Presented by Laura Conway, PhD, CGC on behalf of the Genetic Counseling Advanced Degree Taskforce May 16, 2012

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1 Presented by Laura Conway, PhD, CGC on behalf of the Genetic Counseling Advanced Degree Taskforce May 16, 2012

2 Provide background information on possible options for advanced degrees for genetic counselors who practice in the United States. Summarize the historical discussion among genetic counselors. Provide an opportunity for feedback.

4 Based on at least 3 years of graduate study followed by completion of a dissertation (5-6 years total to earn degree). Highest degree awarded graduate study. (thefreedictionary.com) Requires original research. Degree is available in many areas of knowledge, including many health professions. Focused on research and teaching at an advanced level rather than clinical practice

5 Many people in healthcare with PhDs work in academic centers and are not patient focused. Employers surveyed about PhD in genetic counseling expected less clinical exposure, more time spent conducting research, and writing grants in order to fund position with grant money. Wallace JP, Myers MF, Huether CA, Bedard AC, Warren NS. (2008) Employability of genetic counselors with a PhD in genetic counseling. J Genet Couns, 17:

6 Some programs have option for extended or continuing education culminating in PhD. PhD is typically granted in another area such as human genetics or social and behavioral sciences, but with research focus in area of genetic counseling. Can involve either a continuation of studies following master s level work or resumption of studies following a few years of work experience.

7 More extensive training than a masters: Typically total of 3-4 years post-baccalaureate training. Focus is on clinical practice, rather than on research. Two options: Advanced practice doctorates and Entry-level doctorates.

8 Doctoral program open to people with master s degrees and work experience. In some, but not all, cases programs have been tailored to supplement individual s experience. May involve largely or exclusively online learning. Defined by the Association of Schools of Allied Health Professions (ASAHP) doctoral level programs that are designed to prepare already credentialed or licensed individuals to practice clinically with competencies above and beyond those expected of entry-level professionals.

9 Extended post-baccalaureate training that results in awarding doctorate degree. Involves extended course work and clinical training as compared to a Master s program. Defined by ASAHP as educational programs that prepare students to achieve the knowledge and competencies of first-time graduates expected and articulated by their professional associations...

11 Genetic counseling was established as a master s degree program. The first formal training program was a two year master s program at Sarah Lawrence College begun in A multi-disciplinary conference in 1979 confirmed the need for minimum standards that include a master s degree. At this time, the master s degree is also the terminal degree (the highest degree awarded in this field of study). Scott JA, Walker AP, Eunpu DL, Djurdjinovic L. (1988) Genetic counselor training: a review and considerations for the future. Am J Hum Genet., 42:

12 Other professions in the US often began as certificate programs, transitioned over the years to higher degrees: Physical therapy: began in the early 1900s, required master s beginning in Occupational therapy: began in early 1900s, required master s degree beginning in Physician s assistant: began in 1965, declared in 2009 that the master s should be the entry-level and terminal degree.

13 Potential benefits of PhD included: Acknowledgment of high level skills in an academic setting, leading to easier access to faculty positions and grants. More in-depth training for genetic counselors who wanted to research genetic counseling issues. Opportunity for advanced training for those who wished to pursue it.

14 Concerns included: Creation of a two-tiered system, where the master s degree would be viewed as a lesser degree. Reduction in workforce if many chose to leave the clinic for PhD training. Decision was made that developing a PhD was premature. Walker AP, Scott JA, Biesecker BB, Conover B, Blake W, Djurdjinovic L. Report of the 1989 Asilomar meeting on education in genetic counseling. Am J Hum Genet Jun;46(6):

15 Since then, surveys of practicing genetic counselors, program directors, employers, and students have indicated both support for and concerns about the development of an advanced degree. Focus of these surveys was primarily the PhD

16 Proposed benefits have consistently included: o Time to master the expanded body of scientific knowledge. o Competitive positioning and prestige among health care professions. o Possible development or expansion of career ladder. o Creation of a body of knowledge generated by practitioners within the field (PhD). Proposed concerns have consistently included: o Cost and time burden of additional training, including potential impact on workforce. o Implications for those who choose not to pursue the additional degree. o Possible lack of support by employers and others who may not see the need for additional training.

