Transition to the Clinical Doctorate: Attitudes of the Genetic Counseling Training Program Directors in North America
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- Stuenkel, A.J., Campion, M., Allain, D. et al. J Genet Counsel (2012) 21: 136. doi:10.1007/s10897-011-9407-4
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In North America, genetic counseling is an allied health profession where entry level practitioners currently must hold a master’s degree earned from a graduate program accredited by the American Board of Genetic Counseling. This is one of many health care professions that could transition to an entry level clinical doctorate degree. This study explored the attitudes of genetic counseling training program directors toward such a transition. Thirty-one North American program directors were invited to complete an online survey and a follow-up telephone interview. Twenty-one program directors completed the survey and ten directors also completed a follow up phone interview. There was disagreement among the respondents on the issue of transitioning to a clinical doctorate degree (nine in favor, six against and six undecided). Respondents disagreed about whether the transition would lead to higher salaries (six yes, eight no, and seven unsure) or increased professional recognition (eight yes, eight no, and four unsure). Approximately half (n = 10) of directors were not sure if the transition to a clinical doctorate would help or hurt minority recruitment; six thought it would help and four thought it would hurt. However, the majority (n = 13) thought a clinical doctorate would help genetic counselors to obtain faculty positions. If the field transitions to a clinical doctorate, 11 of the directors thought their program would convert, seven were unsure and one thought their program would shut down. Themes identified in interview data included 1) implications for the profession 2) institution-specific considerations and 3) perception of the unknown. Opinions are quite varied at this time regarding the possible transition to the clinical doctorate among genetic counseling training program directors.
KeywordsGenetic counselingClinical doctorateProgram directorsGenetic educationTraining
Genetic counseling is a relatively new allied health profession which currently requires a master’s degree from a graduate training program with accreditation from the American Board of Genetic Counseling (ABGC). Doctoral degrees in genetic counseling have been considered for some time. More recently, the possibility of transitioning from an entry level master’s to a clinical doctorate degree has been up for discussion. A clinical doctorate is a professional degree emphasizing advanced clinical training (Fields 1988). Contrastingly, the familiar Doctor of Philosophy (PhD) degree prepares candidates for careers focused in research and teaching.
Development of a PhD doctorate degree in genetic counseling has been debated since it was first proposed at the National Society of Genetic Counselors (NSGC) annual conference in 1986 (Scott et al. 1988). A NSGC member-wide survey in 1991 revealed that 54.4% (n = 180) of practitioners felt there was a need for a PhD doctoral degree in the field, while 15.1% (n = 50) did not see a need and 30.5% (n = 101) were undecided (Gaupman). Subsequent studies have investigated the interest in transitioning to a PhD doctorate amongst genetic counseling students and program directors (Bedard et al. 2007) as well as potential employers (Wallace 2008). Of the 201 students surveyed by Bedard et. al., 95 (47%) felt the development of a PhD doctoral degree in the field was either very important or somewhat important, 62 (31%) reported a neutral attitude and 44 (22%) felt advanced degree development was of low importance or not important. The same study also investigated the attitudes of genetic counseling training program directors. At that time, a majority of directors (13/24) viewed PhD doctoral degree development as very important or somewhat important, 4/24 reported a neutral attitude and 8/24 felt it was of low or no importance.
Twenty three of the 30 employers interviewed by Wallace et al. imagined opportunities for genetic counselors with a PhD, especially in research and academic roles (2008). The authors concluded that there may be a unique employment niche for PhD-level practitioners.
Consideration of a clinical doctorate as a degree option for genetic counseling was first proposed in 2006, after results from a NSGC member-wide survey suggested that the degree may be more suitable due to the primarily clinical nature of the profession (Clark et al. 2006). In this study, participants responded to various survey questions regarding their current research activities, desire for involvement in future research and opinions on what would be their ideal percentage of work time committed to research activities. Results indicated that, while an increasing percentage of genetic counselors were involved in research and expressed a desire for continued research involvement, the majority of practitioners (67%) reported their primary role as clinical. In addition, respondents indicated that the ideal amount of work time committed to research activities would be 25%. As such, the authors suggested that a clinical doctorate, not a PhD, may be the most appropriate degree option beyond the master’s for the majority of genetic counselors.
