PAs and the Entry-Level Doctorate

PAs have been Masters of medicine since the 1990s–is it time they move on? Doctors are no longer exclusively MDs or DOs. PAs must ask themselves if it’s time to get on board with the entry-level doctorate. 

Once Upon a Certificate

The PA profession had its genesis in the 1960s awarding certificates and associate’s degrees. As the years passed by, PA programs evolved into a 4-year Bachelor’s degree. Several schools around the country still offer a Bachelor’s of PA medicine including the Army Medical Center of Excellence in San Antonio, Texas. 

23 years after Eugene Stead, MD established the first PA program at Duke University in 1965, Duke became the first school to offer a Master’s degree to PA trainees. 32 years later, the Master’s degree remains the official entry-level degree for PAs. The term “entry-level” refers to the minimum required education and the terminal degree awarded by most programs. 

Is it time for a change? Is it time to start awarding an entry-level doctorate degree in PA medicine? PAs and patients alike might ask why–what would be gained from the added time and expense?

Pros and Cons of a Physician Assistant Entry-Level Doctorate

PAs are literally being left behind. Every other healthcare provider has already made the change. Physical therapists have the DPT, nurse practitioners have the DNP, audiologists have the AuD, etc. 

The counterclaim to the “keeping up with the Jones’s” argument is that PAs were created for rapid deployment. The first PAs were ex-military corpsmen trained in the  “fast-track” model used during World War II. There was a severe shortage of general practitioners at the time and the need grew with the passing of Medicaid and Medicare in the ’60s. That same need still exists today and requiring an extra 1-2 years of training would reduce available graduates and could deter others from ever matriculating. 

Another argument for a physician assistant entry-level doctorate is that the PA profession has grown well beyond assisting physicians–it’s debatable if they ever did. There are two major hurdles, however, that stand in the way of PA progress: their name and their degree. 

Name

Physician assistants don’t actually assist physicians. When first conceived, they went by the title of Physician Associate. Except for those working in surgery, PAs function autonomously from their physician colleagues. PAs usually have their own panel of patients. Even surgical PAs spend much of their time working independently doing pre and post-op assessments and seeing patients in the clinic. 

Consider how PA “supervision” actually works. Most states in the US established practice laws in the 1960s and 70s requiring physician supervision. Yet in reality, this supervision only occurs post hoc, i.e. after a patient is evaluated and treated. “Supervision” has come to refer to having a physician available to consult when needed. This is why “collaboration” is the new term making it’s way into legislation across the country for both PAs and NPs. 

“Supervision” also implies liability. Those who supervise are generally responsible for those under supervision. Yet, who would want to accept liability for the actions of someone else?  It stands to reason that someone with the title of assistant should be supervised–it just doesn’t work that way in reality. At some point, the apprentice proves his skill.

Degree

Although the Master’s is currently considered the terminal degree for PAs, it can be viewed as an intermediate or “mid-level” degree compared to those with a doctorate. Despite the name, it’s a degree more fitting of an assistant when the expert holds a doctorate.  

Extreme Makeover: PA Edition

All PAs have to pass a national certifying exam–the PANCE or Physician Assistant National Certifying Exam. Every PA program must be accredited by ARC-PA. But there’s a wide variety of degrees awarded. For example, some schools may award the MPAS or Master of Physician Assistant Studies while another like Duke may confer the MHS or Master of Health Science. 

With the birth of the Doctor of Medical Science for PAs, it would make sense to standardize the PA Master’s to an MMS or Master of Medical Science, already a popular choice among PA programs. 

The Doctor of Medical Science (DMS/DMSc) is a popular doctorate among PAs but it’s not considered entry-level. It’s entirely optional and there’s significant disparity between DMSc programs. One university, however, is making it easy for Master’s PA students to earn the DMSc. Is this the first step towards an entry-level doctorate for PAs? 

The First Physician Assistant Doctorate

The distinction of having the first clinical doctorate actually goes to the U.S. Army and Baylor University. Their joint doctorate referred to as the Doctor of Science in Physician Assistant Studies (DScPA) was developed for Army PAs who successfully completed an 18-month residency in emergency medicine. The program was not then and is not now open to civilians. In this PA’s opinion, it remains the model for PA clinical doctorates. 

The Future of PA Doctorates

If, or when, the DMS/DMSc becomes the entry-level doctorate for physician assistants, what will happen to Master’s PA-the Master of Medical Science? What will they even be called? Perhaps they will remain just “PAs”. This was suggested in an AAPA campaign several years ago. Perhaps there is no better title than simply P.A. 

When asked, I don’t think it would be a problem to say, “PA used to stand for physician assistant but that name doesn’t reflect what we do anymore.” Pretty simple. 

Or perhaps the MMS PA will be referred to as a Physician Associate? Or simply an MMS… Master of Medical Science. 

How would the two providers (MMS and DMS) work together? Would MMS PAs be subject to and supervised by their fellow PAs now Doctors of Medical Science? It’s conceivable but only if the DMSc can actually produce a better practitioner. Making that point is one of the driving forces behind this blog. 

#ScopeCreep, #ExaggerateMuch?

But that raises a larger question–should any health care provider be subject to another? Medicine is a team sport where no single profession can claim all knowledge and power. There’s also an incredible disparity between rural, urban, and suburban medicine. No single paradigm serves patients living and working in all of these areas. 

Everyone who steps foot into a hospital or clinic and dons a stethoscope and scrubs ought to be responsible for their own actions. Each has his or her own duties established by their training. Each has his or her own scope of practice. Growing within that scope and taking full responsibility for their decisions is not “scope creep.”

The entire PA profession needs a face lift. At its core, the idea of a classically trained clinician that can be rapidly deployed into high-need areas without the same constraints as a physician is a valuable one but the future of the profession is at risk. 

The three giants of medical practice are the MD/DO, PA, and NP. PAs are taller than the shortest giant but represent the fewest in number. There are almost 1 million physicians in the US; 290,000 nurse practitioners, and only 140,000 PAs. Fewer PAs means fewer members of professional organizations, less representation in politics, and even less money to support it all. 

The Best Argument for a Physician Assistant Entry-Level Doctorate

The best argument, however, for a physician assistant entry-level doctorate is that the practice of medicine is a journey, not a destination. If society required doctors, nurses, and PAs to know it all before starting their practice, they would be well into retirement before beginning their careers and yet would still have significant gaps in their knowledge. 

A Post-COVID Prediction

We are in dire need of more healthcare providers. This has been true since the Second World War. It’s even more true in the era of COVID-19. 

The Bureau of Labor Statistics (BLS) predicts that the physician shortage will be around 91,000 by 2026. That number actually may reach as high as 122,000. How many physicians will we lose to COVID? Not just physically, but mentally. Rural areas, where many PAs practice, will be hit the hardest. Yet physician groups squashed an attempt to improve access to care in rural Tennessee and act as though their turf has been invaded. 

Why is there such a shortage of physicians in the first place? The American Association of medical colleges cites a population that is both growing and aging. They also predict that “more than 2 of 5 currently active physicians will be 65 or older within the next decade.” The deficit will grow larger when these physicians retire and the fallout from COVID becomes more clear. 

The MMS/DMS model solves many of these problems. Trained in the same model of care as physicians, Master’s-trained PAs practice safely and effectively. And while less is known about the quality of care provided by doctoral PAs, including those Doctors of Medical Science, one would assume that an extra 1-2 years of clinical training doesn’t hurt.  

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