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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24 Comments

  1. Delmas Lee Abbott, DMSc, PA-C

    I too agree that the DMSc should be our terminal degree. I have recently earned my DMSc and I have learned much about healthcare administration and organizational behavior and leadership. It’s time for us to become leaders and take control of our destiny as a profession. We can still continue to be able to provide care when and where needed to supply high quality health care to our patients. Plus, help our patients and our physician colleagues understand we are here to provide excellent care and then refer to appropriate specialists, as needed. I have been educating my physician colleagues that the model has changed. Most physicians are employed and do not reap the financial rewards of our work, as when they owned their own practices. Now, it makes no sense for them to be liable for the care PAs provide, especially when they may never see the patient or consult with the PA about their care.

  2. Ade Bakare DMSc,MPAS,BSc,PA-C

    This is an excellent perspective about the evolving roles of PAs. As a PA myself who received a BSc in PA studies and eventually DMSc, I can attest to the incredible knowledge I have attained along the way and continue to build on to make me a great provider to my patients. I have 13 years experience as a PA and now I practice independently because I have proven myself as a provider. I hope that the DMSc eventually become an Avenue for PAs to practice completely independent of physicians at least in primary care.

  3. Alex Gabriel

    We needs to standardize the DMsc programs and seek recognition for it as a terminal degree for PAs who want to practice independently. Also there should be a difference between our degrees and the name of our profession. The name of the profession is PA (physician assistant or Physician associate) but the degrees should be called MMsc for master and DMsc for Doctorate.

  4. Alfred B Cichon

    Standardization of the degree names is a great idea – should occur sooner than later. One real consideration is, taking nursing as an example, an individual may choose to continue their career at one stage of the progression. There remain life long CNA, LPN, RN e .
    As a PA (Bachelor Degree), which by the way is as a Physician Associate, my career has included Primary Care, Emergency Medicine, Correctional Health – with brief stints in other areas; a great majority with no on-site physician. Attending a Masters program (Public Administration) was in-the-cards but as there were geographic and financial barriers a ‘clinical’ advanced degree was not available. Perhaps the Masters should be ‘entry’ level and the DMsc the ultimate (excepting specialty programs). Just an opinion.

    • Well said! We firmly believe that PAs can and do good work regardless of their degree (AS, BS, MS), but having the option to “go all the way” and get the DMS should be the norm. Ideally, the MD would have been the “final destination” but the market has not felt that necessary and thus the clinical DMS was born.

  5. Carson

    I am a little confused though, so if someone made entry level doctorate for PAs, which at the end is said to be “an extra 1-2 years”, then would there be a difference between osteopathic/allopathic school versus DMSc training? Would the difference just be a residency? What are the “fewer constraints?”

    Maybe I just don’t fully understand the idea. I liked this part

    “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 then if the PA profession becomes an entry level doctorate, it seems to be the same time constraint as a physician. Or would the option to get an MMS still be an option for practice? I feel like a lot of people choose this profession because they like collaborating, they want to serve their community quickly, and specifically did not want a doctorate and specifically chose a masters degree. The option to choose a doctorate is there already, and people interested in patient care and learning from the medical model could also choose to either further try to earn a DMSc or might have chosen a DO or MD degree. MMS learns from the medical model, so if someone wanted a doctorate level training in the medical model, both of those options are available. Getting an MMS is a choice, and I don’t think it should be eliminated. If PAs are already capable of providing improved access to care and quality health care, I wonder if some people would be discouraged from choosing to do a doctorate. A masters degree is part of the appeal for many. A lot of people feel like they don’t need the title of a doctorate, and they know their training has well prepared them to take care of patients. Not to play devils advocate, but I think we should increase the number of providers and patient access to care! We are not competing with physical therapists or audiologists, and their title of doctorate doesn’t diminish what PAs can do. If adding 1-2 years doesn’t have a shown patient benefit, but is more about convincing legislators and patients that PAs provide good care, then I think there might be other ways to achieve that goal without changing the education system.

    • You bring up some great points.