Program directors from Arcadia University, an accredited genetic counseling graduate program in the US, organized four discussion groups of practicing genetic counselors in 2008 to assess opinions about and knowledge of the clinical doctorate degree (Conway et al. 2009). Intended to inform the design of a follow-up quantitative survey, these discussion groups utilized a convenience sample of 29 genetic counselors and results were presented as tabulated comments. Based on the participants’ feedback, the following conclusions were made: there continued to be significant interest in an advanced degree beyond the master’s amongst practicing genetic counselors and very few genetic counselors were aware of a clinical doctorate as an advanced degree option. Additionally, most discussion group participants were “interested and excited about the possibility” of the development of a clinical doctorate degree. However, given the small sample size, it is unclear if the data collected was representative of the profession as a whole.
The Clinical Doctorate Degree
A clinical doctorate differs from a PhD in that the training is shorter, typically lasting 3 or 4 years, is not as research intensive, and does not require an oral defense of the thesis (Downs 1989). The Association of Schools of Allied Health Professions (ASAHP) released a statement in 2008 listing the following pros and cons for the transition to an entry-level clinical doctorate:
Extended training to address new developments in the field.
More clinical experience is received as a student, leading to improved clinical skills as well as greater breadth and depth of clinical training.
Higher training may result in improved patient care.
Gives more status to the profession as practitioners are more highly qualified by virtue of their additional years of training.
More time to finish a thesis and possibly work toward publication.
May result in higher salaries.
Increased financial burden on students and programs.
Uncertain effects on diversity and student recruitment.
Program faculty may be required to transition to a clinical doctorate. Some faculty may resign over this.
Some programs may be unable to offer doctoral programs.
Unlikely to have a significant positive impact on reimbursement rates, and thus salaries.
Transition from master’s training to an entry-level clinical doctorate has already occurred in many other allied health professions such as physical therapy (DPT degree), audiology (AuD degree), and pharmacy (PharmD degree). Choosing different paths, the field of occupational therapy currently offers both the master’s and clinical doctorate as entry-level degrees while physician assistants have decided to maintain the master’s degree as their entry-level degree. For the professions which have transitioned to an entry-level clinical doctorate, assessment of training program directors’ attitudes and perceptions was a common part of degree development and implementation. In physical therapy, interviews with 15 training program educators just preceding the opening of the first DPT program revealed mixed attitudes (Hummer et al. 1994). Overlapping with issues highlighted by the ASAHP statement, interviewees supporting an entry-level DPT felt the degree would increase students’ clinical capabilities, possibly lead to increased professional recognition and improve reimbursement from third-party payers. Respondents not in favor of the DPT cited a likely increased financial burden on students, creation of conflict among employers and practitioners and perception that other health care practitioners would not understand the degree. In addition, respondents were divided on whether a DPT degree would alter student recruitment and if training programs had adequate faculty resources to support extended training.
Unfortunately, literature documenting the impact of transition to an entry-level clinical doctorate in allied health fields is virtually absent. In one of the only such studies, King et al. investigated the impact of the DPT degree on physical therapy in rural communities by interviewing physical therapist training program directors and faculty, directors of physical therapy departments at hospitals in rural counties and presidents of state physical therapy associations (2010). At that time, most respondents did not perceive that the DPT had greatly impacted the supply or quality of physical therapists in rural communities. However, approximately half of the respondents expressed concern about the DPT having a negative impact on the physical therapy supply in the future. In addition, respondents provided no strong evidence that the DPT had yet resulted in higher salaries. In a presentation at the 2009 NSGC Annual Education Conference, Alison M. Grimes, AuD, past president of the American Academy of Audiology, provided a historical overview and update regarding entry-level AuD degree development in Audiology (Conway et al. 2009). At the time, all existing training programs had reportedly transitioned to offer the AuD and the majority of practicing audiologists had converted to or graduated with the AuD degree. The presenter concluded that the transition was “worth it” for the profession, citing the improved caliber of students attracted to the field, more rigorous educational programs and graduates more well-prepared to begin clinical practice. It was also reported that the transition to the AuD had resulted in increased salaries, however, no specific data were provided.
