Trends in Doctoral Education Among Healthcare Professions: An Integrative Research Review

INTRODUCTION

Recent proliferation of clinical doctoral degrees among health professions has created conversations on educational and professional practice models, quality of professional education, independent practice opportunities, and future directions.¹ Doctoral education with the accompanying title of doctor was never reserved solely for physicians as the Latin root of the word doctor means “to teach”. In fact, the first doctors lectured on finer points of law, philosophy, or the state of man's soul to become a doctor of law, a doctor of philosophy, or a doctor of divinity in order to teach at institutions of higher learning.^1–3

The Medical School of Salerno established the first medical doctorate during the 13th century with a 5-year curriculum and 1 year of supervised practice.³ Columbia University granted the first North American medical doctorate in 1767, with Harvard University transitioning from a bachelor of medicine to a doctor of medicine degree in the 1800s.^2–5 This medical education model persists with slight variations, but generally requires at least 3 years of baccalaureate-level basic science and liberal arts prerequisites, 4 years of entry-level medical training (2 years of didactic courses and 2 years of clinical experiences), and 1 to 5 years of graduate-level residency training, interspersed with required standardized examinations at each step of the process.^5,6

As medical knowledge expanded and unmet patient needs were identified, specialty practice areas developed⁷ and new health professions were born.⁸ With each profession identifying its knowledge base and scope of practice, the need for practice standards and focused educational programs became apparent.⁷ Professional maturation led to further curricular and knowledge expansion culminating in the adoption of a doctoral degree as requisite for professional entry.⁸

Doctoral degrees are generally categorized as entry-to-practice professional degrees (AuD, DDS, DO, DPM, DPT, MD, OD, OTD, PharmD), postprofessional advanced practice degrees (DNP), or postmaster's academic degrees (EdD, PhD) with either practical (EdD) or theoretical (PhD) emphases. Although professional education was once closely tied to academic degrees, a steady move away from the academic model to a professional education model has occurred.^3,8,9 The shift to a professional education model may impact health professions on a variety of levels (eg, salary, public recognition, scope of practice, debt burden, research productivity). Recent discussions in athletic training have focused on determining the best entry-level educational model (ie, baccalaureate, entry-level masters, entry-level doctoral), and the role of doctoral and postprofessional clinical training (eg, residencies and specialty certifications).^10–12

Despite the many professional doctoral programs in existence, differences in curricular approach, educational and professional impact of clinical doctorates, and the relationship between doctoral education and practice opportunities remain poorly understood. Thus, our purpose was to conduct an integrative research review and comparative analysis of doctoral education among health professions to further explore these issues. Our study was guided by the following research questions: What doctoral education models are currently utilized among health care professional education programs in the United States? How do entry-level clinical doctorates in health care professions impact postprofessional training, productivity, and practice opportunities? How do clinical doctorates among health professions influence salary?

METHODS

Data on professional accrediting standards, admission requirements, and doctoral curricular standards were extracted from professional organization and accrediting body Web sites (Table 1) to assess and categorize the professional educational model and provide data for curricular features listed in Table 2. Income data for various health professions was extracted from the US Department of Labor database and are summarized in Tables 3 and 4. A search of 38 databases in the University of Washington libraries including WorldCat, ERIC, ArticleFirst, MEDLINE, BioMed Central, ScienceDirect, and Academic Search Complete for “clinical doctorate” yielded 272 results, primarily editorial in nature. A second search using the keywords “health care professional doctoral education” yielded 39 results. All search results were limited to full-text articles published in English between the years 2001–2011. Articles related to gender studies, minority representation, student success prediction modeling, learning styles, management, educational leadership, continuing education, social work, business management, complementary and alternative therapies, international health care education, and technology literacy were subsequently excluded along with editorial and commentary articles. The remaining article abstracts were reviewed for compatibility with our research questions and, as applicable, included in our literature review of 21 articles. Data were extracted by 2 researchers using a standardized rubric and coded according to emergent themes. Coded data clustered around our research questions to further explain the impact of professional doctorates among health care professions.

Table 1.  Professional and Accrediting Agency Web Sites Utilized During Research Process

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Table 2.  Summary of Doctoral Education Programs Among 14 Health Professions

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Table 2.  Extended

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Table 2.  Extended

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Table 3.  Salary Trends Among Health Professions with Standardized Doctoral Education

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Table 4.  Salary Trends Among Health Professions Without Standardized Doctoral Education

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RESULTS

Our first research question asked what doctoral education models are currently utilized among health care professional education programs in the United States. Results indicated that two-thirds (n = 10) of the 14 examined health professions following the medical model of postbaccalaureate entry-to-practice professional doctoral education with a didactic and clinical experience component. Less than a third (n = 4) of surveyed professions reserved doctoral-level education for advanced practice, and only occupational therapy maintained both entry-level and advanced practice doctoral degrees. Nursing supports both master's and doctoral level advanced practice degrees, with the doctor of nursing practice promoted, but not mandated, as the preferred degree. Physician's assistants maintain master's-level professional education, with the US Army offering an advanced practice doctorate with a specialty in emergency medicine.^13–35