      1. What would be the difference between a DMS and an MD?

      Residency. Medical school wastes a lot of time (see our article on PA vs MD). Residency is where new grads learn to be doctors. PAs get that real-life training over a longer period of time without the benefit of the residency structure. Residency is also a well-known bottleneck in the training of physicians. If med students spent more time on medicine and less time on foundations, perhaps they could enter some sort of practice after school but then that’s exactly who and what PAs are!

      2. Some people like the Master’s option.

      So do we! We think the MMS PA could continue. It’s wonderful that PAs across the country are overcoming their legislative barriers. This is half the battle. The other half of the battle, however, is public perception. Even awesome PAs are lumped in with nurses and MAs. Changing our title to MCP will only further relegate us to the unknown. Becoming a Doctor of Medical Science is the safest long-term destination.

      Thanks for reading and commenting.

  6. Good day All:
    I graduated in 1975 (Retired this year) with BS of science. We started off as associates and ended up as assistant.

    The assistant confuses patients and is the main reason why he nurse practitioners excelled.
    The assistant must go. Associate is much more fitting and we could keep the moniker PA.

  7. brigid

    Since medicine has changed and PAs no longer work in the capacity of assisting the physician – maybe there is no longer a need for this position. Maybe these people should just to medical school instead of some clunky work around substitute.

    • You make a good point except that there are more intelligent people interested in health care than medical schools can educate. The “4 year plus government-funded residency” model failed to produce enough practitioners and the market responded with PAs and NPs. These professions place much more emphasis on previous healthcare experience than medical school. When they were created 50 years ago, it was inconceivable that PAs could replace traditionally trained doctors. Today, however, PAs do most of what doctors did in years past. The rules of the game have changed.

  8. J. Fernandez, MD

    Some concerning comments to point out- Medical school is not a waste of time. The basics and fundamentals are what allows a MD/DO to understand the algorithms and evaluate the need to deviate from those in certain patients. I keep finding that most NP/PA’s do not fully grasp some of these fundamentals. This will be fine in most patients as they fall into algorithm treatment, but can be very dangerous for those that don’t. So, the basic sciences are very important for practice.

    Other point- I agree with allowing free practice, as long as the malpractice is on par with physicians and NP/PA is held to the same standard in a court of law (not currently the case).

    Another one- If you add 2 years to a PA curriculum you’ll end up with 4 years of college and 4 of PA school…. But no residency…. essentially a MD without residency. We have A LOT of those that went unmatched- if the argument is that we have a shortage of medical professionals- we should also look into programs to allow unmatched MD/DO to practice with supervision as well.

    Final point- Stop it with the alphabet soup behind the names. Your credentials shouldn’t have more letters than your actual name. Pick a couple letters and be done. If you are a DNP I can assume you are a NP, RN, BSN…. geez….

    • Dr. Fernandez, thanks for commenting. We value our physician colleagues and want to maintain collegial relationships.

      You make some good points.

      1. We still maintain that some of medical school curriculum is superfluous. If it were not, we would not see a trend toward 3-year programs. I don’t believe I’m any less prepared to manage my patients because I haven’t drawn out the Kreb’s cycle since college biology.

      2. PAs are held to the same standard and my malpractice mirrors that of the physician I work with so I’m not sure what you mean here. We are actively working for statutory language stating that “PAs are responsible for the care they provide”.

      3. We agree that any clinician not trained in a residency model should have a period of graduated supervision and support.

      4. We agree here, too. One day DMS will replace PA. But physicians aren’t above this practice either: MD, MPH, FAAFP or MD, PHD, AAHIVS. This appears to be a human tendency.