It is apparent from the existing literature that genetic counseling training program directors’ opinions specific to a clinical doctorate have not been thoroughly investigated. In addition, exploration into the impact this degree may have on existing master’s programs and potential barriers to development and implementation of such training is needed. Given the existing gaps in literature, the purpose of this study was to explore the attitudes of training program directors in North America regarding a possible transition to a clinical doctorate in genetic counseling.
Directors from 31 of the 32 genetic counseling training programs in North America were recruited via email to complete an online survey. One director (1/32) was excluded from recruitment due to direct involvement in the study (MC). At the end of the survey, respondents were invited to participate in a follow-up qualitative interview. If they indicated their willingness to participate in the interview, they were contacted via email by a member of the study team (AS) for scheduling.
A 38 item survey (appendix A) was created in SurveyMonkey™ with input from the authors and members of the AGCPD clinical doctorate workgroup. At the beginning of the survey, a page was included that explained the difference between a PhD and a clinical doctorate and the known pros and cons of converting to a terminal clinical doctorate degree. In addition to 6 demographic questions, the survey consisted of 32 multiple choice, yes/no, multiple response, and fill-in questions. Questions were chosen to assess 1) participants’ knowledge of the clinical doctorate degree, 2) attitudes about a transition to clinical doctoral training and 3) if the field were to transition, preferences as to how the transition should occur.
The study was approved by the Ohio State University and Boston University Institutional Review Boards and the survey was sent via e-mail on August 24, 2010 and was open until September 24, 2010.
Input from the authors and several program directors was also paramount in developing a semi-structured interview guide. The semi-structured format was chosen due to its strength in allowing for flexibility of questioning structure and sequence while ensuring data is collected in the same general realms of inquiry in all interviews (Patton 2002). The finalized interview guide (appendix B) was composed of questions designed to investigate five primary subject areas: participant demographics, familiarity with the clinical doctorate as an advanced degree option, opinion/attitude regarding the potential transition to the clinical doctorate in genetic counseling, feasibility of a transition at the institution and potential implications of a transition for the existing program. Unscripted probing questions were used to clarify interviewee responses and delve into topics of interest. All interviewees were given an opportunity to expand on previous statements, contribute additional thoughts, and/or suggest topics for future investigation.
The finalized interview guide was piloted on members of the Boston University training program faculty to assess for interview length and clarity and sequence of questions and revised prior to study commencement. Interviews were completed via telephone due to geographical and scheduling constraints and audiotaped following participant verbal consent. Audiotapes were manually transcribed by study staff members and checked for accuracy. Data were independently coded by two study team members (AS and MC) using the content analysis process (Elo and Kyngäs 2008). Discrepancies between descriptive codes were discussed and resolved during the process of creating a master code list. Transcripts were re-coded using the master code list and Cohen’s kappa statistic (Cohen 1960) was applied for calculation of inter-coder agreement. Kappa was utilized because it allows for the measure of overall agreement while correcting for agreements due to chance. A satisfactory level of inter-coder agreement was achieved (K = 0.86). Codes were analyzed for similarities and interrelations in a process known as thematic analysis (Buetow 2010). Given the common criticism that qualitative results can be influenced by an investigator’s personal views (Golafshani 2003), study team members and external study advisors were consulted throughout the qualitative design and analysis processes in order to reduce bias and improve trustworthiness of the interview results.
