo V, Fleming S, Gordes KL, et al. A physician assistant entry-level doctoral degree: more harm than good. BMC Med Educ. 2021;21(1):1–12.
Keywords:

physician assistant; PA; entry-level doctorate; curriculum; post-professional doctorates; doctor of medical science

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