Physician Assistants/Associates With Doctoral Degrees:... : The Journal of Physician Assistant Education (2024)

INTRODUCTION

The physician assistant/associate (PA) profession is one of the fastest growing healthcare careers in the United States, with a projected 30% to 35% growth increase from 2020 to 2035.¹ The educational degree credential offered to students seeking to become PAs is a master's degree, which presently serves as the entry-level and terminal degree in this field. However, the proportion of PAs with doctoral degrees has been growing rapidly from 1% in 2017 to 2.1% 2021.² The most frequent doctoral degrees are PhD, DMSc, MD, and DHSc.² The motivation, impact, and return on investment of holding a doctoral credential among clinically practicing PAs remain to be understood. The influence of factors, such as personal professional development, leadership opportunities, or the pursuit of other interests outside of PA clinical practice, needs to be studied. In addition, there is currently not enough information regarding the comparative advantages between those holding clinical doctoral degrees versus research doctoral degrees among the rank and file PAs.

Despite the efficacy of the master's degree in training PAs to provide excellent patient care and satisfaction, there is debate regarding a potential transition to entry-level and terminal doctoral degree credentials. A move to an entry-level doctoral degree has occurred in recent years in multiple healthcare disciplines, including nurse practitioners, pharmacists, and physical therapists. The process of degree changes in other health professions paves the way for PAs to consider the risks and benefits of a degree change.³ The PA profession is largely divided regarding the potential move to a doctoral degree, and few research studies have been conducted surrounding the topic of adding or requiring a doctoral degree for PAs.⁴ The PA profession does not currently have any programs that offer an entry-level doctoral degree.

The impact of doctoral credentials to PAs is broadly unknown. There are reports of concerns that a degree change may negatively affect diversity within the profession.^5,6 The PA profession has disproportionately low percentages of PAs of color, with 80.6% identifying as White; thus, the risk of widening that gap is an important concern.^2,7 As the United States becomes an increasingly multicultural and diverse society, the PA workforce must reflect that diversity to best serve patients, particularly given that increased diversity in healthcare professionals is associated with positive healthcare outcomes.^8-11 Additional demographic considerations include the sex and gender gaps in the profession. The profession is primarily female²; however, men are more likely to experience professional advancement, have an increased academic rank, and hold various leadership positions in the medical professions.¹²

The potential for leadership opportunities is among the top 3 positive impacts a doctoral degree may have for the profession.^5,13 Physician assistants/associates hold great potential to take on more leadership roles because of the team-based training they have received.¹⁴ Physician assistants/associates are well-situated to be leaders in their field and are a growing voice in leadership as they take on leadership roles in education, research, and administration.^15,16

Physician assistants/associates practice medicine in a large array of settings and specialties. The most common practice areas and positions for PAs are surgical (18.7%), family medicine/general practice (17.7%), emergency medicine (11.8%), and internal medicine (9.7%) subspecialties.² Most PAs work in a hospital (41.6%) and office-based private practice (37.4%).² How these trends differ for PAs with doctoral degrees is currently unknown. Comparatively, higher percentages of PAs in academia hold doctoral degrees.^16,17

The purpose of this study was to describe demographic characteristics and practice patterns of PAs who have doctoral degrees. We hope this work may shed more light on the potential impacts of doctoral degrees for PAs and provide needed evidence for the ongoing debate on whether the PA profession should move to doctoral-level training.

METHODOLOGY

Participants

This study was a cross-sectional retrospective study using deidentified data from the American Academy of Physician Assistant (AAPA) 2021 Salary Survey.¹⁸ The AAPA distributed the survey to all PAs in the United States from February 1, 2021, to March 1, 2021. To be eligible, participants had to be PAs who worked as a clinician, educator, researcher, or administrator in 2020, be based in the United States, and be nonretired. A total of 13,865 responses were received, with an estimated response rate of 13.3%. The overall margin of error for the survey is ±0.79% at the 95% confidence level.

This study focused on a subset of the total responses from clinically practicing PAs. To be included in this analysis, participants must have answered that their primary occupation is a PA (eg, not a student or other healthcare provider) and answered “yes” to the question, “In the prior calendar year, were you clinically practicing at least some of the time?”

Research Instrument and Measures

The AAPA Salary Survey instrument consists of demographic questions such as gender, age, and race/ethnicity. The survey asked PA practice-specific questions including the PAs' primary role (eg, clinician, educator, administrator/manager) and specialty of medicine (ie, primary care, internal medicine subspecialties, pediatric subspecialists, surgical subspecialties, emergency medicine, or other specialists), type of practice, salary, benefits, and titled roles. Physician assistants/associates also provided their highest degree earned (ie, associate's, bachelor's, master's, or doctorate). Physician assistants/associates provided information about the length of time working as a PA, length of time in clinical practice, and years worked at the current employer.

