Out of a sample of 1,368 practicing PAs and PA students, 636 consented and responded to the survey (46% response rate). Table 1 presents the demographic characteristics based on the number of participants who responded to each question.
A majority of respondents were female (n = 433, 69%), non-Hispanic/non-Latinx (n = 584, 93%), and White (n = 523, 82%). Most respondents held a master’s degree (n = 475, 75%), followed by bachelor’s degree (n = 97, 15%), doctoral degree (n = 60, 10%), and associate degree (n = 2, 0.3%). A total of 109 (17%) respondents identified themselves as PA students, and the remainder as practicing PAs (n = 524, 83%). Length of practice ranged from less than 5 years (n = 172, 27%) to more than 25 years (n = 37, 6%). The 38 participants who took part in the semi-structured interviews comprised 19 PA association leaders and members (50%), 9 PA program directors and faculty (24%), 6 non-PA academic leaders (16%), 2 physicians (5%), and 2 employers (5%). A majority of interviewees (n = 25, 66%) were male.
When respondents were asked if the entry-level doctoral credential should be required for PAs, both the majority of practicing PAs and students (n = 457, 72%) disagreed but the extent of disagreement varied between PA clinicians (n = 369, 79%) and PA students (n = 86, 88%). For clinicians, length of professional experience and highest earned academic degree impacted their response to this question, with fewer years of experience (see Figure 1) and lower degree (see Figure 2) tending towards opposition to requiring a doctoral transition.
Notably, when asked if the entry-level doctoral degree should be offered, but not required the majority (n = 341, 54%) of respondents (PAs and PA students) agreed with this statement, 73 (12%) respondents were indifferent, and a total of 221 (35%) combined PAs and PA students disagreed. For those supporting offering but not requiring an entry-level doctoral degree, a majority were practicing clinicians (n = 289, 55%) versus students (n = 41, 45%) who, remained against a doctoral transition.
The overwhelming disagreement with the profession moving toward an entry-level doctorate was consistent with the final question of the survey asking if the entry-level doctorate would do more harm than good to the profession. Notably, more than half of the respondents agreed that transitioning to an entry-level doctoral degree may cause more harm than good to the PA profession (n = 380, 60%) see Table 2.
Approximately one-fifth of the sample responded that transition from the PA profession to an entry-level doctoral degree would not be feasible at all (n = 128, 20%). About 5 in 10 of the respondents agreed that an entry-level PA doctoral degree will negatively impact the PA-physician relationship (n = 317, 50%) and the availability of clinical training sites (n = 334, 53%).
Table 3 presents bivariate relationships regarding perception of an entry-level doctoral degree causing more harm to the PA profession by demographics and the main study variables.
Among demographics, race [χ² (1, N = 633) = 12.07, p <.001], educational attainment [χ² (1, N = 633) = 19.98, p <.001), occupation [χ² (1, N = 632) = 8.60, p <.05], and length of practice as PA [χ² (1, N = 525) = 9.57, p <.05] were significantly associated with perception of an entry-level doctoral degree causing more harm than good to the PA profession.
Specifically, Non-Black/Non-African American respondents, those who held a master’s degree or lower, students, and PAs who have practiced for less than 5 years were more likely than their counterparts to agree that the entry-level PA doctoral degree would cause more harm to the PA profession. Additionally, respondents who disagreed with requiring [χ² (1, N = 632) = 242.54, p <.001] or offering [χ² (1, N = 632) = 86.87, p <.001] an entry-level doctorate were more likely to perceive more harm to the PA profession compared to those who agreed with requiring or offering the degree.
Those who responded that it is not feasible for the PA profession to transition to an entry-level doctoral degree were more likely than those who reported that it is feasible to perceive more harm of entry-level PA doctoral degree to the PA profession [χ² (1, N = 632) = 102.35, p < .001]. Respondents who expected negative impact to the PA-physician relationship [χ² (1, N = 633) = 198.72, p < .001] and the availability of clinical training sites [χ² (1, N = 628) = 167.43, p < .001] were more likely to agree with causing more harm to the PA profession compared to respondents who did not expect a negative impact.
Table 4 presents the results of the binomial logistic regression analysis displaying odds ratios for those who agreed that an entry-level doctoral degree would cause more harm to the PA profession, with those who disagreed as a reference group.
Regression Model 1 assessed how demographic characteristics are associated with the perception that an entry-level doctoral degree would cause more harm. Respondents who held a doctorate degree (OR = .35, 95% CI = .16–.78, p <.05) tend to disagree with an entry-level PA doctoral degree causing more harm to the PA profession. Model 2 included other variables related to the perception/perspectives of an entry-level PA doctoral degree (i.e., requiring, offering, feasibility, negative impact to the PA-physician relationship and the availability of clinical training sites.)