Demographic characteristics of survey respondents
Experience N = 21
Years as a GC
Years as a PD
Education N = 21
Work Setting N = 21
Public, state-funded university
CD Precedent at University N = 21
Respondents had significant experience (20 had >10 years as a genetic counselor and 16 had >5 years as a program director). The majority of respondents (n = 17) had a master’s degree; while 4 had a doctorate (PhD). The majority of program directors (n = 16) worked for public, state-funded universities. Twelve respondents said that other programs at their university had previously transitioned to a clinical doctorate; 6 reported that no other programs at their institution had made this transition and 3 were not sure.
With regard to clinical rotations, the majority of program directors (9) would make changes such that each placement would be longer and also they would add more placements, while some would either add more placements of the same length (three respondents) or have the same number of placements but make them last longer (three respondents). Fourteen program directors felt that a clinical doctorate would place an additional burden on their clinical placement sites.
If the field transitions to a clinical doctorate, 12 respondents felt that the new degree should be offered to master’s level genetic counselors and new students concurrently versus four who felt that it should be first offered to current master’s level genetic counselors. Seven directors indicated that they would be likely to start an on-line training program for practicing genetic counselors to transition from their master’s degree to the clinical doctorate; one director indicated that their program would not and 11 indicated that they were not sure. Finally, program directors were divided on whether or not the field of genetic counseling should transition to a clinical doctorate degree at one time (ten respondents) or convert in a staggered fashion whenever each individual program is ready (seven respondents).
Interviewees expressed some familiarity with a clinical doctorate, although scope of knowledge relating to the degree varied significantly. Of the ten interviewed directors, three were in favor of transitioning to a clinical doctorate, three were against a transition, and four were undecided. A satisfactory level of inter-coder agreement was achieved (K = 0.86). Narrative data analysis revealed three themes central to program directors’ attitudes toward a clinical doctorate transition: implications for the profession, institution-specific considerations, and perception of the unknown. Of note, comments from each of the ten interviewees are represented in the following sections.
Implications for the Profession
All interviewed program directors commented on potential benefits and consequences of a transition to a clinical doctorate in genetic counseling.
Impact on Students
“So we’re [PDs] going to be asking students to train longer, spend more money with us and then go into the workplace and possibly make the same amount of money that they’re making now? I think that’s a huge burden.”
“… it will take longer to train people and potentially cost people more money, um, I think people sort of hope that they will make more money and I don’t think that’s a reasonable expectation.”
“We also have to think about the cost of that [clinical doctorate training] for our students when we aren’t able to get necessarily any federal funding to help with the cost of the tuition. So if you add on another year, you’re adding that much more in tuition and that much more to loans to pay back.”
“If you look at other master’s-level training programs- you’re a MPH with 36 credits and get a master’s in English with 32 credits. The majority of GC master’s programs are very credit-dense and I think that the time and effort that goes into obtaining this degree needs to be validated with something that the outside world understands.”
“Just a Master's”: Status and Respect
“Where I think it’s going to help us is in areas where people are not as familiar with genetic counseling. … so in that sense maybe status will be increased … maybe lay people will value the services that we bring to them seeing that we have this advanced degree and must have highly specialized training in this area.”
“I worry about us [genetic counselors] kinda being shuffled to the side and not keeping up with other allied health professions because so many are moving to the clinical doctorate- that they [other health professionals] will perceive us as second class citizens as a profession because they’ll be like ‘Oh well they’re one of the few in the master’s world. They’re way behind the times’. Um, so yeah I really worry about us being perceived in sort of that lesser status.”
“Every health care professional is becoming- is like ‘I’m a genetics expert too’. So PAs are saying they’re the genetics experts, nurses are saying they’re genetics experts, everybody’s saying they can be genetics experts … kinda drawing a line in the sand and saying ‘we really are the genetics experts’ and ‘we really are better than you or equivalent to you’ would be stronger by having that doctorate.”