Variables

Response options for highest level of education were associate's, bachelor's, master's, or doctorate/professional (eg, PhD, JD, and MD). Responses were used to code a dichotomous variable indicating whether the participant has a doctorate (yes or no).

Additional variables categorized respondent demographics. Respondents indicated their gender (female, male, and prefer to self-describe) and race/ethnicity (Asian, Black/African American, White, Hispanic, Other [recategorized to include American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, 2 or more races], and prefer not to answer). Age was recategorized into ranges (<30, 31–39, 40–49, 50–59, and 60+ years).

We examined several variables related to work-related experiences. Respondents indicated their primary role as a PA as clinician, educator, administrator/manager, researcher, volunteer, or “other.” Primary settings included outpatient clinic or physician office, hospital, or urgent care center. Additional primary setting options (eg, rehabilitation facility or extended care facility) were combined into a single category of other because of low frequency.

Career length was recorded in years and categorized into ranges (0–4, 5–9, 10–14, 15–19, 20+). Length of time at employer was recorded in years and categorized (0–1, 2–4, 5–9, 10–14, 15–19, 20+). Respondents were asked about compensation from various sources, which AAPA used to calculate an estimate of total annual salary. We dichotomized this categorical variable with reference to the median annual salary reported by AAPA for PAs in 2020 ($110k). Respondents were asked if they had a leadership role, with leadership defined through task examples such as supervising staff, educating/orientating/onboarding others (not precepting), leading quality and performance improvement activities, or managing a budget. Response options were yes/formal, yes/informal, and no. Finally, respondents designated their primary specialty as primary care, internal medicine, pediatrics, surgical, emergency medicine, other specialty, or no medical specialty. Owing to the low frequency of pediatric subspecialists, they were combined with the category of “other” specialties.

Data Analysis

To answer the research questions, descriptive bivariate statistics and chi-square tests were used. Chi-square tests of independence or Fisher exact tests were used to examine the cross-tabulation between the demographic variables (age, gender, and race/ethnicity) and whether the respondent had a doctoral degree. Chi-square tests were also used to examine cross-tabulation between doctoral degree and work-related variables, such as leadership role, primary role, primary setting, length of time as a PA, length of time practicing, and years at the current employer. Nonresponse to some items resulted in different samples sizes for some items. A P-value of less than .05 was selected as the alpha criterion.¹⁹ SPSS 26 was used to perform the analysis. All participants consented to taking part in the survey. This study was approved by the (deidentified) University Institutional Review Board.

RESULTS

Demographic Factors

There were significant relationships between holding a doctoral degree and all demographic characteristics examined (Table 1; all P < .001). While 26.0% of participants without a doctoral degree were younger than 30 years, among the participants who had a doctoral degree, only 6.4% were younger than 30 years. The remaining 93.6% of PAs with doctoral degrees were older than 30 years with a fairly even distribution among the decades. Those who were in their 40s had the highest frequency of doctoral degrees.

In addition, 73.5% of PAs without a doctoral degree self-identified as female while only 55% of those with a doctoral degree self-identified as female. Most of the PAs both with and without doctoral degrees identified as non-Hispanic White; however, the percentage was lower for those with doctoral degrees compared with those without (70.4% vs. 82.3%). Those with doctoral degrees had larger proportions of minoritized racial/ethnic groups, with 11.2% identifying as Hispanic/Latinx, 7.5% non-Hispanic Asian, 7.5% non-Hispanic Black/African American, and 3.4% other/multiracial.

Work-Related Factors

There were also significant associations between having a doctorate degree and all of the work-related factors investigated (Table 2; all P < .001). The majority of participants both with and without doctoral degrees reported their primary role as clinician (Table 2). The second largest category were educators, but they made up a larger percentage of those with doctoral degrees compared with those without (9.6% vs. <1%). The remaining few were primarily administrators or researchers. Owing to the very small number of participants, these categories were not included in the analysis. Of PAs without a doctoral degree, 24.4% held an informal leadership role and 10.5% held a formal leadership role. Physician assistants/associates with a doctoral degree held more leadership roles: 30.1% held an informal leadership role and 28.9% held a formal leadership role. A larger proportion of PAs with doctoral degrees had an annual salary above the median (62.3%) compared with PAs without doctoral degrees (40.0%).

Physician assistants/associates primarily worked in outpatient clinics or physician offices or at a hospital (Table 2). Similar numbers of those with (35.1%) and without (36.2%) doctoral degrees worked in a hospital. Physician assistants/associates without a doctoral degree were more likely to work in an outpatient clinic or physician office (54%) compared with those with a doctoral degree (46.6%); those with doctoral degrees instead had higher rates of working at an urgent care center (6.8%) and in “other” settings (11.5%). The most common specialties for both those with and without doctoral degrees were primary care (with doctorate: 21.5%; without doctorate: 20.9%) and “other” specialties (with doctorate: 32.3%; without doctorate: 27.9%) The largest differences between those with and without a doctorate were that 16.8% of participants with a doctoral degree worked in surgical subspecialties compared with 27.9% of those without a doctoral degree while those with doctorates had slightly higher rates of specializing in internal medicine subspecialties (15.9%) and emergency medicine (10.9%).

