A Clinical Look at Clinical Doctorates
By WILLIAM L. SILER and DIANE SMITH RANDOLPH
Universities complain about clinical doctorates, arguing that degrees like doctor of pharmacy represent little more than degree creep and are not equivalent to, say, the Ph.D. or M.D. But few institutions have done much more than complain, instead coming to rely on the revenues clinical programs bring them especially given that many students in those programs pay tuition over a longer period than do students earning bachelor's or master's degrees in the same fields. And clinical doctorates have become increasingly established over time.
The doctor-of-pharmacy degree, created in 1950, has served as a model for clinical doctorates in other fields. The American Council on Education began its justification for the new degree with the fact that the body of pharmacological knowledge was expanding, and mastering it required enough credit hours to merit a doctorate. The ACE also noted that pharmacists were practicing in new settings such as retail chains like Walgreens, and dealing with new diagnoses and new drugs. Finally, the council argued that pharmacology's status among other health-care professions required that its practitioners be called "Doctor."
Since 1950 other professions have created or considered clinical doctorates, such as doctors of audiology, nursing, occupational therapy, and physical therapy. Most of the professions use arguments like those for the pharmacists, with some recent additions: that the clinical doctorate will help practitioners work without requiring referrals by physicians, and it will allow them to charge more for their services.
Those new arguments are intriguing because they suggest that it is the degree, rather than the profession, that commands respect and recognition. In fact, clinical doctorates have so far had little effect on status, compensation, or reimbursement. There is even mounting evidence that the pharmacy doctorate, for example, has led to growing job dissatisfaction as the expectations of new practitioners clash with the realities of American health care like the fact that insurance companies pay for the kind of service provided, rather than the educational level of the provider.
Some professional organizations have pushed for clinical doctorates even though their members oppose the degrees, on the basis that the doctorates are good for the professions. Established practitioners with only a bachelor's degree may oppose the introduction of a clinical doctorate because they feel their experience makes them more qualified than a new graduate with a higher degree.
One response to objections from practitioners is a transitional degree, which awards them a doctorate for taking a few courses after having worked in the field with the required bachelor's or master's degree. Because transitional degrees are given to people who are already licensed professionals, accrediting bodies generally feel that reviewing the degrees is outside their scope; thus the degrees are seldom evaluated.
On the other hand, professions typically try to ensure the quality of new professionals by requiring them to pass a licensing exam, and by allowing only graduates of accredited programs to take the exam. Many universities have been willing to offer clinical doctorates, in spite of their reservations about the degrees' academic credibility, because they fear if they do not, students in the field will attend other universities that do.
Employers who hire new practitioners often oppose clinical doctorates. The professions frequently explain that position away as a result of corporate greed, claiming that industry is willing to place corporate profits above the quality of patients' care. But employers point out that they are reimbursed for clinical services, not according to the degrees held by their clinicians. Employers also argue that if new holders of clinical doctorates do make more money than graduates a few years ago with lower degrees, that is not because of their increased education, but because of the growing shortage of clinicians which is being exacerbated by the increased length of time it takes to earn a clinical degree.
So far, few people have investigated the clinical doctorates' implications for the public health of Americans, but it is easy to argue that the degrees could have unintended adverse effects.
First, the explosion of those doctorates threatens research, which is particularly important today with the growing emphasis on evidence-based medicine. The doctorate programs require minimal research from their students, unlike Ph.D. programs, and as colleges and universities scramble to maintain their share of the student market, they push professors' research activities further down on the list of the programs' priorities.
The programs also find themselves scrambling to get many of their faculty members a doctoral degree any doctoral degree as quickly as possible. Professors who themselves lack Ph.D.'s and who choose to get clinical doctorates learn little in the process about conducting research or advising students who seek research opportunities.
Second, because clinical doctorates require more time and thus tuition than a bachelor's or master's degree, doctorate programs may reduce the number of new graduates at a time when health-care workers are in increasingly short supply. The market may respond by using assistants and technicians to provide more clinical services, deploying people with higher credentials as supervisors and administrators. That has already begun to happen in the field of pharmacology, and job satisfaction and morale are declining because practitioners have less chance to use their clinical expertise and interact with patients.
Third, the increased time and cost involved may also exacerbate health-care disparities in our society. Few health-care professionals now come from minority populations, whose members are much better represented at the level of technician or aide, and students from those groups may be less able to afford the longer educational programs than are students from more-advantaged populations. If minority students see assistant positions as good employment opportunities that are easier and cheaper to get, we may reinforce the pattern of having minority assistants provide the actual services to patients, while supervisors come from more-privileged backgrounds. And given that students from underserved areas are more likely to return to practice in those areas, decreasing the number of minority students could make health care even less available there.
Professional organizations want to raise the status of their professions; universities want their enrollments to increase, or at least not to decline. Neither side can objectively evaluate clinical doctorates.
At the turn of the last century, the medical profession had the vision and integrity to ask the Carnegie Foundation for the Advancement of Teaching to study medical education, with the goal of strengthening it. The result was the landmark report of the Flexner Commission, which recommended standardization of medical-school programs. It's time to have a similar external study of clinical doctorates, to establish uniform criteria for them and for the professions that offer them.
William L. Siler is associate dean for research and an associate professor of physical therapy, and Diane Smith Randolph is an assistant professor of occupational therapy, at Saint Louis University's Doisy College of Health Sciences.