“I think a lot of how you’re perceived and recognized is who you are. I’ve seen genetic counselors who demand the utmost respect and they get it and for those people who struggle with that it’s because either they feel they’re not worth- I mean, sometimes I feel that we’re the ones that put that on ourselves maybe more than the outside.”
“You know, students would always ask me about the respect thing and my own personal feeling is that you sort of get the respect that you earn from your colleagues. There are plenty of people who are going to respect you or not respect you based on a degree, but once they get to know you- that should be where the wind changes.”
“There are some practitioners out there who are in favor [of transition] who think that it [a clinical doctorate] will make them more highly valued in the workplace, but I don’t think that’s going to happen actually. You get valued because of your expertise, not based on a label of a doctorate.”
Risk of Fractionation
“I have to say that [loss of training programs] would be a real problem for me because I feel like we’re limited enough with our programs that if we lost one or two, that would be a real concern for me and, I think, a problem for the profession.”
“There are going to be programs that are not going to be able to offer this degree, and that would fractionate the profession. The profession is barely 3,000 people in the whole of North America to begin with so this just seems like kind of a crazy time to split the profession.”
“I’ve been a genetic counselor for 35 years and you would say to me I don’t know what I’m doing? Then that wouldn’t sit well. It wouldn’t be fair.”
“All fields evolve. Wasn’t it unfair to ask them [practicing genetic counselors] to go get their certification? … You can’t look at it from the standpoint of the individual, you have to see what’s good for the greater number, the field in general as moving forward. I hear them, it’s a pain … I don’t want to do it either, but I think it’s the best thing for us … It’s the future of the field.”
Need for a “Unified Front”
“I think that it would be a huge mistake if the field didn’t do whatever it’s going to do as a whole and not bits and pieces. Not ‘some people wanted to do this and some people wanted to do that’.”
“From the program level it [clinical doctorate transition] probably shouldn’t be a problem because other allied health professions within our university have clinical doctorates.”
“Having students on campus for an extra year, obviously that creates demands… demands on clinical training sites, demands on faculty, demands on even space issues…”
Other interviewees specifically talked about the lack of financial resources to support extended training given that “we [training programs] have limited funding to begin with.” Of note, one director was optimistic that an advanced degree in the field would allow training programs to more easily secure funding.
Perception of the Unknown
“… to be honest, at this point I have not made a firm decision about it [the clinical doctorate] because I think that there is still a lot that we need to know and explore about the issue.”
“I understand the rationale behind considering this [transition to a clinical doctorate] and I guess what I really want to look at is the other fields that have done this [transition] and have they truly been able to document increased salaries and is that truly what it’s all about?”
“Something else I’d like to understand more fully is, for other allied health professions who implemented the clinical doctorate, how has that changed their workforce picture? Um, has it increased in terms of numbers? Has it increased their salaries? My understanding is that maybe it hasn’t done those things, but I would like to see it researched more fully.”
“We need some good education about what’s going on in other fields and what the implications have been for other fields so that people can provide informed responses and have a chance to think about those issues.”
Of note, four other interviewees (two in favor of transition and two against) also suggested continued investigation into other fields’ transition models and clinical doctorate impact.
“I don’t think we’re missing any data- I’ll be honest with you. I think we’re missing chutzpah … Change happens and we’re just going to have to go for it. … You know, somebody started the genetic counseling field because they thought it was a good idea. There was no data about how it would turn out …”
These results help to illuminate some of the issues influencing program directors’ attitudes regarding the development of a clinical doctorate in genetic counseling as well as provide insight into directors’ preferences towards a potential transition. While more participants were in favor of the transition to a clinical doctorate (n = 9/21) than against (n = 6/21), it is unclear how the opinions of those who remain undecided (n = 6/21) may influence future discussions and an eventual decision regarding transition.