In general, PAs with doctoral degrees had been at their current position longer than those without doctoral degrees (Table 2). Among PAs who had a doctoral degree, 64.9% have been a PA for at least 10 years, with 28% having been a PA for 20 or more years. By comparison, 37.4% of PA without a doctorate degree have been a PA for at least 10 years and only 13.5 have been a PA for 20 years or more. Furthermore, 38% of those without doctoral degrees have been a PA for <5 years. Of PAs with doctoral degrees, only 15.5% have been at their employer for 1 year or less while this is the case for 28.0% of PAs without doctoral degrees. Finally, 47.7% of those with doctoral degrees have been with their employer for 10 or more years compared with 33.8% of PAs without doctoral degrees.

DISCUSSION

This study investigated demographic characteristics and practice patterns of PAs who have doctoral degrees. We found significant differences in multiple demographic factors and work-related factors between PAs with and without doctoral degrees. Taken together, the results suggest that holding a doctoral degree may be associated with upward mobility at workplaces. The study also has implications for the PA profession's ongoing debate regarding terminal doctoral credentials.

Demographic Factors

This study describes PAs with doctoral degrees in relation to age, gender, and race/ethnicity. By and large, PAs with doctoral degrees tended to be older than those with doctoral degrees, and most were older than 30 years, which is not surprising considering the time investment it takes to complete a doctoral degree. The 6.4% younger than 30 years who have doctoral degrees may have obtained the degree before becoming a PA or they may have pursued it for professional development reasons early in their career, such as working in academia, where doctoral degrees are encouraged or sometimes required based on the position held.

Of participants without a doctoral degree, 73.5% of the PAs were female, which reflects the overall gender distribution of the profession. However, this study demonstrated that the gender disparity is smaller in PAs with doctoral degrees with 55% female and 45% male. This is more consistent with the general US gender distribution in the population. This distribution of closer “equality” was supported by the hypothesis of male pursuit of professional development.¹²

In general, most of the PAs surveyed identified as White (80%), and among PAs with a doctorate, also most were White (82.3%). However, compared with those without doctoral degrees, among participants with a doctoral degree, there were significantly higher proportions of PAs who self-identified as Hispanic/Latinx (11.2%) and non-Hispanic Black/African American (7.5%). These are closer to statistics of US demographics in the general population. The association between having a doctorate degree and race may be attributed to the pressure of non-White PAs to hold more education to achieve similar leadership positions.¹⁶

Work-Related Factors

This study found that clinically practicing PAs with doctoral degrees are statistically more likely to hold both informal and formal leadership roles compared with those without doctoral degrees. Because the analysis in this study is of associations and not causal relationships, further studies are needed to explore whether those interested in leadership positions are more likely to pursue further doctoral credentials or whether the doctoral degree provided a specific skill set or competitive resume to be equipped for a leadership role. Overall, our findings are consistent with previous survey findings which have revealed low leadership aspirations among newly certified PAs who generally do not have doctoral degrees. In 2020, only 13% of newly certified PAs shared that leadership potential was an employment incentive that was offered to them.²⁰

Physician assistants/associates with doctoral degrees were also more likely to have salaries above the median. Because most of those with doctoral degrees were older than 30 years and/or have been a PA for 5 years or more, length of time as a PA or length of time worked at the current employer (job tenure) could be contributing factors both to gaining leadership positions and increased salary. Leadership and salary in health professions can also be influenced by other factors including race and gender.^21,22 Future investigations that control for individual variables will be essential to fully elucidate the associations between doctoral degrees and salaries for PAs.

While prior studies have shown PA educators commonly pursue doctoral degrees for promotion, the motivation for doctoral credential pursuits in clinical settings for PAs remains unknown. Further development of leadership skills could include interpersonal skills, conflict resolution, leadership styles and theories, and implicit bias training. While many PA programs already offer PA professionalism content, specific competencies toward leadership skills may vary from program to program. Physician assistant/associate educators should consider what curriculum changes are needed in doctoral education for PA students. Accreditation considerations also should adapt clear leadership competencies and outcomes if the terminal degree change is desired to increase leadership positions held by PAs.