Respondents who agreed that the entry-level PA doctoral degree should be required (OR = .07, 95% CI = .02–.21, p <.001) tend to disagree with it causing more harm to the profession. Expectations of having a negative impact on the availability of clinical training sites (OR = 4.39, 95% CI = 1.57–12.32, p <.05) has strong positive association with the perception of an entry-level doctoral degree causing more harm while adjusting for covariates.
When respondents were asked about the potential impact of transitioning to a doctoral degree on the PA scope of practice and patient related outcomes, responses varied depending on the aspect of practice and outcome in question (see Figure 3).
Positive impacts included, enhanced billing and reimbursement opportunities (n = 277, 44%), enhanced optimal team practice (n = 248, 39%), enhanced capacity for PAs to practice at the top of their license (n = 305, 48%), and the possibility of enhancing practice autonomy (n = 374, 60%). The majority of respondents agreed that a doctoral transition would not: increase access, quality and cost effectiveness of care (n = 308, 49%) or increase patient satisfaction (n = 297, 47%). Regarding impact on flexibility, respondents (n = 249, 40%) indicated agreement a transition would not impact PA flexibility for working across specialties.
When respondents were asked about the potential impact of transitioning to a doctoral degree on the impact of the PA profession as a whole, responses also varied depending on the category item (see Figure 4).
Positive impacts included, advance public recognition (n = 309, 49%), parity with other professions (n = 342, 54%), enhanced billing and reimbursement opportunities (n = 289, 46%), and enhanced competitive advantage (n = 345, 55%). Negative impacts included, increase to the cost of PA education (n = 585, 93%) and negative impact on diversity (n = 403, 64%). Many respondents agreed that a doctoral transition would not increase enrollment and demand (n = 367, 58%) or boost career satisfaction (n = 284, 45%).
When respondents were asked to rank aspects of the PA profession that would either be positively or negatively impacted by a doctoral transition, the top three positive impacts were leadership opportunities; parity with other professions; and competitive advantage (edge), whereas the top three ranked negative impacts were cost of PA education programs; diversity in the PA profession; and PA-physician relationship.
If the PA profession opted to have a doctoral degree as the terminal agree, 73 respondents (12%) supported a Bachelor’s to Doctorate pathway, 113 (18%) supported a Master’s to Doctorate pathway and 435 (70%) supported a bridge program (working clinically) to doctorate. When exploring title nomenclature for a PA doctoral degree, respondents reported that the most appropriate title from the choices provided was Doctor of Medical Science (DMSc, 24%), followed by 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 appropriate title being the Doctor of Health Science (DHSc, 4%).
Using a deductive approach, we analyzed the semi-structured interview data and the responses to the open-ended survey questions. The following perceived risks and impact of a doctoral transition were expressed by various stakeholders, see Table 5 for sample responses.
Perceived Risks. Participants expressed concern that a doctoral degree transition might harm the PA-physician relationship, confuse patients, and defeat the purpose of having advanced practice providers that are mid-level general practitioners. There was also consideration that it would potentially marginalize PAs with master’s degrees. More concerns included the potential increase in cost of education and student debt, possibility of a longer curriculum, and an increase in faculty shortage. These concerns were seen as a potential threat to building diversity within the profession as well as reducing overall PA career flexibility. Stakeholders commented on how the PA profession has served as a cost savings for the health care system and contemplated how a doctoral degree transition, resulting in potential higher salaries for entry-level graduates, would dissipate this cost savings. Further, concern included that an entry-level doctoral requirement would be misaligned with the historical roots of the PA profession. Noting, any increases in the length of entry-level education would defeat the original mission and design of PA education to provide a quick supply of healthcare workforce.
Perceived impact on PA profession. Responses directed at how this transition would impact the PA profession, included comments that a doctoral degree would put PAs on a level playing field with NPs and enable PAs to remain competitive in healthcare. Several stakeholders stated a belief that the current master’s degree is the most appropriate terminal degree and were concerned about how a transition would affect PAs already practicing. Some participants felt a doctoral degree would have no immediate return on investment with no change in patient perception, clinical expertise or impact on the scope of PA practice. However, other participants felt that a doctoral degree would open the scope of PA practice in states where PAs are more limited. A subset of those interviewed, primarily individuals identifying as having a primary role in higher education, suggested a doctoral transition could increase leadership opportunities within education and research. Participants also noted that having a doctoral degree would allow PAs access to administrative positions in the healthcare system and entry into policymaking and regulation.