The potential transition to a clinical doctorate in the field of genetic counseling is a polarizing issue, which is reflected in the lack of agreement between program directors in survey responses and variation in interview data. Many of the motivations and concerns identified in this study overlap with findings from previous explorations regarding doctoral degree development in genetic counseling (Clark et al. 2006; Gaupman et al. 1991; Walker et al. 1990) as well as other fields (Conway et al. 2009; Hummer et al. 1994; ASAHP 2008). Through our mixed-methods approach, the program director participants were able to provide greater insight into the rationale behind their opinions than previously reported. In addition, interviewees could explain any potential barriers to transition at their respective institution.
For the majority of program directors, the decision to support a transition to clinical doctorate training is influenced by a variety of factors. Results from Gaupman et al. (1991) and the AGCPD workgroup suggest that the impacts on career aspects (status, professional freedom, salary, etc.) are the primary factors influencing a genetic counselor’s perception of a doctoral transition. However, data from this study suggests that additional factors influence program directors’ attitudes towards a clinical doctorate, such as the implications a transition may have for the cost and length of training for students, and the additional resources that would be required by the training programs to offer a clinical doctorate.
While the utility of a doctorate degree in genetic counseling has been debated for more than 20 years, the relatively new option of a clinical doctorate (Clark et al. 2006) has spurred a fresh wave of discussions regarding the future of genetic counseling. Building upon the results from the AGCPD workgroup discussion groups, which indicated that practitioners were interested in and excited about the possibility of a clinical doctorate in genetic counseling (Conway et al. 2009), results from this study demonstrate that, if a transition were to occur, the majority of training programs would transition to offer the new degree and many master’s level program directors would personally pursue the new degree. As the field enters into an era where a decreasing number of allied health professions offer a master’s as the terminal degree, genetic counselors should continue to explore the option of transitioning to a clinical doctorate as a future direction. To this end, the Genetic Counseling Advanced Degree Taskforce (GCADT) was recently formed to explore possible advanced degree options for the genetic counseling profession. The GCADT is comprised of representatives from the American Board of Genetic Counseling, the National Society of Genetic Counselors, and the Association of Genetic Counseling Program Directors. They had their first meeting in March of 2011 and reported that a lengthy and robust discussion occurred and the group outlined plans to pursue capturing greater input about advanced degree options from the many stakeholders that would be affected.
Feedback received during interviews indicated that directors may have felt limited by the survey question format in that some questions did not include an “other” or “uncertain” option. As such, our survey data may under-represent the amount of uncertainty program directors feel about transitioning to a clinical doctorate. Additionally, our survey sample was composed of directors with varying levels of self-reported familiarity with the clinical doctorate degree, a factor which may have influenced survey results. Our interview sample was comprised entirely of volunteers, which raises concern of an ascertainment bias. However, the similar representation of in favor, undecided, and against viewpoints in the ten interviews reduces the chance that major concepts were not captured in the qualitative data. Lastly, two of the AGCPD workgroup members consulted during survey and interview guide development were included in the survey and interview sample, which may have biased our data.
There continues to be some lack of familiarity with the clinical doctorate even within the program director community and therefore, likely within the profession as a whole. As such, continued investigation of a clinical doctorate as a doctoral degree option for the profession is warranted. Future studies should involve education that aims to clarify differences between the PhD and clinical doctorate degrees and should include all available stakeholders (e.g., institution administration, potential employers, and national organization members) in addition to program directors and the greater genetic counseling community. Many interview respondents expressed a desire for continued investigation into the clinical doctorate transition models utilized in other allied health professions as well as the impact of transition in those fields. These investigations may help reduce the uncertainty surrounding this topic and, subsequently, the number of individuals who are undecided about whether or not to support development of an entry level clinical doctorate.
The authors would like to acknowledge Laura Conway, PhD, CGC and Kathleen Valverde, MS, CGC for their review of the survey instrument and advice on the study. We would also like to thank Bev Yashar, PhD, CGC and Monica Marvin, MS, CGC for piloting the survey. We also extend our gratitude to the program directors who completed our survey and volunteered for follow-up interviews.