Of PAs with doctoral degrees, 90.4% were primarily clinicians and 9.6% were primarily educators. The larger frequency of educators among those with doctoral degrees compared with those without was expected; however, we may have expected an even higher percentage of educators among those with doctoral degrees. The largest frequency of PAs with doctoral degrees were working in an outpatient setting, followed by a hospital and urgent care setting. The significant association between setting and doctoral degree was likely among the “other settings” category, which had a higher frequency among participants with doctoral degrees. This may be because “other settings” included the education sector.

The most notable difference in specialties was that 27.9% of PAs without a doctoral degree are in surgical subspecialists compared with 16.8% of PAs with doctoral degrees. Physician assistants/associates working in surgical subspecialties may have been trained on the job for their unique skill sets and not see a need for a doctoral degree. Alternatively, the PAs in surgical subspecialties may be pursuing fellowships specific to their area of expertise without a need for a doctoral degree credential.

Possible Implications for the Terminal Degree Debate

This study was a descriptive analysis of PAs who already hold a doctorate degree and cannot be directly applied to the entry-level doctorate debate for the PA profession. However, this study does provide possible implications for terminal-doctoral PA credentials. It also has implications for PA educators as they design doctoral-level programs to meet the growing trends.

If the PAs change to a terminal doctoral degree, there could be a potential to attract more men to pursue the profession because of the title, rank, and potential leadership potential. This has implications for marketing of the profession to pre-PA students, as well as current PAs to consider a terminal degree as a method of professional development. If the doctoral degree results in a trend toward more equality in gender distribution, then this has implications not only for patient care but also on healthcare team dynamics. Having an increase in gender diversity in PAs who work primarily in clinical medicine and in PAs who work in education will be an important step to better reflect patient populations.

It could be argued that the higher proportion of people of color among those with doctorates counters concerns that a change to a terminal doctoral degree will negatively affect diversity. However, there are several reasons to think this is not the case. A potential increase in tuition cost is likely if the length or credit load of a doctoral PA program is altered.²³ An increased PA school tuition cost may weigh heavily on PA students, many of whom already take on significant debt to complete their training. There are additional barriers for low socioeconomic status students to PA school admission including influences of financial challenges on preadmission and admission processes, in addition to historical macroaggressions and microaggressions in education parity in the United States.²⁴ Regardless of the terminal degree, understanding barriers and challenges of applicants to the PA profession is key to ensure the future diversifying of the profession to better reflect the diversity of the patient population in the United States.

This study describes practice patterns of PAs holding doctoral degrees such as a leadership role, primary role, and primary workplace setting. One perceived benefit of a doctoral degree is the potential for increased leadership opportunities. Accreditation considerations also should adapt clear leadership competencies and outcomes if the terminal degree change is desired to increase leadership positions held by PAs.

Physician assistants/associates with doctoral degrees tended to have been PAs longer and employed at their current workplace longer than PAs without doctoral degrees. It is unknown whether this has to do with job satisfaction or reduced career flexibility that may be associated with holding a doctoral credential. Owing to the nature of the study, it is unknown when the PAs obtained doctoral degrees in relation to becoming PAs or taking their current positions. Regardless of the order of degree, the participants with doctoral degrees were largely more experienced PAs. In general, because the master's degree is the terminal degree, most PAs chose their employer for clinical reasons and not necessarily for credential changes. For PAs who have pursued a doctoral degree, it may indicate a desire to change career areas within their clinical practice such as entering education or focusing on public health.

Strengths and Limitations

This is among the first studies to our knowledge that examined demographic and work-related differences between PAs with and without doctoral degrees, providing important information in the debate around doctoral degrees for PAs. Despite the low response rate (13.3%, n = 13,865), this study is based on a national large data set with the potential to be representative of the PA profession for those with terminal doctoral credentials. For instance, the proportion of respondents with a doctorate degree (2.6%) was consistent with data reported by other surveys such as the 2021 National Commission on Certification of Physician Assistants report. However, the observed trends could be different in subgroups of PAs, and we are unable to examine the chronology of PA and doctoral degree credentials. In addition, we were unable to examine the specific type of doctoral degrees held by participants. This was a descriptive study, without controlling for individual variables. We recommend that future researchers examine the order of credentialing and motivating factors for doctoral degrees. There is currently not enough information about the specific motivating factors for PAs to hold a doctoral degree, but factors including personal professional development, leadership opportunities, or the pursuit of other interests before or after becoming a PA should be considered. Differences between those holding clinical doctoral degrees versus research doctoral degrees may also affect the PA profession doctorate debate.

CONCLUSION

This study was among the first to analyze data surrounding the characteristics of clinically practicing PAs with terminal doctoral degrees. Physician assistants/associates with doctoral degrees have higher frequencies of men and PAs of color; however, this result may not necessarily be because of the degree itself. Most of the PAs with doctoral degrees in the sample were holding informal or formal leadership positions, which may be influenced by the fact that most doctoral-credentialed PAs have been PAs and at their current positions for longer lengths of time.

REFERENCES