17 Previous studies primarily addressed a PhD A clinical doctorate in genetic counseling has many unknowns Type of training Views of employers Implementation Although no other fields offer an exact parallel, their experiences can inform the discussion.

18 Clinical doctorates have been discussed and/or developed for US practitioners in audiology, laboratory science, nursing, nutrition, occupational therapy, pharmacy, physical therapy, clinical social work, speechlanguage pathology.

19 Advanced practice doctorates first offered in 1992, entry level doctorates first offered in Advanced practice doctorates were offered to people with experience in the field. Once entry level doctorates became available, the advanced practice degrees were described as transitional doctorates. Coursework in the transitional programs includes training in health promotion and education, healthcare management, and more technical information (Pharmacology, Diagnostic Imaging).

20 The field is transitioning entirely to entry-level doctorates. No programs will award masters degrees after Concerns were raised over the potential devaluing of a master s degree. American Physical Therapy Association s response involved working to ensure that licensure focused on competencies rather than specific degree, and by phasing in the entry level degree over more than 15 years.

21 Some (audiology, pharmacy, physical therapy) have completely converted to entry-level clinical doctorates. PhD degrees available in these fields as well.

22 Some have multiple options: Social work has an advanced practice doctorate that often requires prior work experience at master s level. Counseling can be provided by people trained at a master s level in psychology; a clinical doctorate (PsyD) is also available as either entry level or advanced degree. Some occupational therapy schools offer entry-level doctorate, others offer masters degree; the accrediting body will accept either option.

23 Up to 2009, no requirement for a particular degree as entry-level. Some practitioners had a certificate, some had a bachelor s degree, some had a master s degree. In 2007, Baylor created a clinical doctorate program for Army PAs wanting to specialize in emergency medicine. Summit held in 2009 decided that the field would not pursue clinical doctorates. Field of practice and scope too similar to that of MDs, could lead to confusion. Determined they would not be allowed to practice independently. Endorsed masters degree as entry-level and terminal degree.

24 Field Physical Therapy Audiology Occupational Therapy Physician Assistant Clinical Social Work Counseling Psychology Minimum entry level degree Clinical doctorate Clinical doctorate Master s or clinical doctorate Entry level clinical doctorate? Yes Yes Yes Advanced practice clinical doctorate? Transitional Transitional Yes Master s No No Master s No Yes Master s Yes Yes

25 In the past, scope of practice and physician supervision as defined in licensure laws limited independent practice by many allied health practitioners Advanced degrees expanded scope of practice, allowing licensure laws to be amended and increasing independence in delivering services.

26 To date, all genetic counselor laws allow for independent practice, within the scope of practice defined by legislation. Advanced degrees that incorporate training in additional skills and their application may allow expansion of the scope of practice in licensure language. Scope of practice is the primary driver behind determining who is allowed to bill for providing a defined service. Reimbursement is not directly tied to academic degree.

27 No reported issues with employers in audiology and physical therapy. Professional organizations endorsed the change. Mixed results on salaries. Physical therapy and audiology professional status surveys report that members with either a clinical doctorate or a PhD earn higher salaries, but data are confounded by years of experience.

28 Mixed results on student/program impact. No loss of programs in physical therapy, some loss of programs in audiology. Audiology reported in 2007 that most programs were small and underfunded with inadequate numbers of faculty. Physical therapy reports increases in male applicants, minority applicants. Enrollment of underrepresented minorities in schools of pharmacy increased from 10.6% to 14% between 1988 and 2002 (PharmD introduced in 1990). 1 Total cost of programs increased due to additional time involved in training. 2 1 Nkansah, NT et al. (2010). Fostering and Managing Diversity in Schools of Pharmacy. American Journal of Pharmaceutical Education. 2 Thompson, K et al. (2011). Financing Physical Therapy Doctoral Education. J Allied Health 2011; 40(4):

29 Very little data on patient impact No evidence that DPT has reduced access in rural areas, but there are concerns that it could reduce access in the future. King, J et al. (2010). What does the Clinical Doctorate in Physical Therapy Mean for Rural Communities? Physiotherapy Research International. In counseling psychology, a few studies have found a slight benefit to clients when the practitioner has an advanced degree; other studies have seen no effect. Stein, DM and Lambert, MJ (1995). Graduate Training in Psychotherapy: Are Therapy Outcomes Enhanced? Journal of Consulting and Clinical Psych.