    • LOL
      DOs are not even recognized as Doctors of allopathic medicine.
      They do not go to Medical Schools, they go to Osteopathic Schools.
      DOs struggled for years and even now to get recognition to get in to main stream.
      They are such hypocrites, they used to be only trained for osteopathic type of medicine just like Chiropractors.
      They got evolved from being chiropractors to doctor of osteopathy.
      Then they were restricted to family medicine and that’s it.
      I applaud their struggle for their evolution but it does not mean that they are Allopathic doctors, they are still osteopaths like chiropractors.
      They should have more empathy to our profession because they were in the same shoes 👞 prior to calling themselves doctors which still they are struggling because patients still do not like to be treated by DOs and they rather have Physician Associate or MDs practicing Allopsthic medicine rather than manipulating all their bones and muscles.
      Honestly, in all my years of practice I have seen DOs struggling with their skills and knowledge because they are not trained like PAs and like MDs.
      Their training revolves round whole body muscles 💪, which becomes confusing for most of the patients.
      The funny part is this that they do not introduce themselves as DOs because of their professional dishonesty and intellectual disrespect towards the patient standard of Care and safety.
      If they are honest they must and should introduce themselves as DOs without hiding behind MDs.
      Poor patients don’t even know if they are being treated by DOs which are trained differently than PAs and MDs.
      PAs are trained exactly like MDs and I know that.
      Now this article to target PA profession is utter Insecurity, harassment, attack and jealousy towards our respectable PA profession.
      I request all my PA colleagues to stand up and rebuttal for their own professional integrity.
      Enough is enough!!!
      Who are DOs to stop us from our struggles. Who are DOs to suppress and oppress us from becoming independent.
      Yes, we are DOCTORS, we are doctors by all means…
      They better should straighten this up.
      Give us a plain level field to play and then see who is doctor and who is not.
      We must go for residencies and fellowships and then see who is more competitive and who is more competent.
      Enough of this stupidity.
      Can’t take this any more.
      Wake up my fellows and stand up before your profession is eaten by DOs alive.
      This is the time to show your muscles 💪 to these OSTEOPATHS who are not even ALLOPATHS and who are ashamed to call themselves DOs.
      Hiding behind MDs.

    • Devony Hitt

      I’ve long felt there ought to be some form of modified medical school for PAs with a Master’s with say 10 years experience who could attend a 2 year program to come out with a doctorate and practice as a general practitioner. They could come out MD, or DO depending on there program and be called “Doctor”. This seems much less confusing to the patients who are just now understanding the role of the “physician assistant”. It would be the choice of that individual provider to choose to go to one of these programs. They could be utilized in primary care areas that need more providers. Again, holding true to the original mission of the profession.: to extend medical care to those in need. And , perhaps if they work with a board certified physician in whichever field, ie: family practice, internal medicine, pediatrics, etc…, they could then choose to sit for their boards after a designated time to become board certified in their chosen area. It just seems to make more sense to me.
      Devony Hitt, PA-C, MMSc

  9. Daniel

    A few points of concerns regarding DMsc. As “entry level” why should a doctoral degree be required? Has our past decades of practice not proven a masters degree is sufficient for “entry level”? Agreed that “a few more years of training doesn’t hurt” but why does that have to be me paying thousands of dollars a year to a University vs taking advantage of one of the numerous PA fellowships offered throughout the country? Some may argue and say “well why’d we move from BS to masters?” My answer to that is, that ship has sailed many years ago and isn’t going to change back. Let’s try not to repeat the past.

    Research has proven time and time again patients’ care is equitable to physician care in most settings. Just as the best doctors were not as bright/skilled/refined the day they stepped out of residency, a PAs quality improves over time with clinical care too, regardless of the degree.

    If you want to discuss PA leadership, no one is stopping us from pursuing other degrees. I personally am interested in administration so I went back to get my MBA with a healthcare focused program. That shouldn’t become the expectation for everyone. That’s not “entry level”. While I encourage all of my colleagues and PA students to become a leaders, not everyone wants to, nor should become them. There is nothing wrong with working hard in school to provide great care to patients, but wanting to clock in and clock out on a time card.

    Last, regarding NPs. Ask your NP colleagues if they appreciated the extra years of school for the same title, same pay, and unfortunate still be called “nurses” most of the time. We don’t call NP doctors (nor should we, although that’s a different topic) and initials are not appropriate titles, NP, PA, etc. Let’s settle the much larger and more obvious issue with our name first so your degree, whether MPAS, MMS, MSc, or DMSc doesn’t have to say Assistant.

  10. Alfred Cichon

    Appreciate the discussion regarding additional ‘school’ time adding to a depth of understanding. Yet, that does not acknowledge the ‘learning’ associated with practice. The understanding of adapting patient care to the particulars of a specific case is an essential for any care giver.