The second research question explored the impact of entry-level clinical doctorates in health care professions on postprofessional training, productivity, and practice opportunities. Results suggested that entry-level clinical doctorates provide adequate knowledge and skills to begin clinical practice, but insufficient research and specialty training, necessitating further education after graduation. A theme of low student motivation to pursue further education after obtaining a clinical doctoral degree was also observed. Of the 15 professional doctoral degrees examined, only 4 required completion of an original research project (Table 2). Our review revealed themes of an overall shortage of faculty with research expertise and decreased research productivity among physical therapy faculty. Paradoxically, while academia may be negatively affected by clinical doctorates, practice opportunities were perceived to expand.^36–50

The third research question focused on the influence of clinical doctorates on salary. Results indicated that salary trends among health professions that transitioned to clinical doctorates during the past decade reflected increases of 29–65% with a mean salary of $77 198 in 2009 (Tables 3 and 4).^51,52 Factors contributing to this increase were not evaluated.

DISCUSSION

Our review indicated that many health professions have adopted an entry-to-practice doctoral education model, which is perceived to increase practice opportunities, professional standing, depth and breadth of learning, and curricular space.^35,38,41 Distinct philosophical and role differences exist between professions that have embraced entry-level clinical doctorates and those that have reserved clinical doctorates for advanced practice (Table 2). Direct access to patient populations and health provider referral are 2 defining attributes of professions that have adopted clinical doctorates, not by virtue of the degree alone, but in accord with regulatory support and establishment of professional autonomy. Notably, professions requiring physician oversight or that are limited to a narrow range of technical tasks have not adopted doctoral education.^{13–35,42–44}

Concerned stakeholders have articulated that clinical doctorates constitute degree inflation with unchanged entry to practice standards that are merely repackaged into a doctoral degree,^3,33,35 while others cite greater breadth and depth of foundational scientific knowledge, ability to critically adapt skills and knowledge in context of new knowledge, and comprehensive understanding that can be realized in a program with greater curricular space.^{3,33,34,44,49} Additional supportive arguments include an assertion that entry-to-practice doctoral training assists in career advancement, leads to higher salaries, enhances third party reimbursement, and improves public recognition.^29,34,49 One study indicated that graduates with professional doctorates reported greater employment satisfaction compared with baccalaureate graduates.⁴⁴

Some professions have observed unintended consequences with the transition to entry-level doctoral education. Academic departments housing physical therapy doctoral programs have experienced exacerbated shortages of qualified faculty and decreased research productivity.^38,47,53 Students reported low motivation to pursue advanced practice and research-oriented credentials citing finances, time constraints, disinterest, and lack of perceived benefit after already completing a doctoral degree.^30,36,45,54 Some professions, such as pharmacy, continue to debate whether students graduating with an entry-level clinical doctorate do so with insufficient patient access and clinical experience. The concept of mandatory postprofessional training (eg, residencies) following the completion of the entry-level clinical doctorate has emerged from this discussion.³⁶ However, adding a residency experience further increases the cost of doctoral level professional education, increasing ethnic and socioeconomic disparities, and decrease workforce diversity.^39–41,55

In light of these consequences, nurses have reserved doctoral education for postprofessional training to enhance career advancement opportunities, help a practitioner specialize,^29,39,40 improve patient outcomes,³⁵ and support translational research.³⁹ Advanced practice specialties within nursing include nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each advanced practice area has associated subspecialties, all of which are regulated by national specialty boards. Most advanced practice nursing programs have existed at the master's degree level, but the American Association of Colleges of Nursing has designated the DNP as the terminal clinical degree to be implemented by 2015, though many programs have already adjusted their curricula.^{3,8,25,30,56,57} A student must possess a bachelor of science in nursing and current registered nurse licensure before pursuing the 3-year doctor of nursing practice (DNP) degree.⁸

CONCLUSIONS

Most health care professions follow the medical model for professional preparation, though at reduced intensity with fewer clinical hours than physician training. Clinical doctorates have become the new educational standard among most health professions with perceived increases in professional opportunities and are associated with higher salaries. However, research training, research productivity, diversity, and professional debt burden have been negatively impacted by this trend. Various strategies have successfully incorporated clinical research training into existing professional and postprofessional doctoral programs but must be planned into the curriculum.

When athletic training education is considered in context with trends in other health professions, it appears that the most realistic next step for athletic training education is to transition to the master's degree for entry to the profession and officially reserve the Doctor of Athletic Training for advanced practice. Furthermore, vigorous efforts to expand opportunities for direct access to patient populations and increased reimbursement rates are necessary to secure athletic training's place as a provider of patient services and improve professional standing beyond the technician's role to which many athletic trainers have been relegated. The official stance by the profession is important to maintain athletic training's professional niche and provide clarity in the profession's educational sequencing. Currently, no entry-level doctoral degrees in athletic training exist, which makes official decisions on the future of professional and post-professional education timely. If not prohibited, it will only be a matter of time until we see our first entry-level doctoral degree in athletic training, which will once again create degree ataxia. With careful planning, athletic training can learn from consequences of policy changes among other professions, strategically avoid repeating mistakes, and create a roadmap to the future that will ensure professional integrity and viability in the healthcare marketplace.