30 Clinical doctorate remains controversial in occupational therapy: One survey suggested that few practitioners were interested in advanced education. Concerns included cost, time, and perceived lack of a reward. The accrediting body, ACOTE, has standards both for masters level and doctoral level programs. Dickerson, A.E., Trujillo, L. (2009) Practitioners Perceptions of the Occupational Therapy Clinical Doctorate. Journal of Allied Health.

31 The Association of Schools of Allied Health Professions (ASAHP) developed two reports on professional doctorates that enumerate the pros and cons seen across professions.

32 Area Impact on students Possible Pros Increased time for study and clinic Possible Cons Increased cost Decreased enrollment of underserved minorities Impact on practitioners Impact on programs Increased status/ salaries Opportunity for career ladder Increased time to incorporate relevant information Salaries usually tied to reimbursement, not degree Payer recognition of advanced practice uncertain Increased need for resources Lack of support from administrations could lead some programs to close

33 Educational: What, if any, are the gaps in training as identified by graduates and employers? What is the impact on the training programs? Professional: What is the potential impact on scope of practice, state licensure, billing and reimbursement? What is the potential impact on growth of the profession?

34 Accreditation: What is the impact on establishing and setting standards for the programs? Credentialing: What is the impact on the certification and recertification programs? What changes would need to be made?

35 Model 1: Decide to maintain the Master s degree as the entry-level and terminal degree. The Accreditation Council of Genetic Counseling (ACGC) will not accredit programs that offer degrees other than Master s degree. This may include a recommendation for revisiting this decision at regular intervals in the future based on changes in specific factors determined through the decision-making process.

36 Model 2: Introduce an optional advanced practice clinical doctorate in the near future. This would maintain the Master s as the entry level degree. Individuals with a Master s degree could choose to engage in the optional advanced practice clinical doctorate. The ACGC would work toward developing standards to accredit these degree programs. Programs could choose to offer advanced practice clinical doctorates.

37 Model 3: Introduce an entry-level clinical doctorate in the near future. This could be the sole path, required of all individuals entering the field after a defined date, with an option, but not a requirement that practicing counselors move to the higher degree; OR This could be a requirement of all individuals in the field with the requirement that all practicing GCs move, over several years, to the higher degree. The ACGC would work toward developing standards to accredit these degree programs.

38 Educate genetic counselors about the issue. Obtain and review feedback. Determine what additional information is needed and how to get it. Summit of key stakeholders to be organized by the ACGC in Spring Decision on whether to move forward to be made by all genetic counseling organizations following summit.

39 American Board of Genetic Counseling: Erynn Gordon, Holly Peay, Sheila O Neal National Society of Genetic Counselors: Brenda Finucane, Rebecca Nagy, Meghan Carey Canadian Association of Genetic Counselors: Jennifer Fitzpatrick, Jaspreet Sekhon-Warren, Josh Silver Association of Genetic Counseling Program Directors: Catherine A. Reiser, Carol Walton, Laura Conway

40 Members of the AGCPD workgroup: Susan Hassed, Lynn Holt, Jessica Rispoli Joines, Anne Matthews, Kathleen Valverde, Carol Walton, Bev Yashar

41 Survey associated with webinar Questions or comments can be posted on the Clinical Doctorate Discussion Forum by NSGC members Questions or comments can be ed to Please put Clinical Doctorate Webinar in the subject line

Alyson D. Stover, MOT, JD, OTR/L, BCP

Alyson D. Stover, MOT, JD, OTR/L, BCP Curriculum Vitae BIOGRAPHICAL INFORMATION Business Address: Department of Occupational Therapy School of Health & Rehabilitation Sciences University of Pittsburgh