  11. Howard Silver

    1977 PA, BS graduate . I have not seen what the newer MS, Or Doctorate training offers in advancing Clinical ability. If in fact it improves Clinical abilities , that is great, Health Care needs more care givers . If it adds yet another administrative bound “care giver ’’, don’t Add that as an un necessary burden , ticket punch, to the PA . Recall the initial vision for PAs , was a low cost, faster trained , highly capable provider which It still does, and which my “ Generation “ of PAs documented was possible. 20 years ago no one knew what a PA was, including Physicians. That is no longer the case. Physician Associate is a reasonable title for PAs, but it has its problems, resistance from Associated Physicians using that term now, as well as the cost and difficulties associated with changing established Law language in 50 States and the Federal PA categories. From what I have heard, advanced Degrees add only Liberal Arts education, research Paper writing, and Leadership courses. None of which add any acumen to Clinical abilities. Its any old saw, but if you want to be a Dr. go to Medical School. If you want to improve your Clinical skills, seek a position that challenges you. If you want more money, get a Business Degree. After caring for Patients over many years , I never had a Patient say you are only an Assistant. Usually, I had to correct them with pride saying no I am a PA.

    Doctorate

  12. Sandy

    All of these points are well taken. As a PA of more than 20 years, I strongly believe in gaining an edge on the evolving practice as discussed primarily. Our competition, NPs, are now required to obtain a terminal degree. Also, as independent contractors, they are able more freely run a private practice. I believe that if we want to change the landscape (better suited title, etc) we should focus on continuing education. I also believe it leads to growth, as there is so much more to learn about politics, administration, studies, particularly what goes on behind the scenes. What if we were successful in changing some of the terms, including scope of practice, title, independence, etc. and could open up a private practice if a doctorate was obtained? I am working on my doctorate, particularly to have credentials to continue to provide education to certain organizations where many more lives can be changed. Unfortunately, regardless of how much knowledge, experience and the like you have — when you have certain credentials, your voice is louder and better received. Particularly if you want to make major changes for the profession.

  13. Danny McFarlin

    I have been a PA for over 22 years. Credential creep is a disease for those who believe they are not adequate. Irregardless of the letters you put behind your name, you should be continually learning and trying to be a better health care provider. I read a comment about learning better administrative/leadership skills when getting an advanced degree. If you want to get into management then takes business or management classes. I know physicians who are doing so in order to move up the corporate ladder. Unless our goal is to be independent, which for many I suspect they are, then leadership and administrative skills are only for those who don’t necessarily wish to continue in the practice of medicine but would like to fill an administrative roll. I don’t see a problem with that but if you wish to enter into other aspects of the medical field such as management then take courses at your local college or university that will provide you with that knowledge. And you can add a few more letters behind your name! Or maybe we should add a business class into the PA curriculum. That way we could remove a class on say, orthopedics. Or did they already do that since most providers, M.D., PA, NP, already have no idea how to manage simple orthopedic cases. We need to focus on being the best health care providers we can be and quit focusing on mundane matters such as calling ourselves Entry-Level Doctors.
    By the way, NPs will always be more in number. They spew them out like too much alcohol on a bad Saturday night. Quantity will never outdo quality. Our PA programs need to keep working hard to graduate excellent health care providers who are knowledgeable and caring. You have to stand for something and our patients deserve that much.

  14. Alfred Cichon

    The discussion has progressed – good. However. it seems that we may be trying to reinvent the wheel.
    There are a number of post grad ‘residencies’ for Physician Associates – often in specialty care areas. Unfortunately they seem to not include traditional academic ‘credit’. It may be ‘time’ for development of post grad residencies that are developed to include some of the more academic subjects – suggest STEM / Administration type material with the clinical formation. Also suggest that residencies in Family Practice and Internal Medicine. Finally, agree with development of the profession that would lead to a point where a PA can ‘open a practice ‘ – the IRS already determined that we can be Independent Contractors. Yet, there should be a predictable pathway for those who would choose to transition to physician. Perhaps after course work equal to a BA take the MCAT, then after obtaining an MS and some defined point in practice enter a residency – for those who wish to transition then take USMLE and then a residency match. [just a thought]

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